Volume 09 Number 1 & 2 April & October 2019

EDITORIAL Research Promotion for Sustainable Health Development 5-7 Md. Nurul Amin

ORIGINAL ARTICLES Long-Term Survival Outcomes after Coronary Artery Revascularization Surgery of 8-15 Bangladeshi Population: A Single Centre Study Rezaul Karim, Masoom Siraj, Md. Nurul Amin, Mohammad Abdur Rashid, Hemanta I. Gomes, Naziat Shahrin Amin, F. Aaysha Cader, Jamal Uddin Classic Imaging Findings of Tetralogy of Fallot with 64-slice Multidetector Computed Tomography 16-22 Nawshin Siraj, Nusrat Ghafoor, Md. Rokonujjaman Selim, S M Shaheedul Islam, Khalada Parvin Deepa, Mir Mahin Ashraf Safety and Feasibility of Transradial Approach for Coronary Artery Bypass Graft Intervention 23-28 Hemanta I Gomes, C M Shaheen Kabir, Saidur Rahman Khan, M G Azam, S M Rahman Epidemiological Features of Hospital Acquired Infection in a Tertiary Military Hospital 29-35 Muhammad Junayed Alam, A K M Mustafa Kamal Pasha Evaluation of Outcome of Treatment of Intertrochanteric Fracture with Dynamic Hip Screw (DHS) 36-41 Jonaed Hakim, Afrina Jahan, Mahbubur Rahman Khan, Md. Humayun Reza, Rasel al Zilani , Muhammad Shahiduzzaman, MKI Quayyum Choudhury

Volume 09 Perception About the Use of Over-the-Counter Antibiotics Among Patients Attending Outpatient 42-48 Department of a Tertiary Care Hospital of Bangladesh Md. Ashraf Uddin Ahmed, A.S.M. Morshed, Farzana Yasmin, Dwijraz chakraborty State of Working Slum Children in Dhaka City 49-53 Md. Nurul Amin, Shayela Farah, Mohoshina Karim, Farhana Rahman, Shitil Ibna Islam Pattern of Drugs Use in Selected Paediatric Diseases in Outpatients Departments of Public and 54-59 Number 1 & 2 Private Teaching Hospitals in Bangladesh Tasnin Afrin,Rumana Afroz, Shahin Sultana, Kamrunnesa, Mahbuba Jahan Lotus Variation in Coronary Artery Disease Pattern and Risk Factors among Female Patients of 60-66 Different Age Groups in Bangladesh Shitil Ibna Islam, Md. Nurul Amin, Sahela Nasrin, F. Aaysha Cader Prediction of Perinatal Outcome with Meconium-stained Liquor 67-73

April & October 2019 Monowara Khatun, Runa Parvin, Samaria Naurin Comparative Study of Management of Intrauterine Fetal Death by Misoprostol versus Oxytocin 74-79 Lipika Ghosh, Fatema Binta Islam, Farjana Maksurat, Mamata Manjari, Rowshan Afrooz

REVIEW ARTICLE Health Vulnerabilities and Resilience to Climate Change : An Update of International Progress 80-92 Mohd. Arifuzzaman, M. Mizanur Rahman, Md. Sultan-Ul-Islam, Md. Nezam Uddin

CASE REPORT A Case Report : Pregnancy with Multiple Sclerosis 93-95 Shiuly Chowdhury, Nilufar Islam, Khadiza Nurun Nahar, Kaniz Fatema, Salma Akter Munmun, Sudip Barua www.ibrahimcardiac.org.bd; www.banglajol.info Volume 09 Number 1 & 2 April & October 2019

Professor Dr. Mashhud Zia Chowdhury MBBS, DTCD, MD (Card), FACC (USA) Professor A. K. Azad Khan Clinical & lnterventional Cardiologist President Senior Consultant, Department of Cardiology Diabetic Association of Bangladesh Professor Dr. Md. Saidur Rahman Khan Md. Sayef Uddin MBBS, MD, PhD, FACC (USA) General Secretary Clinical & lnterventional Cardiologist Diabetic Association of Bangladesh Senior Consultant, Department of Cardiology Professor Dr. Mahmuder Rahman Professor Dr. Md. Sharif Hasan Chairman, Board of Management MBBS, MS (Cardiovascular & Thoracic Surgery) Ibrahim Caradiac Hospital & Research Institute Senior Consultant, Dept. of Cardiac Surgery Dr. Sarwar Ali Professor Dr. Md. Sirajul lslam Chairman, Board of Management, BIRDEM MBBS, DA, MD (Anaesthesiology) Member of the National Council of BADAS Senior Consultant, Department of Cardiac Anaesthesiology Professor Dr. Hajera Mahtab Dr. Nawshin Siraj Professor Emeritus of BIHS MBBS, M.Phil (DU) Member of the National Council of BADAS Associate Professor & Senior Consultant Head, Department of Radiology & Imaging Professor Dr. Nazma Haque Dr. Md. Rezaul Karim Principal, Ibrahim Medical College MBBS, D. Card (UK) Professor Dr. Zafar Ahmed Latif Associate Professor & Consultant, Department of Cardiology Director General, BIRDEM Dr. Sheikh Muhammad Shaheedul lslam Professor Dr. T A Chowdhury MBBS, DC, FCPS, Fellowship in Ped. Cardiology (India & South Korea) Associate Professor & Paediatric Consultant, Department of Cardiology Chief Consultant Dept. of Gynae & Obs Special Unit & Care, BIRDEM Dr. Sahela Nasrin MBBS, MCPS, MD (Card) Professor Dr. Subhagata Choudhury Associate Professor and Consultant, Department of Cardiology Former Director, Laboratory Services, BIRDEM Dr. C M Shaheen Kabir EDITORIAL BOARD MBBS, MD (Card), FACC, FSCAI (USA) Chief Patron Associate Professor and Consultant, Department of Cardiology Professor Dr. M.A. Rashid Dr. Syed Dawood Md. Taimur MBBS, MPH (HM). DTM, D-CARD, FACC (USA), FRCP (Giasg.) MBBS, CCD, D-Card (DU). MPH (Epidemiology) WHO Fellow in Cardiology Assistant Professor and Associate Consultant Senior Consultant & Chief Executive O cer Department of Cardiology Ibrahim Cardiac Hospital & Research Institute Editor in Chief INTERNATIONAL EDITORS Professor Dr. M. Maksumul Haq Chowdhury H Ahsan MBBS, FCPS, FACC, FRCP (Edin) MRCP, MD, Ph.D, FSCAI, FACC Clinical & lnterventional Cardiologist Clinical Professor of Medicine Senior Consultant & Head, Department of Cardiology Visiting Professor, Ibrahim Cardiac Hospital & Research Institute Executive Editor Director, Cardiac Catheterization & Intervention Dr. Md. Nurul Amin Director, Cardiovascular Research University Medical Center MBBS, DMCH, M. Phil (PSM). MPH (Thailand) 1800 Charleston Blvd., Las Vegas, Nevada Cath Lab Associate Professor (Part-time) E-mail: [email protected] Ibrahim Cardiac Hospital & Research Institute Dr. Ra que Ahmed Acknowledgement MD, PhD, FACC Shitil lbna Islam Specialist in EPS & RFA Research O cer, Ibrahim Cardiac Hospital & Research Institute Secretary General Bangladesh Medical Association of North America (USA) MEMBERS 4250 Hempatead Turnpike, Suite, 17 Bethpage, NY, 11714-5707USA Professor Dr. Masoom Siraj E-mail: [email protected] MBBS, FRCS (Edin) Senior Consultant & Head, Department of Cardiac Surgery Dr. Dinyuan Li Professor Lt Col (Rtd.) Dr. Md. Hamidur Rahman Associate Professor, Department of Cardiac Surgery MBBS, FCPS Fuwali Hospital, Beijing, China Senior Consultant & Head, Department of Cardiac Anaesthesiology E-mail: [email protected] Professor Dr. M H Millat Dr. Biswajit Bandyopadhyay MBBS, FRCS (Edin) MBBS (Cal), DNB (Ped). F. Fed Card (MMM), F. Ped Card (Aus) Senior Consultant (Honr), Department of Cardiac Surgery Head of the Department Professor Dr. Mohammad Liaquat Ali Sr. Consultant interventional Pediatric Cardiologist MBBS, FCPS (Med.), MRCP (UK) Rabindranath Tagore International Institute of Cardiac Sciences Clinical & lnterventional Cardiologist 124, Mukundapur, E. M. Bypass, Kolkata-700099, India Senior Consultant, Department of Cardiology E-mail: bisban@redimail.com, [email protected]

01 ABOUT THE JOURNAL Full Name of the Journal : Ibrahim Cardiac Medical Journal Short Name : Ibrahim Card Med J Nature of Publication : Bi-Annual Published From : Ibrahim Cardiac Hospital & Research Institute Address : 122, Kazi Nazrul lslam Avenue, Shahbag, Dhaka, Bangladesh Tel: 88-02-9671141-43, 9674031, 9670034, Fax: 9674030, E-mail: [email protected] Aims & Scope The Ibrahim Cardiac Medical journal is an English Language Scientic dealing with cardiovascular medicine addressing preventive, curative and rehabilitative cardiac services. It is an ocial journal of Ibrahim Cardiac Hospital & Research Institute and is published bi-annually. The Ibrahim Cardiac Journal of Bangladesh intends to publish the highest quality material on all aspects of cardiovascular health and disease. It includes articles related to original research ndings, technical evaluations and reviews. In addition, it provides readers opinion regarding the articles published in the journal.

Instruction to Authors for possible publication. The Editor may wish to see the raw data (electronic form) if necessary. Papers The Ibrahim Cardiac Medical Journal (published bi- In preparing the manuscript, use double spacing throughout, annually) accepts contributions from all branches of including title, abstract, text, acknowledgement, references, cardiovascular diseases which include original articles, table and legends for illustrations with font size 'Times New review articles, case reports and letter to the Editor. Roman 12'. Begin each of the following sections on a separate paper. Number pages consecutively. The articles submitted are accepted on the condition that they must not have been published in whole or in part in The standard layout of a manuscript is: any other journal and are subject to editorial revision. The - Title page Editor preserves the right to make literary or other - Abstract, including Keywords alterations which do not a ect the substance of the contribution. It is a condition of acceptance that the - Introduction (not headed) copyright becomes vested in the journal and permission - Methods to republish must be obtained from the publisher. - Results Authors must conform to the uniform requirements for - Discussion manuscripts submitted to biomedical journals (JAMA - Acknowledgements 1997; 277: 927-34). - Funding Legal Considerations - List of references Authors should avoid the use of names, initials and - Tables & Figures (including legends) hospital numbers which may lead to recognition of a - Illustrations (including legends) patient. A table or illustration that has been published elsewhere should be accompanied by a statement that The pages should be numbered in the bottom permission for reproduction has been obtained from the right-handcorner, the title page being page one, etc. Start authors or publishers. each section on a separate page.

Preparation of manuscript Title page Each manuscript should indicate the title of the paper, A separate page which includes the title of the paper. and the name(s) and full address (es) of the author(s). Titles should be as short and concise as possible Contributors should retain a copy in order to check proofs (containing not more than 50 characters). Titles should and in case of loss. Two hard copies of each manuscript provide a reasonable indication of the contents of the (double-spaced) should be submitted. If a manuscript is paper. This is important as some search engines use the accepted for publication in the ICMJ, the editor title for searches. Titles in the form of a question, such as 'Is responsible for it may request a soft copy (a CD or via plasma homocystine a cause or manifestation of acute internet) of the nal revision. Each paper will be reviewed myocardial infarction?' may be acceptable.

02 The title page should include the name(s) and address (es) description of the process of the study. Subjects covered of all author(s). Details of the authors' quali cations and in this section should include: post (e.g., professor, consultant) are also required. An - Ethical approval / license author's present address, if it diers from that at which the - Patient population work was carried out or special instructions concerning - Inclusion/ exclusion criteria the address for correspondence), should be given as a footnote on the title page and referenced at the - Conduct of the study appropriate place in the author list by superscript - Data handling numbers (1, 2, 3 etc.). If the address to which proofs should - Statistics used to analyse the data including level of be sent is not that of the rst author, clear instructions signi cance should be given in a covering note, not on the title page. - (CTA)

Abstract Ethical clearance The 'Abstract' will be printed at the beginning of the Regardless of the country of origin, all clinical paper. It should be on a separate sheet, in structured investigators describing human research must abide by format (Background; Methods; Results; and Conclusions) the Ethical Principles for Medical Research Involving for all Clinical Investigations and Laboratory Human Subjects outlined in the Declaration of Helsinki Investigations. For Reviews and Case Reports, the Abstract and adopted in October 2000 by the World Medical should not be structured. The Abstract should give a Association, last ammended in 2013. This document can succinct account of the study orcontents within 350 be found at: words. The results section should contain data. It is http://ohsr.od.nih.gov/guidelines/helsinki.html. important that the results and conclusion given in the Investigators are encouraged to read and follow the 'Abstract' are the same as in the whole article. References Declaration of Helsinki. Clinical studies that do not meet are not included in this section. the Declaration of Helsinki criteria will be denied peer Keywords review. If any published research is subsequently found to Three to six keywords should be included on the be non-compliant to Declaration of Helsinki, it will be summary page under the heading Keywords. They should withdrawn or retracted. On the basis of the Declaration of appear in alphabetical order and must be written in UK Helsinki, the Ibrahim Cardiac Medical journal requires that English spelling. all manuscripts reporting clinical research state in the rst paragraph of the 'Methods' section that: Introduction - The study was approved by the appropriate Ethical The recommended structure for this section is Authority or Committee. - Background to the study - Written informed consent was obtained from all - What is known /unknown about it subjects, a legal surrogate, or the parents or legal - What research question/hypothesis you are interested in guardians for minor subjects. - What objective(s) you are going to address Human subjects should not be identi able. Do not The introduction to a paper should not require more than disclose patients' names, initials, hospital numbers, dates 300 words and have a maximum of 1.5 pages of birth or other protected healthcare information. If double-spaced. The introduction should give a concise photographs of persons are to be used, either take account of the background of the problem and the object permission from the person concerned or make the of the investigation. It should state what is known of the picture unidenti able. Each gure should have a label problem to be studied at the time the study was started. pasted on its back indicating name of the author at the Previous work should be quoted here but only if it has top of the gure. Keep copies of ethics approval and direct bearing on the present problem. The nal written informed consents. In unusual circumstances the paragraph should clearly state the primary and, if editors may request blinded copies of these documents to applicable, secondary aims of the study. address questions about ethics approval & study conduct.

Methods Detailed description The title of this section should be 'Methods'–neither' The methods must be described in sucient detail to Materials and methods' nor Patients and methods'. The allow the investigation to be interpreted, and repeated if Methods section should give a clear but concise necessary, by the reader. Previously documented standard

03 methods need not be stated in detail, but appropriate gures in the text. Summarize the salient points. Mention reference to the original should be cited. However, any the statistics used for statistical analysis as footnote under modi cation of previously published methods should be the tables or gures. Figures should be professionally described and reference given. Where the programme of drawn. Illustration can be photographed (Black and White research is complex such as might occur in a glossy prints) and numbered. cardiovascular study in animals, it may be preferable to provide a table or gure to illustrate the plan of the Discussion experiment, thus avoiding a lengthy explanation. In Comments on the observation of the study and the longitudinal studies (case-control and cohort) exposure conclusion derived from it. Do not repeat the data in and outcome should be de ned in measurable terms. Any detail, already given in the results. Give implications of the variables, used in the study, which do not have universal ndings, their strengths and limitations in comparison to de nition should be operationalised (described in such other relevant studies. Avoid un-quali ed statements and terms so that it lends itself to uniform measurement). conclusions which are not supported by the data. Avoid Where measurements are made, an indication of the error claiming priority. New hypothesis or implications of the of the method in the hands of the author should be given. study may be labeled as recommendations. Letters are The name of the manufacturer of instruments used for welcome. They should be typed double-spaced on side of measurement should be given with an appropriate the paper in duplicate. catalogue number or instrument identi cation (e.g. References Radiometer PHM 7). The manufacturer's town and country must be provided. In the case of solutions for laboratory References should be written in Vancouver style, use, the methods of preparation & precise concentration numbered with Arabic numerals in the order they appear should be stated. in the text. The reference list should include all information, except for references with more than six Single Case Reports authors, in which case give the rst six names followed by Single case reports of outstanding interest or clinical et al. relevance, short technical notes and brief investigative Examples of correct forms of references studies are welcomed. However, length must not exceed 1500 words including an unstructured abstract of less Journals: Dosi R, Bhatt N, Shah P, Patell R. Cardiovascular than 200 words. The number of gures / tables must not disease and menopause. J Cli Diagn Res 2014;8(2),62-64. be more than 4 and references more than 25. Chapter in a book: Hull CJ. Opioid infusions for the management of postoperative pain. In: Smith G, Covino Animal studies BG, eds. Acute Pain. London: Butter worths. 1985;155-79. In the case of animal studies, it is the responsibility of the All manuscripts for publication should be addressed to author to satisfy the Board that no unnecessary suering the Executive Editor: has been inicted on the animal concerned. The refore, Dr. Md. Nurul Amin studies that involve the use of animals must clearly Associate Professor (Part-time) indicate that ethical approval was obtained and state the Ibrahim Cardiac Hospital & Research Institute Home Oce License number or local equivalent. 122, Kazi Nazrul Islam Avenue, Shahbag, Dhaka-1000 Drugs E-mail: [email protected], Tel: 88-02-9671141-43 When a drug is rst mentioned, it should be given by the Cell: +880-1753-178452 international non-proprietary name, followed by the Subscription chemical formula in parentheses if the structure is not The Ibrahim Cardiac Medical Journal is published twice in well known, and, if relevant, by the proprietary name with a year (bi-annually). The annual subscription rate is Taka an initial capital letter. Dose and duration of the drug 200.00 or $ 25.00 only, payable in advance to: should be mentioned in sucient details. If the drug is already in use (licensed by appropriate licensing Ibrahim Cardiac Hospital & Research Institute authority), generic name of the drugs should preferably 122, Kazi Nazrul Islam Avenue, Shahbag, Dhaka-1000, be used followed by proprietary name in brackets. Bangladesh. Results Present the result in sequence in the text, table and gures. Do not repeat all the data in the tables and/ or

04 EDITORIAL Ibrahim Card Med J 2019; 9 (1&2): 5-7  Ibrahim Cardiac Hospital & Research Institute

Research Promotion for Sustainable Health Development Md. Nurul Amin1

Research is a prerequisite for any field of scientific Health research is no luxury. The unprecedented and social development. So is applicable for Medical health gains in the last century are undoubtedly the Science. The central role of health research in fruits of research. Conception prevails that health improving health and stimulating national economic research should be conducted only by countries growth is now well-established. Health research with resources to spare. When India gained supports and strengthens the health systems, in independence, the country faced the problem of the delivery of better and more rational health care how to allocate its scarce resources to areas of most to people. It does so by identifying felt-need of the need. Pandit JawaharLal Nehru, in this context, people and providing best solutions to them, and made the following statement: “We cannot afford monitoring how health systems perform and how it not to do research”. The participation and should perform. It produces new knowledge, contribution of developing countries in scientific technologies and improved approaches to public research has been well-expressed by Pakistani health. The World Health Organization (WHO) has, Nobel Laureate Abdul Salam, as follows: “Science time and again, affirmed that all national and and Technology are shared heritage of all mankind; international health policies should be based on East and West, South and North have equally valid scientific evidence, the evidence that derives participated in their creation in the past, as we from scientific reasoning and logical propositions. hope, they will in the future-the joint endevour in The application of such knowledge, information and science is becoming one of the unifying forces technology that emanates from health research has among the diverse people of the globe2. enormous potential in promoting health, preventing disease, disability and death1 In recent years, the United Nations are trying consistently to make the world a better place for Shifting epidemiological trend in disease patterns, people to live including the destitute and the rich. In rapid increase in populations, emerging and pursuance of this, the United Nations had put reemerging health problems, increasing commercial various polices in place aiming at achieving the set interests of private health sectors and ever goals. In the documentations of several world shrinking public health resources all contribute to renowned investigators3,4 and the UNDP5, it was global inequity in health care. It is, therefore, recorded that owing to the ravaging challenges extremely important to identify the priorities in faced by a lot of people across the globe, ranging health sector so that national and international from rampant epileptic lifestyle of the people to development partners can focus on the most poverty, gender segregation and dichotomy, important health issues and determinants of health. ecosystem depletion, and the likes, all development For this to happen, our health systems should have efforts are nipped in the bud. This led to the to be capable enough to provide convincing data conglomeration of leaders from 189 countries in a resulting from research activities to justify meeting that held in the UN headquarters in New allocation of the scarce resources1. York in September 2000. The resolution of the meeting birthed the popularly known MDG

Author’s information: 1Dr. Md. Nurul Amin, Assistant Professor, Department of Community Medicine, Rajshahi Medical College, Rajshahi & Executive Editor, Ibrahim Cardiac Medical Journal, Ibrahim Cardiac Hospital & Research Institute, Shahbag, Dhaka. Correspondence : Dr. Md. Nurul Amin, Mobile: 01753178452, e-mail: [email protected]

05 Research Promotion for Sustainable Health Development Amin

(Millennium Development Goals).6 This was meant evaluation of what is right and what is wrong1. to address the development bottlenecks round the Health policy-makers, particularly in developing

EDITORIAL various nations of the world. Upon the review of the countries may not appreciate the contribution, MDGs made by the United Nation in 2015, several which research can make. There is still a division shortcomings were discovered pertaining to the between the domain of research and domain of effectiveness of the MDGs. This review eventually policy-making. The stereo type of the researchers birthed the currently known SDGs (Sustainable in their ‘ivory tower’ still persists. In fact, health Development Goals). Although the millennium managers and policy-makers may be doing goals that were way back established had some research without knowing it. level of achievement, but not withstanding. The sustainable development goals were initiated to Thus, it appears that research paves the way of improve on the deficiencies of Millennium goals development. Accordingly, our Tertiary Medical implemented thus far, covering 17 core necessities Institutes should have been equipped with research for living that spans through quality research to ‘know-how’ and ‘expertise’. But unfortunately, there environmental sustainability.7 are dearth shortages of either of the two. None of the Government Postgraduate Medical Institutes Since the launching of sustainable development have any Research Cells or Departments. The goals of the United Nations, it targeted towards National Institute of Preventive & Social Medicine, making the world a very conducive and suitable the only Government Postgraduate Institute in the place for humanity to stay in. This means that the preventive sector, had its glorious past in making seventeen (17) SDGs were born out of a passion to public health experts and researchers. But recently solve the generic problems of humanity. Hence, the the institute has lost its name and fame. A number role of research becomes extremely germane to of postgraduate institutes in the Private Sector are positively catalyzing the processes and procedure currently offering Masters in Public Health, but only required to attain the reality of it. The SDGs talks few of them making quality researchers to about the level of poverty, the standard of living the contribute to the health sector. people, the ecosystem all have immense impact on health of the people. All of these are the make ups A large number of postgraduate students are of the human survival mission. So, the role of enrolled every year in different postgraduate research in the attainment of the SDGs should be medical institutes of the country for higher the primary focus.8 As health development is one of education and as a part of the course curriculum the 17 goals of SDGs, health professionals cannot they have to undertake a study which requires keep themselves away from research to make research ‘know-how’. Given the above situation sustainable health development. prevailing in the Tertiary Medical Institutes, it is Considered in above context, all health professionals quite unusual to expect that they will conduct should have some know-how about research, or research independently. They need training on should have at least a level of research knowledge different aspects of research methodology, like that will help them understand the published protocol writing, data analysis, statistical researches/studies. Even if they wish to spend their interpretation of data, report writing and so on. But professional lives dealing with patients or health there are limited scopes of learning on these topics administration, a scientific approach is essential. As in their respective institutes. Besides these, many the practice of medicine is advancing rapidly, the beginners and young researchers seek formal need for critical evaluation of new developments is training on ‘Research Methodology’ so that they can a must. The medical past is littered with examples conduct study of their own. of possible major advances eventually being shown to be of no value, or even to be harmful. Research In the context of the problem stated and scope helps to develop a scientific critical attitude in the prevailing, Planning and Research Department of

06 EDITORIAL Ibrahim Card Med J 2019; 9 (1&2): 5-7  Ibrahim Cardiac Hospital & Research Institute

DGHS, Dhaka could launch a formal Training Course 3. Hwang S, Jiwon K. UN and SDGs: A Handbook for the on ‘Research Methodology.’ As a pilot testing Youths, 2016:1–74. Cited by 03-Jan-2020; Available at: ///C:/Users/HP/Downloads/UN and SDGs_A Handbook ‘Promoting Research in Health, Population & For Youth.pdf Nutrition Sector for its Sustainable Development’ could be started first in some Postgraduate 4. Lennon S (nd). The Sustainable Development Goals Institutes and Medical Colleges and based on the and Australia – A National and Personal Roadmap to Sustainability. Cited by 02-Jan-2020; Available at: success of this project, the programme could be https://www.unaa.org.au/wp-content/uploads/2017/0 gradually phased out in other Postgraduate 4/WA_UN_SDGsAndAustralia.pdf Institutes and Medical Colleges. The project is 5. UNDP. (2016). From the MDGs to Sustainable expected to produce researchers and public health Development for All. Lessons of 15 Years of Practice. experts who could contribute to health development United Nations Development Programme, 92. of the country, which in turn, would help people of our country to lead a socially and economically 6. Rahdari A, Sepasi S, Moradi M. Achieving sustainability through Schumpeterian social entrepreneurship: The productive life. role of social enterprises. Journal of Cleaner Production 2016;137:347–360. Reference : 7. Boateng R, Heeks R, Molla A, Hinson R. E-commerce and 1. WHO Regional Publications Eastern Mediterranean Series Socio-Economic Development: Conceptualizing the Link. 30, A Practical Guide for Health Researchers, Mahmoud Internet Research 2008;18(5):562–592. F. Fathalla, World Health Organization, Regional Office for the Eastern Mediterranean Cairo, Egypt 2004. 8. Fayomi OSI, Okokpujie IP, Udo Mfon. The Role of Research in Attaining Sustainable Development 2. Salam A. Notes on science, technology and science Goals. ICESW, IOP Publishing, IOP Conf. Series: education in the development of the south. Prepared Materials Science and Engineering . 2018;413:012002. for the fifth meeting of the South Commission, May doi:10.1088/1757-899X/413/1/012002 27–30, 1989, Maputo, Mozambique. Trieste, The Third World Academy of Sciences.

07 Ibrahim Card Med J 2019; 9 (1&2): 8-15  Ibrahim Cardiac Hospital & Research Institute

Long-Term Survival Outcomes after Coronary Artery Revascularization Surgery of Bangladeshi Population: A Single Centre Study Rezaul Karim,1 Masoom Siraj,2 Md. Nurul Amin,3 Mohammad Abdur Rashid,4 Hemanta I. Gomes,5 Naziat Shahrin Amin,6 F. Aaysha Cader,7 Jamal Uddin8

ABSTRACT Background & objective : Coronary artery bypass graft (CABG) surgery has given symptomatic and structural release of coronary atherosclerotic heart disease. CABG has been performed frequently for more than 30 years in Bangladesh. But there are no nationwide studies on the rate of survival in Bangladesh. The present study was undertaken to find the post CABG surgery survival outcomes and association between risk factors and survival over long time span. Methods: We studied 650 consecutive patients’ post-operative clinical data retrospectively and survival outcome data were collected prospectively who had CABG surgery from 2010 to 2015 in Ibrahim Cardiac Hospital & Research Institute. Of the 650 patients, 84(12.9%) died after a median follow up of 4.9 years. Demographic, clinical, operative and postoperative characteristics were then compared between survived and died patients to find the factors associated with survival. Result: Analysis revealed that younger patients were more likely to survive [RR = 1.1(95% CI = 1.0-1.2)] longer than those who have had their CABG at or > 55 years (p = 0.001). Males generally had a higher likelihood of survival [RR = 1.1(RR = 1.1(95% CI = 0.9-1.2)] than their female counterparts (p = 0.038). Non-diabetics tend to have a better survival [RR = 2.3(95% CI = 1.3-3.9)] than diabetics (p = 0.001). Non-smokers also have a higher chance of longer survival [RR = 1.5(95% CI = 0.9-2.2)] than the smokers. CABG patients without CKD enjoyed longer survival [RR = 1.4(95% CI =

ORIGINAL ARTICLE 0.9-2.2)] than CABG patients with CKD (p = 0.006). None of the operative and postoperative factors but hospital stay was associated with longer survival. The survived patients had a shorter mean hospital stay than the patients who died (p = 0.001). Analyses of the causes of death revealed heart disease to be the predominant cause (38%) followed by stroke (12%), CKD (8%) and other causes like cancer, liver disease etc. (42%). Conclusion: Younger, male, non-smoker, non-diabetic patients may enjoy long-term survival following CABG surgery. Prediction of long-term survival can be used to determine the most appropriate post-discharge care strategies. This would undoubtedly help both patients and doctors to implement behavioral and therapeutic modifications to optimize benefit from surgery. Key words: Coronary Artery Bypass Grafting (CABG), postoperative survival, factors influencing survival etc.

Authors’ information: 1 Dr. Rezaul Karim, Associate Professor and Consultant, Department of Cardiology, Ibrahim Cardiac Hospital & Research Institute, Shahbag, Dhaka, 2 Prof. Masoom Siraj, Senior Consultant, Department of Cardiac Surgery, Ibrahim Cardiac Hospital & Research Institute, Shahbag, Dhaka, 3 Dr. Md. Nurul Amin, Assistant Professor, Department of Community Medicine, Rajshahi Medical College, Rajshahi & Executive Editor, Ibrahim Cardiac Medical Journal, Ibrahim Cardiac Hospital & Research Institute, Shahbag, Dhaka. 4 Prof. Mohammad Abdur Rashid, Senior Consultant, Department of Cardiology, Ibrahim Cardiac Hospital & Research Institute, Shahbag, Dhaka, Bangladesh. 5 Dr. Hemanta I. Gomes, Assistant Professor and Associate Consultant, Department of Cardiology, Ibrahim Cardiac Hospital & Research Institute, Shahbag, Dhaka, 6 Naziat Shahrin Amin, Chest Physiotherapist, Physiotherapy Unit, Department of Cardiac Surgery, Ibrahim Cardiac Hospital & Research Institute, Shahbag, Dhaka, Bangladesh. 7 F. Aaysha Cader, MD (Cardiology), MRCP (UK), Registrar & Specialist in Cardiology, Ibrahim Cardiac Hospital & Research Institute Dhaka. 8 Md. Jamal Uddin, Senior Chest Physiotherapist, Physiotherapy Unit, Department of Cardiac Surgery, Ibrahim Cardiac Hospital & Research Institute, Shahbag, Dhaka, Bangladesh. Corresponding author: Md. Jamal Uddin, Tel: +88-9671141-43, Fax: +88-2-9674030, E-mail address: [email protected]

08 ORIGINAL ARTICLE

32 et. al.

As yet yet As Karim 28-31 But long- But 18-22 The postoperative The postoperative 23 26,27 though, the return to work rate after after rate work to return the though, 24,25 term outcome data following CABG surgery is surgery CABG following data outcome term a represents mortality Although lacking. grossly to is useful that surgery after end-point hard the surgery operative of quality the benchmark life of quality long-term good a desire patients short- simply a than rather operation their from are patients addition, as In survival. term of is it CABG, of choice the offered increasingly surgical community the that importance utmost both on data accurate patients their will offer long-term likely the also and survival long-term of life from the surgery. quality CABG is influenced by a wide variety of cultural, cultural, of variety wide a by influenced is CABG social & economic conditions. the hospital have also improved. hospital have the capacity functional in improvement effective The life of quality better a to leads CABG following as to work (RW) is recently described (QoL). Return restored life functioning and of main indicator a undergo who patients in well-being of state CABG, However, there are limited data available globally available data limited are there However, at all to help there is no data and in Bangladesh have to likely are patients which identify clinicians long-term overall their in improvement an outcomes following coronary revascularization to intended was study present the So, surgery. long-term the on data comprehensive provide work to return readmission, hospital rate, survival as Bangladesh in ADLs by well-being of state and risk between association the explore to as well outcomes. survival postoperative and factors re-admission rate is also one potential indicator of indicator of is also one potential rate re-admission the of Most CABG. of outcome long-term the as of early re-admission studies focused on the rate the at care medical of quality the of measure a CABG. for hospitalization (index) primary there have been no reports on readmission rates in rates readmission on reports no been have there morbidity, Long-term perspective. long-term a activities and work to return readmission, hospital not been have CABG after of daily livings (ADLs) reliable obtaining in difficulties are there as studied demonstrated been have benefits Survival data. patients. of groups certain in CABG after 09

7–10 30-day 30-day 11 There has There 1 Prediction of Prediction 12,13 The prediction of The 3-6 CABG surgery was was surgery CABG 2 Among them Ibrahim Cardiac Ibrahim them Among Short and mid-term survival survival mid-term and Short 14,15 17

12 In-hospital morbidity and mortality of mortality and In-hospital morbidity 16 Long-Term Survival Outcomes after Survival Coronary Outcomes Artery Study Centre A Single Surgery Population: of Bangladeshi Revascularization Long-Term mortality rates have declined over the last few the over declined have rates mortality surgical in advancements to due decades care. post-operative and peri- and technologies following survival long-term of Improvement concern more a become now has surgery cardiac for strategies management the incorporate to surgery. following CABG patients the determine to used be can survival long-term strategies. care post-discharge appropriate most and patient both help doubt, beyond would, This behavioral implement to community doctor their benefit modifications to optimize therapeutic and from surgery. and quality of life of patients after discharge from discharge after patients life of of quality and introduced nearly five decades ago and it has and ago decades five nearly introduced angina relieves this operation that clear become prolongs life and of quality improves and pectoris CABG surgery. after survival Anesthesiologist. INTRODUCTION: the is presently (CAD) disease artery Coronary worldwide. death of leading cause patients undergoing cardiac surgery have have surgery cardiac undergoing patients fallen. gradually Hospital & Research Institute (ICHRI) is a center a (ICHRI) is Institute Research Hospital & where in Bangladesh, care in cardiac excellence of during the done were operations cardiac 828 period. 30-day or in-hospital mortality is popularly used popularly is mortality in-hospital or 30-day surgery. cardiac in risk operative evaluate to In 2017, the total number of cardiac operations operations cardiac of number total the 2017, In as 11,674 was hospitals 25 by Bangladesh in done Cardiothoracic of Society Bangladesh by reported been huge improvement in the management in the improvement huge been in both Bangladesh in disease heart of strategies and therapy pharmacological of terms coronary percutaneous either by revascularization Graft Bypass Artery Coronary or intervention is still lagging Bangladesh But (CABG) surgery. by prevention secondary of terms in behind rehabilitation. cardiac However; this short-term mortality does not does mortality short-term this However; long-term guide to information adequate provide management. patient post-surgery Ibrahim Card Med J 2019; 9 (1&2): 8-15  Ibrahim Cardiac Hospital & Research Institute

METHODS: (88%) was observed in the series with male to female ratio roughly being 9:1. The mean Body Using Cardiac Surgery Department Register Book Mass Index (BMI) was 25 ± 3.07 kg/m2. The study isolated post CABG patients were identified, who subjects were generally hypertensive (79%), were discharged between January 1, 2010 and followed by diabetic (67%), dyslipidemic and December 31, 2015 from Ibrahim Cardiac Hospital smoker (39%). Over 40% had family history & Research Institute (CHRI). However, patients ischemic heart disease (Table I). Majority (95%) who underwent emergency CABG surgery, CABG of the cases was operated on On-pump. The with valve or any great artery surgery with number of grafts needed was on an average 3 ± 1. implanted ventricular assisted device were The average cross-clamp time was 47 ± 20 excluded. Data were collected on baseline minutes, while the average ICU stay and hospital demographics (age at operation, sex), stay were 3±1.6 and 9±1.8 days respectively anthropometric variables (weight and height) and (Table II). Nearly 90% of the patients attended preoperative risk factors (hypertension, postoperative physiotherapy training class hypercholesterolemia, diabetes, CKD, COPD, following operation, 5% did not receive the stroke, smoking status and renal dysfunction training and 6% could hardly remember whether etc.), peroperative data (On or Off-pump CABG, they received it (Table III). Evaluation of patients number of grafts needed and cross-clamp time after a median follow up period of 4.9 years from etc.) and also on post-operative clinical and the day of discharge demonstrates that majority ORIGINAL ARTICLE surgical procedure including ICU and hospital (87.1%) remain survived. Over 60% of the stay. From patients their relatives’ mobile patients returned to work and 15% required numbers were collected and were contacted. A re-hospitalization. Overall 98% were involved in total of 1055 mobile calls were made; of them 650 activities of daily living (Table IV). responded and agreed to participate in the study by answering our structured questions. Then data Factors associated with survival: on survival outcome were collected prospectively Younger patients (patients who underwent CABG by telephone call. The primary outcome variable before 55 years) were more likely to survive [RR was post-CABG survival and secondary outcomes = 1.1(95% CI = 1.0 – 1.2)] longer than those who were hospital readmission, return to work and have had their CABG at or > 55 years (p = 0.001). state of well-being assessed by ADLs. Males generally had a higher likelihood of survival Data were analyzed using the statistical analysis [RR = 1.1(RR = 1.1(95% CI = 0.9 – 1.2)] than their software SPSS, version 19.0 (IBM Corp, Armonk, female counterparts (p = 0.038). Non-diabetics NY). The test statistics used to analyze the data tend to have a better survival [RR = 2.3(95% CI were descriptive statistics, Chi-square (χ2) Test = 1.3-3.9)] than diabetics (p = 0.001). Non-smokers and Unpaired t-Test. While categorical data were also have a higher chance of longer survival [RR = compared between groups using Chi-square (χ2) 1.5(95% CI = 0.9 – 2.2)] than the smokers. CABG Test, continuous data were compared between patients without CKD enjoyed longer survival [RR groups using Student’s t-Test. The level of = 1.4(95% CI = 0.9 – 2.2)] than CABG patients significance was set at 5% and p-value < 0.05 with CKD (p = 0.006) (Table V). None of the was considered statistically significant. operative and postoperative factors but hospital stay was associated with longer survival. The RESULTS: survived patients had a shorter mean hospital stay Baseline characteristics of the 650 patients are than the patients who died (p = 0.001) (Table VI). illustrated in Table-I. The mean age of the study Mortality data analyses revealed that mortality patients was 56 ± 8 years. A male preponderance rates were 2.1% at 1 year, 3.27% at 2 years,

10 Long-Term Survival Outcomes after Coronary Artery Revascularization Surgery of Bangladeshi Population: A Single Centre Study Karim et. al.

8.04% at 3 years, 14.14% at 4 years, 16.84% at Table III. Distribution of patients by long-term outcome 5 years and 19.71% at 6 years (Fig-1). Analyses (n=650) of the causes of death revealed heart disease to Physiotherapy training Frequency (%) be the predominant cause (38%) followed by Received 578(88.9) stroke (12%), CKD (8%) and other causes like Not received 35(5.4) cancer, liver disease etc. (42%) (Fig- 2). Don’t know 37(5.7)

Table I. Demographics characteristics, risk factors, peri and post-operative data (n=650) Table IV. Distribution of patients by long-term outcome* (n=650) Follow-up long term outcome Frequency (%) Baseline Frequency (%) Mean ± SD Survival rate 566(87.1) ORIGINAL ARTICLE characteristics Return to work 397(61.0) Age (years) -- 56±8 Re-hospitalization rate 95(15.0) Sex ADLs 637(98.0) Male 571(88.0) -- * Multiple response

Female 79(12.0) -- Table V. Association between characteristics of the patients Occupation & survival Previously involved with work 468(72.0) -- Outcome p-value Relative Risk Risk factors* Survived Died (95% CI of RR) Retired 163(25.0) -- (n = 566) (n = 84) BMI -- 25±3.07 Age (years) Risk factors: < 55 247(92.5) 20(7.5) 0.001 1.1(1.0-1.2) DM 434(67.0) -- ≥ 55 319(83.3) 64(16.7) Sex HTN 516(79.0) -- Male 503(88.1) 68(11.9) 0.038 1.1(0.9-1.2) DL 388(60.0) -- Female 63(79.7) 16(20.3) CKD 15(2.3.0) -- Diabetes COPD 4(1.0) -- Yes 365(84.1) 69(15.9) 0.001 2.3(1.3-3.9) Smoking status: No 201(93.1) 15(6.9) Ex-smoker 254(39.0) -- Hypertension Yes 446(86.4) 70(13.6) 0.338 Not computed Non-smoker 396(61.0) -- No 120(89.6) 14(10.4) Family history CAD 275(42.0) -- Smoking Yes 213(83.9) 41(16.9) 0.050 1.5(0.9-2.2) Table II. Per- and post-operative (in-hospital) status (n=650) No 353(89.1) 43(10.9) DL Per- and post-operative Frequency (%) Mean ± SD (in-hospital) status Present 339(87.4) 49(12.6) 0.786 Not computed Absent 227(86.6) 35(13.4) Operative procedure CKD On-pump 617(95.0) -- Present 9(60.0) 6(40.0) 0.006 1.4(0.9-2.2) O -pump 33(5.0) -- Absent 557(87.7) 78(12.3) Number of grafts needed -- 3 ± 1 Family history of IHD Present 243(88.4) 32(11.6) 0.402 Not computed Cross-clamp time (min) -- 47 ± 20 Absent 323(86.1) 52(13.9) ICU stay (days) -- 3 ± 1.6 Figures in the parentheses indicate corresponding %; Total Hospital Stay (days) -- 9 ±1.8 *Chi-squared (χ2) Test was done to analyze the data.

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Table VI. Association between characteristics of the patients & survival survival was evident in age-cohorts of patients undergoing surgical and percutaneous Outcome Operative & p-value revascularization.33 Studies also revealed older postoperative factors* Survived Died (n = 566) (n = 84) patients with higher all-cause mortality and other Pumping status post-operative outcomes compared to younger On-pump 539(87.4) 78(12.6) 0.355 patients.34,35 An understanding of the efficacy of O -pump 27(81.8) 6(18.2) CABG in patients of different ages is, therefore, Number of grafts needed to help inform clinical decision making.36 < 4 319(85.9) 64(14.1) 0.185 ≥ 4 175(89.7) 20(10.3) Women have a worse long-term outcome after Cross-clamp time (minutes) 47.1 ± 20.4 49.5 ± 22.9 0.312 CABG than men which is consistent with the ICU stay (days) 2.9 ± 1.4 3.1 ± 2.2 0.533 previous studies.37 One reason may be that Total hospital stay (days) 8.5 ± 1.8 9.4 ± 2.2 0.001 women in the present study were older than men Figures in the parentheses indicate corresponding %; (on an average > 1 year older) at time of surgery. *Chi-squared Test (χ2) was done to analyze the data. Women more often require urgent surgery and have a smaller body surface area and luminal 25 diameter of the coronary artery than men, which 19.71 20 may lead to more challenging surgery, and could 16.84 38,39

e possibly explain our findings. 15 14.14 a g t ORIGINAL ARTICLE n e c

r However, impact of age associated mortality

e 10 8.04 P correlates on survival varies considerably. One 3.27 5 2.1 would expect that the effect of age on mortality

0 might be partially accounted for by other risk 1 year 2 years 3 years 4 years 5 years 6 years factors associated with the aging process, such as Post CABG mortality rate by year higher prevalence of diabetes mellitus, systemic

Figure-1: Post CABG mortality rate by year hypertension and CKD. In the present study, diabetic patients carried significantly higher risk of long-term mortality than the non-diabetics. Similarly, previous studies showed diabetes

Others (Cancer, Lever Heart Disease mellitus to be independently associated with 38% Disease, Multi organ increased mortality among patients with ischemic failure etc.) 42% cardiomyopathy and as an independent predictor of 5-year mortality and of lower 5-year cardiac- Brain Stroke CKD 8% related event-free survival.40,41 Smokers and CKD 12% patients were also less likely to enjoylong-term survival as evident in the present study.

The prognosis of patients with ischemic heart disease has improved over the past 3 decades.42 Fig. 2: Distribution of died patients by their causes This improvement in survival occurred despite a of long-term mortality concomitant increase in comorbidity in CABG 43 DISCUSSION: patients over the past 30 years. Possible explanations include improved surgical In the present study, the subjects who have had techniques, as well as wider use of post CABG CABG surgery at ages 55 or > 55 years had higher medical treatments, such as statins and long-term mortality. Dramatic impact of age on

12 Long-Term Survival Outcomes after Coronary Artery Revascularization Surgery of Bangladeshi Population: A Single Centre Study Karim et. al.

aspirin.44,45 Areas of future investigation include 6. Coronary Artery Surgery Study (CASS) principal assessment of CABG-related morbidity, quality of investigators and associates. CASS: a randomized trial of coronary bypass surgery. Circulation 1983;68:939– life, and functional status. 950.

LIMITATIONS 7. Osswald BR, Blackstone EH, Tochtermann U, Thomas G, Vahl CF, Hagl S.The meaning of early mortality after The 8-year time period that the patients in this CABG. Eur J Cardio thorac Surg 1999;15:401–7. study were recruited may introduce a time factor 8. Billah B, Reid CM, Shardey GC, Smith JA. A preoperative error. This is a common confounding factor of any risk predictionmodel for 30-day mortality following large study over a prolonged period of time. LVEF cardiac surgery in an Australiancohort. Eur J

was not found in discharge summary. Cardiothorac Surg 2010;37:1086–92. ORIGINAL ARTICLE CONCLUSION: 9. Nashef SA, Roques F, Sharples LD, Nilsson J, Smith C, Goldstone AR et al. Euro SCORE II. Eur J Cardio thorac Younger, male, non-smoker, non-diabetic patients Surg 2012;41:12. may enjoy long-term survival following CABG 10. D’Errigo P, Seccareccia F, Rosato S, Manno V, Badoni G, surgery. Long-term survival outcome evaluation Fusco D et al.Comparison between an empirically following CABG surgery have made cardiac derived model and the Euro SCOR Esystem in the surgeons motivated to refine their coronary evaluation of hospital performance: the example of the Italian CABG Outcome Project. Eur J Cardio thorac Surg revascularization techniques in order to maximize 2008;33:325–33. clinical effectiveness, limit costs and reduce 11. Carr BM, Romeiser J, Ruan J, Gupta S, Seifert FC, Zhu invasiveness. Prediction of long-term survival can W et al. Long-termpost-CABG survival: performance of go a long way to determine the most appropriate clinical risk models versus actuarialpredictions. J Card post-discharge care strategies. This would Surg 2016;31:23–30. essentially help patients and their doctors to 12. Prospective randomised study of coronary artery bypass implement behavioral & therapeutic modifications surgery in stable angina pectoris. Second interim report to optimize benefit from surgery. by the European Coronary Surgery Study Group. Lancet 1980;2:491–495. REFERENCES: 13. Goldman S, Zadina K, Moritz T, Ovitt T, Sethi G, 1. Strategic Plan for Surveillance and Prevention of Copeland JG, Thottapurathu L, Krasnicka B, Ellis N, Noncommunicable Diseases in Bangladesh 2011e2015. Anderson RJ, Henderson W. VA Cooperative Study Dhaka: Directorate General of Health Services, Ministry Group. Long-term patency of saphenous vein and left of Health and Family Welfare; August 2011. internal mammary artery grafts after coronary artery bypass surgery: results from a Department of 2. Department of Public Health and Primary Care, Veterans. Affairs Cooperative Study. Journal of University of Cambridge. High-risk Hearts: A South American College of Cardiology 2004;44(11):2149-56. Asian Epidemic. [Home page on the Internet] c2013 [cited 2013 Jul 3]. 14. Hosaina N, Aminb F, Rehmanc S, Koiralad B. Know thy neighbors: The status of cardiac surgery in the South 3. Favaloro RG. Saphenous vein autograft replacement of Asian countries around India. Indian Heart Journal severe segmental coronary artery occlusions: operative 2017:69. technique. Ann Thorac Surg 1968;5:334–339. 15. Cardiovascular surgery in Bangladesh 2017. Bangladesh 4. The Veterans Administration Coronary Artery Bypass Journal of Cardiovascular Thoracic Anesthesiology 2018; Surgery Cooperative Study Group. Eleven-year survival 05(1):42. in the Veterans Administration randomized trial of coronary bypass surgery for stable angina. N Engl J 16. Ibrahim Cardiac Hospital & Research Institute annual Med 1984;311:1333–1339. performance report-2017:49.

5. Varnauskas E, European Coronary Surgery Study Group. 17. Ahmed WA, Tully PJ, Baker RA, Knight JL. Survivals Twelve-year follow-up of survival in the randomized after isolated coronary artery bypass grafting in European Coronary Surgery Study. N Engl J Med patients with severe left ventricular dysfunction. Ann 1988;319:332–337. Thorac Surg 2009;87:1106–12.

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18. Cardiovascular surgery in Bangladesh 2016. Bangl J 30. Stewart RD, Campos CT, Jennings B, Lollis SS, Levitsky Cardiovasc Thorac Anesthesiol 2017;04(1):51. S, Lahey SJ. Predictors of 30-day hospital readmission after coronary artery bypass. Ann Thorac Surg 2000; 19. Coronary artery bypass surgery compared with 70:169–74. percutaneous coronary interventions for multivessel disease: a collaborative analysis of individual patient 31. Herlitz J, Albertsson P, Brandrup-Wognsen G, et al. data from ten randomised trials. Lancet 2009;373: Predictors of hospital readmission two years after 1190–7. coronary artery bypass grafting. Heart 1997;77: 437–42. 20. Loef BG, Epema AH, Navis G, Ebels T, Stegeman CA. Postoperative renal dysfunction and preoperative left 32. Rahimtoola SH, Bennett AJ, Grunkemeier GL, Block P, ventricular dysfunction predispose patients to Starr A. Survival at 15 to 18 years after coronary increased long-term mortality after coronary artery bypass surgery for angina in women. Circulation bypass graft surgery. Br J Anaesth 2009;102:749–55. 1993;88(5 Pt 2):II71–8.

21. Serruys PW, Morice MC, Kappetein AP, Colombo A, 33. Taddei CF, Weintraub WS, Douglas JS, et al. Influence of Holmes DR, Mack MJ, et al. Percutaneous coronary age onoutcome after percutaneous transluminal intervention versus coronary-artery bypass grafting for coronary angioplasty. Am J Cardiol 1999;84:245–251. severe coronary artery disease. N Engl J Med 2009; 34. Kieser TM, Lewin AM, Graham MM, et al. Out comes 360:961–72. associated with bilateral internal thoracic artery grafting:The importance of age. Ann Thorac Surg 2011; 22. Thourani VH, Myung R, Kilgo P, Thompson K, Puskas JD, 92:1269–76. Lattouf OM, et al. Long term outcomes after isolated aortic valve replacement in octogenarians: a modern 35. Benedetto U, Codispoti M. Age cutoff or the loss of ORIGINAL ARTICLE perspective. Ann Thorac Surg 2008;86:1458–64. survival benefit from use of radial artery in coronary artery bypasses grafting. J Thorac Cardiovasc Surg 23. Panagopoulou E, Montgomery A, Benos A. Quality of life 2013;146:1078–85. after coronary artery bypass grafting: evaluating the influence of preoperative physical and psychosocial 36. Dalen M, Ivert T, Holzmann MJ, Sartipy U. Coronary functioning. J Psychosom Res 2006;60:639–44. artery bypass grafting in patients 50 years or younger: a Swedish nationwide cohort study. Circulation 2015; 24. Boudrez H, De Backer G, Comhaire B. Return to work 131:1748–54. after myocardial infarction: results of a longitudinal population based study. Eur Heart J 1994;15:32-36. 37. Risum O, Abdelnoor M, Nitter-Hauge S, Levorstad K, SvennevigJL.Coronary artery bypass surgery in women 25. Caine N, Harrison SCW, Sharples LD, Wallwork J. and in men; early and long-termresults. A study of the Prospective study of quality of life before and after Norwegian population adjusted by age and sex. Eur J coronary artery bypass grafting. BMJ 1991;302: Cardiothorac Surg 1997;11:539–546. 511-516. 38. Khan SS, Nessim S, Gray R, Czer LS, Chaux A, Matloff 26. McGee HM, Graham T, Crowe B, Horgan JH. Return to J. Increased mortalityof women in coronary artery work followmg coronary artery bypass surgery or bypass surgery: evidence for referralbias. Ann Intern percutaneous transluminal coronary angioplasty. Eur Med 1990;112:561–567. Heart J 1993;14:623-628. 39. Christakis GT, Weisel RD, Buth KJ, Fremes SE, Rao V, 27. Oberman A, Wayne JB, Kouchoukos NT, Charles ED, Panagiotopoulos KP, Ivanov J, Goldman BS, David TE. Russell RO, Rogers WJ. Employment status after Is body size the cause for pooroutcomes of coronary coronary bypass surgery. Circulation 1982;65(suppl II): artery bypass operations in women? J Thorac Cardiovasc 115-119. Surg 1995;110:1344–1356; discussion 1356.

28. Lahey SJ, Campos CT, Jennings B, Pawlow P, Stokes T, 40. Domanski M, Krause-Steinrauf H, Deedwania P, et al. Levitsky S. Hospital readmission after cardiac surgery. The effect of diabetes on outcomes of patients with Does “fast track” cardiac surgery result in cost saving advanced heart failure in the BEST trial. J Am Coll or cost shifting? Circulation 1998;98(19 Suppl):35–40. Cardiol 2003;42:914–22.

29. Zitser-Gurevich Y, Simchen E, Galai N, Braun D. 41. Rajakaruna C, Rogers CA, Suranimala C, Angelini GD, Prediction of readmissions after CABG using detailed Ascione R. The effect of diabetes mellitus on follow-up data: the Israeli CABG study (ISCAB). Med patientsundergoingcoronary surgery: a risk adjusted Care 1999;37:625–36. analysis. J Thorac Cardiovasc Surg 2006;132:802–10.

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42. Royston P, Altman DG. External validation of a Cox 44. Herlitz J, Haglid M, Albertsson P, Westberg S, Karlson B, prognostic model: principles and methods. BMC Med Hartford M et al. Short- and long-term prognosis after Res Methodol 2013;13:33. coronary artery bypass grafting in relation to smoking habits. Cardiology 1997;88:492–7. 43. Gardner SC, Grunwald GK, Rumsfeld JS, Mackenzie T, Gao D, PerlinJBet al. Risk factors for intermediate-term 45. Yap CH, Mohajeri M, Ihle BU, Wilson AC, Goyal S, Yii M. survival after coronary artery bypass grafting. Ann Validation of Euro SCORE model in an Australian patient Thoracic Surgery 2001;72:2033–7. population. Aust ANZ J Surg 2005;75:5. ORIGINAL ARTICLE

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Classic Imaging Findings of Tetralogy of Fallot with 64-slice Multidetector Computed Tomography Nawshin Siraj,1 Nusrat Ghafoor,2 Md. Rokonujjaman Selim,3 S M Shaheedul Islam,4 Khalada Parvin Deepa,5 Mir Mahin Ashraf 6

ABSTRACT Background & objective: The present study was intended to demonstrate the role of Multidetector Computed Tomography (MDCT) in defining the extracardiac vascular abnormalities including the pulmonary arterial tree, Major Aortopulmonary Collateral Arteries (MAPCAs), patent ductus arteriosus (PDA), and detection of the common and uncommon findings in Fallot’s Tetralogy cases for proper pre-surgical evaluation.

Methods: A retrospective review of all multidetector CT images acquired to evaluate suspected cases of Tetralogy of Fallot, presented at Ibrahim Cardiac Hospital & Research Institute between July 2017 and July 2018, was done. This comprised of a total of 35 cases who were examined by 64-slice MDCT. The patients were divided into four main groups: those with classic Tetralogy of Fallot with no associations, those with common associations, those with uncommon associations and those with a combination of common and uncommon associations.

Results: In the present study, majority of the patients had levocardia (93.6%), situs solitus (96.9%) with none of the patients having either atrio-ventricular or arterio-ventricular discordance. Major findings of the patients were VSD (93.8%), right ventricular outflow tract obstruction (65%) with ventricular hypertrophy (75%). All patients had overriding of aorta with over 60% of the patients having 50% and 28% > 50% overriding. Approximately 3.1% of

ORIGINAL ARTICLE the patients had MPA atresia. MPA stenosis was detected in 93.3% of the cases.

Conclusion: A customized approach to MDCT imaging improves the diagnostic accuracy and reduces unnecessary prolongation of the study and sedation times. A careful preoperative perception of the complex cardiovascular anatomy in patients with Tetralogy of Fallot aids in exposing the patients to a directed and prepared surgical approach.

Key words: Tetralogy of Fallot, 64-slice multidetector computed tomography (64-MDCT), Image findings etc.

INTRODUCTION: of the aortic root, overriding of the muscular The Tetralogy of Fallot is a common congenital ventricular septum, obstruction to the right anomaly causing cardiac morbidity and mortality ventricular outflow tract, and right ventricular in pediatric population. It was first described by hypertrophy.2 The incidence of these malformations Louis Arthur Etienne Fallot in 1888 as “La Maladie occur in 3 of every 10,000 live births, and Bleue”.1 It is a clinical condition formed by a group accounts for 7-11% of all congenital heart of anatomical malformations of heart and its great diseases (CHDs).3,4 Common associations of vessels with fundamental features consisting of Fallot's Tetralogy are pulmonary artery atresia ventricular septal defect, biventricular connection (varying from mild hypoplasia to complete

Authors’ information: 1 Dr. Nawshin Siraj, Associate Professor & Senior Consultant & Head of the Department of Radiology & Imaging, ICHRI, Dhaka 2 Dr. Nusrat Ghafoor, Associate Professor & Consultant, Department of Radiology & Imaging, Ibrahim Cardiac Hospital & Research Institute, Dhaka 3 Dr. Md. Rokonujjaman Selim, Associate Professor & Consultant, Department of Cardiac Surgery, Ibrahim Cardiac Hospital & Research Institute, Dhaka 4 Dr. S M Shaheedul Islam, Associate Professor & Consultant, Department of Cardiology, Ibrahim Cardiac Hospital & Research Institute, Dhaka 5 Dr. Khalada Parvin Deepa, Specialist, Department of Radiology & Imaging, Ibrahim Cardiac Hospital & Research Institute, Dhaka 6 Dr. Mir Mahin Ashraf, Medical O cer, Department of Radiology & Imaging, Ibrahim Cardiac Hospital & Research Institute, Dhaka Correspondence: Dr. Nusrat Ghafoor, Phone: +8801711316595 Email: [email protected]

16 Classic Imaging Findings of Tetralogy of Fallot with 64-slice Multidetector Computed Tomography Siraj et. al.

absence of the main pulmonary artery or the evaluation of patients with CHD even in small non-confluence of its branches), right-sided aortic infants.11 When combined with electrocardiographic arch (25%), atrial septal defect (ASD) (10%) (so (ECG) gating, CT images perfectly define the called Pentalogy of Fallot) and coronary artery moving cardiac and extracardiac structures and abnormalities (10%). Other less common permits evaluation of associated coronary artery associations include persistent left superior vena anomalies.12,13 Multiplanar reformation is easily cava (SVC) and aberrant right subclavian artery. obtainable with the new advanced software thus Rarely, tracheoesophageal fistula, rib anomalies, reducing the prior disadvantage of CT image and scoliosis may be encountered.5,6,7 The acquisition being solely in the transaxial plane.10

manifestations and management of the disease ORIGINAL ARTICLE are dependent on the severity of each component The purpose of this study was to demonstrate the as well as age of the patients at which corrections role of MDCT in defining the extracardiac vascular are made. Presently, surgical correction is abnormalities including the pulmonary arterial performed by closure of the VSD and relief of right tree, MAPCAs, and patent ductus arteriosus ventricular outflow obstruction when patients are (PDA), and also the detection of the common and young.7,8,9 So, in order to plan an effective uncommon findings in Fallot Tetralogy cases for management of the disease, the surgeon needs proper pre-surgical evaluation. the best perception of the malformation. METHODS: Congenital heart disease can be diagnosed by Having obtained an ethical clearance from the different imaging modalities. Echocardiography Ibrahim Cardiac Hospital & Research Institute, we with Doppler performs well in defining intracardiac retrospectively reviewed all multidetector CT anomalies and estimating hemodynamics. images acquired to evaluate suspected cases of However, it is limited by a small field of view, a Tetralogy of Fallot referred by the physicians of variable acoustic window, inability to penetrate air the same or different Institutes/Hospitals between and bone, difficulty in well-delineating extracardiac July 2017 and July 2018. This comprised of a total vascular structures.10 Cardiac angiography, of 35 cases who were examined by MDCT. Of them although an invasive modality, it illustrates 3 cases were excluded from the study, as they significant hemodynamic data and invariably were not diagnosed as Tetralogy of Fallot by MDCT demonstrates the accessible vascular anatomy. imaging and the preliminary clinical diagnosis was However, its ability to diagnose venous proven to be wrong. The patient population connections and arterial anatomy distal to consisted of 23 males and 9 female patients with high-grade stenosis or atresia is limited. It also a mean age of 6 ± 4 (range: 1-14) years. CT uses high doses of ionizing radiation and is limited scans were obtained with a 128 slice-MDCT by the risks attributed to iodinated contrast scanner (GE Revolution EVO). The patients were material.10 Magnetic resonance (MR) imaging and divided into four main groups: those with classic MDCT are valuable noninvasive options. They are Tetralogy of Fallot with no associations, those with useful in demonstrating the complex common associations, those with uncommon cardiovascular morphology of Fallot's Tetralogy, associations and those with a combination of especially the extracardiac associations as well as common and uncommon associations. the pulmonary artery anatomy & aortopulmonary collateral vessels.10 The development of MDCT Imaging protocol: 64-section MDCT, with its high scanning speed, Data acquisition was performed in a craniocaudal superior spatial resolution, and improved direction from the level of the thoracic inlet down capabilities for concurrent assessment of to the diaphragm. The scanning parameters cardiovascular structures & lung parenchyma, has include 64–0.6 mm detector collimation, 64–0.6 demonstrated its improved application for mm section collimation with a z-flying focal point,

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330 ms gantry rotation time, 0.9 pitch and 120 stands for McGoon ratio, LPA = left pulmonary kVp tube potential. Contrast enhancement was artery, RPA = right pulmonary artery and DAo = achieved by non-ionic contrast agent (Iohexol 350 descending aorta at the level of the diaphragmatic [Omnipaque], Cork, Ireland) calculated according crus. The cut-off value of the McGoon ratio is 1.7, to the patient weight, with a maximum dose of 2 below which a rather small caliber central ml/kg, injected at 1.2-2 ml/s, pressure 80-100 pulmonary artery indicates that may warrant through an 22-gauge canula into peripheral vein. faster surgical shunts. In the study, the diameters The initiation of scanning was triggered by of major aortopulmonary collateral (MAPCAs) and locating the ascending aorta with a density of 100 patent ductus arteriosus (PDA) were also H. Images are restored with the least moving calculated. objects and then moved for storage to a workstation (ADW GE Health Care). Statistical analysis: Data were analyzed using SPSS (Statistical Image analysis: Package for Social Sciences). Descriptive statistics The axial image examination was the most were used to analyze the data. Results were important step in image analysis, with the vessels expressed as frequency with corresponding being carefully traced even if it was so fragile. percentage for categorical data and as medean Multiplanar reformations were used in the analysis and standard deviation from the mean for as a confirmatory method. The data set was then continuous data.

ORIGINAL ARTICLE selected as representing the optimum setting of the reconstruction window with the least motion RESULTS: objects. The selected images were displayed using The median age of the patients was 6 years with two techniques of visualization, multiplanar youngest and the oldest patients being 1 and 14 reformation and 3D reconstruction made by volume. years respectively. Approximately 72% of the To obtain accurate measurements, multiplanar patients were male with male to female ratio reformation was individually adjusted to the long being roughly 7:3 (Table I). Majority (93.6%) of axis of the structure of interest. Volume rendering the patients had levocardia (Table II). Of the total was the longest post-processing procedure, but it patients, 31(96.9%) had situs solitus and only helped to envision complex anatomy in 3D. 1(3.1%) patient had situs inversus. None of the Imaging data analyses were carried out by one patients had either atrio-ventricular or researcher with six years of experience in MDCT arterio-ventricular discordance. Thirty (93.8%) imaging in congenital heart disease, supervised patients had ventricular septal defect (VSD). by a second investigator with ten years of MDCT Approximately 85% of the patients had right imaging experience. The two investigators were ventricular outflow tract obstruction leading to unaware of the research study being contemplated. ventricular hypertrophy (75%). All patients had overriding of aorta. Over 60% of the patients had Calculations: 50% and 28% > 50% overriding of aorta (Table Measurements were taken from the infundibulum, III). Thirty one (96.9%) patients had main pulmonary arteries, the total transverse diameter pulmonary artery (MPA) stenosis and 3.1% of the main pulmonary spine, the right main and patients had main pulmonary artery (MPA) left main pulmonary arteries in the axial images in atresia. While MPA stenosis was detected in their widest form. The diameters of the 96.9% of the cases, RPA and LPA stenoses were descending aorta were determined on axial found in 50 and 59.4% of the cases respectively. images at the level of the diaphragm crus. For MPA, RPA and LPA were confluent in almost all patients with proof of pulmonary hypoplasia, the cases (96.9%). Angle between MPA and LPA were CT McGoon ratio was determined using the acute (53.1%) and obtuse (46.9%). In majority following formula14:X = LPA + RPA/DAo where, X (87.5%) of the cases McGoon ratio was reduced,

18 Classic Imaging Findings of Tetralogy of Fallot with 64-slice Multidetector Computed Tomography Siraj et. al.

with more than two-thirds being significantly Table IV. Distribution of patients by pulmonary arteries and reduced (68.8%) (Table IV). In terms of common its types (n = 32) associated anomalies, 30(93.3%) patients had Pulmonary artery major aorto-pulmonary collaterals and IVC anomalies and its types Frequency Percentage (Inferior Vena Cava) draining into the RA (right MPA Atresia 1 3.1 atrium), and 29(90.6%) patients had left-sided MPA Stenosis (n = 31) 28 96.9 aortic arch and 3(9.4%) patients had right-sided RPA Stenosis 16 50.0 aortic arch (Table V). Other less common LPA Stenosis 19 59.4 associated anomalies were PDA (9.4%), ASD MPA, RPA & LPA Non-con uent 1 3.1

(12.5%), aberrant left subclavian artery (9.4%) ORIGINAL ARTICLE and coronary artery anomalies (12.5%) (Table Con uent 31 96.9 VI). Angle between MPA-LPA Acute 17 53.1

Table I. Demographic characteristics of the patients (n = 32) obtuse 15 46.9 Acute angle between MPA-RPA 2 6.2 Demographic Mean ± SD variables Frequency Percentage (range) McGoon ratio Normal 4 12.5 Age (years) -- -- 6.0 ± 4 (1-14) Reduced 28 87.5 Sex If McGoon ratio reduced (n=28) Male 23 71.9 -- Signicant 22 68.8 Female 9 28.1 -- Not Signicant 6 18.8

Table II. Distribution of patients by their cardiac position (n = 32) Table V. Distribution of patients by commonly associated Cardiac position Frequency Percentage anomalies (n = 32) Levocardia 30 93.8 Commonly associated anomalies Frequency Percentage Dextrocardia 2 6.2 PDA 3 9.4 MAPCAs 30 93.8 Table III. Distribution of children by common image ndings of TOF ASD 4 12.5 Classic TOFs Frequency Percentage Coronary Artery Anomalies 4 12.5 Aortic arch Cardiac situs Right sided 3 9.4 Situs solitus 31 96.9 Left sided 29 90.6 Situs lnversus 1 3.1 Double SVC 1 3.1 Atrio-ventricular connection IVC drains into RA 30 93.8 Concordance 32 100.0 Ventriculo-arterial connection Concordance 32 100.0 Table VI. Distribution of patients by common associated anomalies (n = 32) VSD 30 93.8 Right ventricular out ow tract obstruction 27 84.4 Less common anomalies Frequency Percentage Right ventricular hypertrophy Persistent left superior vena cava 1 3.1 Mild 12 37.5 Aberrant left subclavian artery 3 9.4 Moderate 12 37.5 Not hypertrophied 3 9.4 Discussion: Overriding of aorta The complex pulmonary artery anatomy and 50 % 20 62.5 pulmonary atresia in patients with tetralogy of >50 % 9 28.1 Fallot is easily defined by MDCT, along with the <50 % 3 9.4 major aorto-pulmonary collateral vessels.14,15 Double outlet right ventricle 32 100.0 Pulmonary atresia is the most severe form of

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antero-cephalad deviation of the outlet septum. morphologic right atrium and is different from However, in some occasions the pulmonary valve cardiac position, cardiac orientation, and the is affected solely by being completely imperforate, positions of the ventricles or great arteries. not just stenotic.3 In the present study, majority However, in some rare cases of Fallot's Tetralogy of the patients had levocardia (93.8%), situs there is associated situs inversus. In the present solitus (96.9%) with none of the patients having study only one case (3%) was found so. All other either atrio-ventricular or arterio-ventricular cases were situs solitus. In situs solitus (the normal discordance. Major findings of the patients were configuration), the morphologic right atrium lies to VSD (93.8%), right ventricular outflow tract the right of the morphologic left atrium. In situs obstruction (85%) with ventricular hypertrophy inversus, the morphologic right atrium lies to the (75%). All patients had overriding of aorta. Over left of the morphologic left atrium13. 60% of the patients had 50% and 28% > 50% overriding of aorta. Thirty-one (96.9%) patients In cases with overriding of the aorta, the aorta had main pulmonary artery (MPA) stenosis and becomes more inclined to the right ventricle than 3.1% patients had main pulmonary artery (MPA) to the left ventricle, leading in many cases to the atresia. While MPA stenosis was detected in ventriculo-arterial connection of double outlet majority (96.9%) of the cases, RPA and LPA right ventricle.3 In patients where the aorta stenoses were found in 50 and 60% of the cases originates mainly from the right ventricle there is respectively. Zakaria and colleagues16 in their a greater risk of developing obstruction of the left

ORIGINAL ARTICLE study showed that 9% of pulmonary atresia ventricular outflow tract. This tract is produced by involved the main trunk as well as its major a patch which closes the ventricular septal defect branches. The rest of the cases were diagnosed by connecting the left ventricle to the aorta. In these MDCT with different degrees of pulmonary artery cases, this patch is markedly longer than that stenosis.16 In patients with tetralogy-type seen when the aorta arises mostly from the left pulmonary atresia, a diversity of systemic sources ventricle.3 In our study all cases had double outlet share in the pulmonary blood flow.17 In about 50% right ventricle. Zakaria16 found 2 out of 23 cases of the patients with pulmonary atresia, there was with double outlet right ventricle, one being confluence of the right and left pulmonary associated with a right-sided aortic arch. arteries, with persistently patent arterial duct giving blood to the pulmonary arteries.18 However, Two percent of patients with tetralogy of Fallot the present study demonstrated a higher have an associated atrioventricular septal defect.3 incidence of confluence (96.9%) of MPA, RPA and However, in the current study, 12.5% of the LPA. In cases with atretic pulmonary arteries, patients were found with ASD which compares multiple collateral arteries give the blood supply to well with the findings of Zakaria et al16 who found the lungs, or a combination of collateral arteries 13% of the cases with ASD. The presentation and and an arterial duct are the source.3 initial medical management of Tetralogy of Fallot patients with this association remain unchanged. Very few patients in the present study were However, surgical repair and post-operative care diagnosed with PDA. Zakaria and colleagues16 are more complex.3 Available literatures reported demonstrated a significant presence (48%) of that 25-30% of patients with tetralogy of Fallot PDAs in their study with MDCT clearly have an associated right aortic arch3,16 which demonstrating their patency, extensions, length causes no haemodynamic consequence. However, and diameter as well as their exact location. The the present study observed a low incidence assessment of sidedness in general (situs) should (9.4%) of right-sided aortic arch. include cardiac, pulmonary, and abdominal sidedness, which are usually concordant. Cardiac Summarizing the findings of the study and sidedness is identified by the position of the discussion thereof, it is evident that MDCT clearly

20 Classic Imaging Findings of Tetralogy of Fallot with 64-slice Multidetector Computed Tomography Siraj et. al.

demonstrates information about the complex This customized approach is an adjunct to clinical cardiovascular anatomy of Tetralogy of Fallot, and other imaging findings and thus improves the which is supported by Khositseth et al.19 Its diagnostic accuracy and reduces the unnecessary diagnostic accuracy in assessing the Tetralogy of procedural prolongation & sedation time. A careful Fallot patients’ central and peripheral pulmonary preoperative evaluation of the complex arteries, aorto-pulmonary collateral vessels as cardiovascular anatomy in patients with Tetralogy well as in demarcating the abnormal venous of Fallot aids the cardiac surgeons in deciding their anatomy & veno-atrial connections is commendably surgical approach. high. It has already been demonstrated by several 10 REFERENCES: investigators. Moreover, it can be done safely ORIGINAL ARTICLE and quickly even in small infants. 1. Fallot ELA. Contribution a l’anatomie pathologique de la maladie bleu (cyanose cardiaque). Marseille Med 1888: 77–93. Strengths and limitations: 2. Becker AE, Connor M, Anderson RH. Tetralogy of Fallot: Easy availability, short scanning time and a morphometric and geometric study. Am J Cardiol non-invasive vascular imaging are some of the 1975;35:402-412. advantages of MDCT. Accurate extracardiac 3. Bailliard F, Anderson RH . Tetralogy of Fallot. Orphanet arterial and venous vascular imaging is attainable J Rare Dis 2009;4:2. by contrast-enhanced MDCT. However, there are 4. Ferguson EC, Krishnamurthy R, Oldham SAA. Classic still drawbacks of MDCT including patient imaging signs of congenital cardiovascular abnormalities. Radio Graphics 2007;27:1323-334. exposure to ionizing radiation and the risks of 5. Boechat MI, Ratib O, Williams PL, et al. Cardiac MR 10 iodinated contrast material. So, due stress must imaging and MR angiography for assessment of be put on radiation exposure issues, because the complex tetralogy of Fallot and pulmonary atresia. Radio Graphics 2005;25:1535-546. first CT examination in patients with tetralogy of Fallot usually applies in childhood or in early 6. Dabizzi RP, Teodori G, Barletta GA, et al. Associated coronary and cardiac anomalies in the tetralogy of adulthood, and more often than not repeat Fallot: an angiographic study. Eur Heart J 1990;11: scanning is needed. ECG-gated MDCT exposes the 692-704. patient to a higher risk of radiation, so the 7. Brickner ME, Hillis LD , Lange RA. Congenital heart benefits of evaluating the ventricular function, disease in adults-second of two parts. NEJM 2000; 342(5):334-342. cardiac valves, small intracardiac abnormalities, 8. Groh MA, Meliones JN, Bove EL, et al. Repair of and coronary arteries must outweigh these risks. tetralogy of Fallot in infancy: effect of pulmonary artery The effective radiation dose from ECG-gated CT of size on outcome. Circulation 1991;84(Suppl.5):III- the heart is estimated to be approximately 15 206-III-212 mSv. For comparison, the effective radiation dose 9. Touati GD, Vouhe PR, Amodeo A, et al. Primary repair of tetralogy of Fallot in infancy. J Thorac Cardiovasc from non-gated CT of the chest is approximately 5 Surg 1990;99:396-402. mSv. 13 The second issue of contrast enhancement 10. Haramati LB, Glickstein JS, Issenberg HJ, et al. MR risks was partially resolved in the current study by imaging and CT of vascular anomalies and connections the use of non-ionic contrast agent calculated in patients with congenital heart disease: significance in surgical planning. Radio Graphics 2002;22:337-349. according to the patient weight, with a maximum dose of 2 ml/kg, injected at 1.2-2 ml/s, thus 11. Flohr T, Stierstorfer K, Raupach R, et al. Performance evaluation of a 64-slice CT system with z-flying focal reducing the risks of use of iodinated contrast spot. Rofo 2004;176:803-810. material and the higher doses needed. 12. Manghat NE, Morgan-Hughes GJ, Marshall AJ, et al. Multidetector row computed tomography: imaging congenital coronary artery anomalies in adults. Heart CONCLUSION: 2005;91:1515-522. MDCT examinations are essential when specific 13. Leschka S, Oechslin E, Husmann L, et al. Pre- and diagnostic questions are asked by the cardiologists, postoperative evaluation of congenital heart disease in surgeons, & radiologists after careful assessment children and adults with 64-section CT. Radio Graphics 2007;27:829-846. of the clinical condition and other image findings.

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14. Westra SJ, Hill JA, Alegjos JC, Galindo A, Boechat MI, 17. Mawson JB. Congenital heart defects and coronary Laks H. Three-dimensional helical CT of pulmonary anatomy. Tex Heart Inst J 2002;29(4):279-289. arteries in infants and children with congenital heart disease. AJR Am J Roentgenol 1999;173:109-115. 18. Tetralogy of Fallot and Pulmonary Atresia. Pediheart Website.Published clamshell incision for bilateral pulmonary artery February 14, 2004. [accessed 20.03.10]. reconstruction in tetralogy of Fallot with pulmonary atresia J. Thorac Cardiovasc Surg 1997;113:443-452. 19. Khositseth A, Pornkul R, Siripornpitak S. Diagnosis of tetralogy of Fallot with anatomically corrected 16. Zakaria RH, Barsoum NR, Asaad RE, El-Basmy AA, Azab malposition of the great arteries and single coronary AO. Tetralogy of Fallot: Imaging of common and artery by multidetector CT. Br J Radiol 2006;79:e5-e7. uncommon associations by multidetector CT. The Egyptian Journal of Radiology and Nuclear Medicine 2011;42(3–4):289-95. ORIGINAL ARTICLE

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Safety and Feasibility of Transradial Approach for Coronary Artery Bypass Graft Intervention Hemanta I Gomes,1 C M Shaheen Kabir,2 Saidur Rahman Khan,3 M G Azam,4 Syed Mos qur Rahman5

ABSTRACT Background & Objective: To compare the safety and feasibility of using radial versus femoral access during coronary artery intervention of patients who had previously undergone coronary artery bypass graft (CABG) surgery.

Methods: The study was conducted in Ibrahim Cardiac Hospital & Research Institute (ICHRI), Dhaka from January ORIGINAL ARTICLE 2013 to December 2015. During the period a total of 380 patients with past CABG surgery underwent diagnostic coronary angiogram (CAG) and percutaneous coronary intervention (PCI) at our institution. We retrospectively evaluated 98 consecutive patients who underwent graft intervention via the transradial (TRA, n=54) or transfemoral approach (TFA, n=44) route. Baseline clinical characteristics, angiographic characteristics and complications between the two study groups were observed. Result: The baseline clinical characteristics between the two study groups were similar. No significant difference was observed in terms of angiographic characteristics between the two groups. Contrast volume in between the groups was pretty similar (p = 0.267). Procedure time (40±20 min vs. 41±7 min, p=0.36) and fluoroscopy time (11.1±6.5 min vs. 12.5±8.7 min, p=0.19) were almost similar in both access for graft intervention. All PCI attempts were successful in both groups. Stent deployment was significantly more common in the TR access group. No significant difference was observed between the groups in terms of target vessel intervention. There was no major adverse cardiac event during hospitalization. However, the vascular access site complications were significantly lower (p=0.003) in the TRA group. Conclusion: The TRA for coronary artery bypass graft intervention is safe and feasible. Key words: Transfemoral, Transradial, Coronary Artery Bypass Graft intervention etc.

INTRODUCTION: operator preference in recent years, based on a Among patients undergoing coronary procedures, reduction in vascular complications and mortality patients with coronary artery bypass grafts (CABG) when compared with transfemoral approach (TFA).1,2 represent an important, high risk subgroup. However, it has been suggested that these Coronary angiography (CAG) via transradial advantages come at the cost of increased procedure approach (TRA) has gained growing acceptance and time and fluoroscopy dose.3–5

Authors’ information: 1 Dr. Hemanta I Gomes, D-Card, Assistant Professor& Associate Consultant in Cardiology, Ibrahim Cardiac Hospital & Research Institute, Dhaka-1000, Bangladesh. 2 Dr. C M Shaheen Kabir, MD, FSCAI, FACC, Associate Professor & Consultant in Cardiology, Ibrahim Cardiac Hospital & Research Institute, Dhaka-1000, Bangladesh. 3 Dr. Saidur Rahman Khan, MD, PhD, FACC, Professor & Senior Consultant in Cardiology, Ibrahim Cardiac Hospital & Research Institute, Dhaka-1000, Bangladesh. 4 Dr. M G Azam, MD, FSCAI, Professor of Cardiology, National Institute of Cardiovascular Diseases, Dhaka-1207, Bangladesh. 5 Dr. Syed Mos qur Rahman, FCPS, Registrar in Cardiac Surgery, Ibrahim Cardiac Hospital & Research Institute, Dhaka-1000, Bangladesh. Correspondence: Dr. C M Shaheen Kabir, Phone: +880 1817578389 E-mail: [email protected]

23 Safety and Feasibility of Transradial Approach for Coronary Artery Bypass Graft Intervention Gomes et. al.

Considering the significant morbidity and mortality endpoint whereas the procedural and fluoroscopy benefits, increased patient preference and cost time, procedural success (less than 50% residual effectiveness, the European Society of Cardiology stenosis with antegrade TIMI flow grade 3 at the end now advocates TRA as the default access route for of the procedure), access site major bleeding, pre CAG.6-8 Studies comparing access route preference discharge major adverse cardiovascular events mainly involve native coronary vessel angiograms, (MACE) were the secondary endpoint both for CAG mostly excluding patients post CABG surgery.9 and PCI. Although there is insufficient evidence to advocate TRA for patients with coronary grafts, both native Statistical analyses were performed using Statistical arteries and grafts, including the left internal Package for Social Sciences(SPSS), version 20. mammary artery, can be commonly studied from the Continuous variables were presented as mean with left radial artery. We sought to compare safety and SD and categorical variables as counts and feasibility using radial versus femoral access during percentages. While continuous data were compared coronary intervention of patients who had previously between groups using Unpaired t-Test, categorical undergone CABG surgery. data were compared between groups using Chi-square (χ2) or Fisher's Exact Test. Level of METHODS: significance was set at 5% and differences between A retrospective analysis was undertaken of groups were considered statistically significant when demographic, clinical and procedural variables of all p-value was observed to be <0.05. ORIGINAL ARTICLE patients with past CABG surgery who underwent diagnostic CAG and percutaneous coronary RESULTS: intervention (PCI) at Ibrahim Cardiac Hospital & There was no significant difference between TRA and Research Institute (ICHRI) between January 2013 TFA in terms of age, gender, BMI, prior MI, prior PCI and December 2015. The study protocol was and diabetes and all other clinical variables of approved by the Ethics Committee of ICHRI. Choice interest. The mean LVEF was also similar between of TRA or TFA was at the consultant/operator's the groups (Table I). Compared with femoral access, discretion. During the period a total of 380 patients diagnostic CAG in TRA required relatively low with past CABG surgery underwent diagnostic contrast volume though the difference was not coronary angiogram (CAG) and percutaneous statistically significant (70±34 vs. 72±40 ml, coronary intervention (PCI) at our institution. TRA p=0.267). Procedure time (25.2±10.7 vs. 26.9±6.8 was accessed in 54 cases, while TFA was accessed in min, p=0.735) and fluoroscopy time (10.7±5.5 vs. 44 cases. For TRA catheterization, a satisfactory 9.5±4.7 min, p=0.424) were almost similar in both Allen's test result was confirmed. Cardiology fellows access groups for CAG (Table II). No significant were equally involved in both TRA and TFA cases difference was found between TRA and TFA with during the study and were supervised throughout, regard to mean number of grafts used and number with prompt consultant intervention if access of lesions treated (p > 0.05 in each case) (Table III attempts failed twice or difficulties arose during the & IV). Stent was deployed in more than 90% cases procedure. After subcutaneous local anesthesia, the in both groups (p < 0.05). The mean diameter of the radial artery was cannulated with a 6 Fr Radifocus stents was larger in the TFA group, but no significant introducer sheath (Terumo Corporation). Then, 5000 difference was found with regard to mean number of U of intraarterial unfractionated heparin and 2.5 mg stents used (Table IV). of intraarterial verapamil were administered. Radial hemostasis was subsequently obtained using digital All PCI attempts were successful in both groups. pressure. Femoral arteries were cannulated similarly There was no major adverse cardiac event during with 7 Fr sheaths and hemostasis was later obtained hospitalization. However, TRA was associated with by digital pressure. Contrast volume was the primary significantly lower rate of vascular complications

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(p = 0.003) and less access site-related bleeding Table III. Procedural outcomes in patients undergoing diagnostic CAG (p = 0.404). Major complications were limited to 2 Group cases of acute renal failure and 1 case of Procedural p-value outcomes Radial access Femoral access cerebrovascular event in the TFA group, and 1 case (n =155) (n=225) of acute renal failure in the TRA group. Three failed No of patent grafts* cases of TRA necessitated crossover to TFA-one due No patent graft 9(5.8) 16(7.1) to the spasm of the radial artery and two others due 1 graft 58(37.4) 78(34.7) to the tortuosities of the upper arms (Table V). 2 graft 59(38.1) 84(37.3) 0.567 Table I. Distribution of patients by their baseline characteristics 3 graft 28 (18.1) 41 (18.2) ORIGINAL ARTICLE Group 4 graft 1 (0.6) 5 (2.2) Baseline p-value characteristics Radial access Femoral access 5 graft - 1 (0.4) (n =155) (n=225) No of diagnostic Demography catheters used# 1.9±0.7 2.5±1.3 0.529

Age # (years) 60.7±8.9 60.3±8.2 0.555 Figures in the parentheses denote corresponding percentage. Men* 129 (83.2) 181 (80.4) 0.089 *Data were analyzed using Chi-square (χ2) Test. BMI# (kg/m2) 26.1±4.4 25.7±3.4 0.479 #Data were analyzed using Unpaired t-Test and were presented as mean ± SD. Clinical presentation SA* 75 (48.4) 88 (39.1) 0.103 Table IV. Procedural outcomes in patients undergoing PCI UA* 23 (14.8) 39 (17.3) 0.736 Procedural Group outcomes in patients p-value NSTEMI* 36 (23.2) 60 (26.7) 0.633 Radial access Femoral access undergoing PCI (n =155) (n=225) HTN* 122 (78.7) 164 (72.9) 0.368 No of lesions treated # DL* 59 (38.1) 86 (38.2) 0.735 1 lesion 43(79.7) 36(81.4) DM* 109 (70.3) 167 (72.9) 0.583 2 lesion 11(20.4) 7(15.9) 0.583 HF* 24 (15.5) 25 11.1) 0.424 3 lesion - 1 (2.3) Previous MI* 29 (18.7) 43 (19.2) 0.883 No of stents used # Previous PCI* 14 (9.0) 11 (4.9) 0.267 1 stent 36(66.7) 27(31.4) Previous stroke* 4 (2.6) 1 (0.4) 0.197 2 stent 14(25.9) 10(22.7) CKD* 18 (11.6) 18 (8.0) 0.471 0.194 3 stent 3(5.6) 3(6.8) PAD* 1(0.6) 5 (2.2) 0.475 4 stent - 1 (2.3) LVEF# 50.7±9.2 51.4±9.8 0.469 Average stent length #(mm) 29.8±15.4 31.2±16.5 0.689 Figures in the parentheses denote corresponding percentage. No of balloons used # 1.2±0.9 1.3±1.5 0.404 2 *Data were analyzed using Chi-square (χ ) Test. Stent deployment* 53(96.3) 41(93.2) 0.002 #Data were analyzed using Unpaired t-Test and were presented POBA* 4(7.4) 6(13.6) 0.985 as mean ± SD. Target vessel intervention* Table II. Distribution of patients by their procedural characteristics SVG 13 (24.1) 13 (29.5) 0.590 Group LCx 22 (38.9) 16 (36.4) 0.073 Procedural p-value characteristics Radial access Femoral access RCA 19 (35.2) 18 (40.9) 0.367 (n =155) (n=225) LAD 10 (18.5) 3 (6.8) 0.026 Contrast volume # (ml) 70±34 72±40 0.267 LIMA 3 (5.6) 3 (6.8) 0.891 Procedure time # (min) 25.2±10.7 26.9±6.8 0.735 Fluoroscopy time # (min) 10.7±5.5 9.5±4.7 0.424 Figures in the parentheses denote corresponding percentage. *Data were analyzed using Chi-square (χ2) Test. #Data were analyzed using Unpaired t-Test and were presented #Data were analyzed using Unpaired t-Test and were presented as mean ± SD. as mean ± SD.

25 Safety and Feasibility of Transradial Approach for Coronary Artery Bypass Graft Intervention Gomes et. al.

13 Table V. Procedural success & MACE in patients undergoing PCI patients undergoing SVG PCI. Consistent with these results, the present study showed similar Procedural success Group procedural success and short-term clinical outcomes & MACE in patients Radial access Femoral access p-value undergoing PCI (n =155) (n=225) between TRA and TFA. Procedure success* (%) 96.2 96.0 0.445 Cross over 3(5.6) - 0.194 Access site-related bleeding accounts for Vascular complications* 1(2.3) 6 (13.6) 0.003 approximately 50-80% of all major bleeding events Access site bleeding - 2 (4.6) 0.404 in patients undergoing PCI.13,14 A recently published Access site haematoma* 1(2.3) 2 (4.6) 0.531 meta-analysis showed that the introduction of TRA Stroke 0 1 (2.3) 0.376 decreased the risk of access site related bleeding by Acute Kidney Injury* 1(2.3) 2 (4.6) 0.590 73%.This reduction could lead to better patient Figures in the parentheses denote corresponding percentage. outcomes.15 More type 2 bleeding was detected in *Data were analyzed using Fisher’s Exact Test. the TFA group than in the TRA group, indicating the benefit of TRA in reducing nuisance bleeding, even DISCUSSION: under the frequent use of GP IIb/IIIa inhibitors. The Patients with a history of CABG usually have severe rates of access site complications were almost coronary lesions & are at high risk of cardiovascular similar between TRA & TFA (5.1 vs. 7.0, P = 0.22).16 events. Although the graft works well right after the bypass surgery, the long-term patency of the graft Reduced procedure times are important, not just for ORIGINAL ARTICLE raises concerns. Saphenous vein graft (SVG) and the patient comfort, but also for improving catheter internal mammary artery (IMA) are estimated to laboratory efficiency and therefore the cost block up again within 10 years.10 A second CABG effectiveness of angiography. Previous studies have surgery was not suggested because of the serious already shown that TRA is more cost-effective than chest tissue adhesion and the increased risk of death TFA due to earlier ambulation and time to after the surgery. However, PCI is still effective in discharge.17 Our study revealed that the important treating occluded grafts. This retrospective analysis procedural variable of procedure time, in addition to shows that angiography and intervention of post- radiation dose, was unaffected by transradial access CABG patients can be safely performed via left TRA route choice for CABG patients, which may result in without significantly altering procedure time and improved cost-efficiency and patient satisfaction, fluoroscopy dose when compared with TFA. TRA is without affecting patient safety. Fluoroscopy dose associated with a lower rate of access site-related remains one of the main safety concerns in coronary bleeding. angiography, due to the link between radiation exposure and malignancy in operators and While there are numerous studies to support the patients.18 Importantly, we have been able to show feasibility and safety of TRA of native coronaries, that there was no significant difference in radiation evidence is limited for performing graft angiography. dosage between TFA and TRA groups. Transradial approach PCI has been increasingly used since its first successful application in 1993 not only Michael and associates demonstrated that TRA because of the easier puncturing and haemostasis, resulted in longer procedure times, but no but also for the better survival rate in certain statistically significant increase in patient radiation patients.11 Han and associates12 found similar rates exposure. Interestingly, in the subgroup of patients of short-term major adverse cardiac and who underwent PCI, there was no significant cerebrovascular events between TRA and TFA (1.5 vs. difference between TRA and TFA in terms of 5.4, P = 0.479) in post-CABG patients undergoing procedural time and radiation exposure.19 There was angiography or PCI. Several investigators reported no significant crossover rate from radial to femoral similar short-term death and MACE in post-CABG route (3%). This crossover rate may have been

26 Ibrahim Card Med J 2019; 9 (1&2): 23-28  Ibrahim Cardiac Hospital & Research Institute

partly attributed to trainee involvement as first 4. Neill J, Douglas H, Richardson G, Chew EW, Walsh S, Hanratty C. Comparison of radiation dose and the effect of operators and their underlying inexperience in TRA. operator experience in femoral and radial arterial access This inexperience might be a major contributor to for coronary procedures. Am J Cardiol 2010;106:936–40. the prolonged procedural times in the TRA group. 5. Cooper CJ, El-Shiekh RA, Cohen DJ, Blaesing L, Burket MW, Our results are comparable with two similar Basu A, Moore JA. Effect of transradial access on quality of life and cost of cardiac catheterization: a randomized retrospective studies, where there was no difference comparison. Am Heart J 1999;138:430–36. in procedural time and radiation exposure in patients 6. Roussanov O, Wilson SJ, Henley K, Estacio G, Hill J, Dogan with coronary grafts undergoing PCI and diagnostic B, Henley WF, Jarmukli N. Cost-effectiveness of the radial angiography.19 Both of these studies involved over versus femoral artery approach to diagnostic cardiac catheterization. J Invasive Cardiol 2007;19:349–53. 300 patients and had similar crossover rates from ORIGINAL ARTICLE radial to femoral route of around 4%. However, the 7. Hamon M, Pristipino C, Di Mario C, Nolan J, Ludwig J, Tubaro M et al. Consensus document on the radial following limitations of study should be considered approach in percutaneous cardiovascular interventions: before generalizing the findings to reference position paper by the European Association of Percutaneous Cardiovascular Interventions and Working population. Groups on Acute Cardiac Care and Thrombosis of the European Society. Euro Intervention 2013;8:1242–51.

LIMITATIONS: 8. Frangos C, Nobel S. How to transform you into a radialist: The retrospective design was the inherent weakness literature review. Cardiovasc Med 2011;14:277–82. of our study. The selection of the route was not 9. Rao SV, Tremmel JA, Gilchrist IC. Best practices for randomized but was at the doctor's discretion, which transradial angiography and intervention: a consensus statement from the Society for Cardiovascular might have resulted in selection bias. However, most Angiography and Intervention's Transradial Working of the patients' baseline characteristics were similar Group. Catheter Cardiovasc Interv 2014;83:228–36. between the TRA and TFA groups. All the PCIs were 10. Chew DP, French J, Briffa TG, Hammett CJ, Ellis CJ, Ranasinghe I et al. Acute coronary syndrome care across conducted only in one hospital, which may restrict Australia and New Zealand: the SNAPSHOT ACS study. the extrapolation of the result to reference Med J Aust 2013;199:185–91. population in general. 11. Bertrand OF, Rao SV, Pancholy S, Jolly SS, Rodés-Cabau J, Larose E, et al. Transradial approach for coronary angiography and interventions: Results of the first CONCLUSION: international transradial practice survey. JACC Cardiovasc The TRA for coronary artery bypass graft Interv 2010;3:1022-31. intervention is safe and feasible in terms of contrast 12. Han H, Zhou Y, Ma H, Liu Y, Shi D, Zhao Y, et al. Safety and volume, procedure and fluoroscopy time and other feasibility of transradial approach for coronary bypass graft angiography and intervention. Angiology 2012;63: clinical endpoints comparing to femoral access in 103-8. patients previously under went CABG. 13. Amoroso G, Kiemeneij F. Transradial access for primary percutaneous coronary intervention: The next standard of References: care? Heart 2010;96:1341-4. 1. Jolly SS, Yusuf S, Cairns J, Niemelä K, Xavier D, Widimsky 14. Burzotta F, Trani C, Hamon M, Amoroso G, Kiemeneij F. P et al. Radial versus femoral access for coronary Transradial approach for coronary angiography and angiography and intervention in patients with acute interventions in patients with coronary bypass grafts: Tips coronary syndromes (RIVAL): a randomised, parallel and tricks. Catheter Cardiovasc Interv 2008;72:263-72. group, multicentre trial. Lancet 2011;377:1409–20. 15. Mehran R, Rao SV, Bhatt DL, Gibson CM, Caixeta A, 2. Romagnoli E, Biondi-Zoccai G, Sciahbasi A, Politi L, Rigattieri Eikelboom J, et al. Standardized bleeding definitions for S, Pendenza G et al. Radial versus femoral randomized cardiovascular clinical trials: A consensus report from the investigation in ST-segment elevation acute coronary Bleeding Academic Research Consortium. Circulation syndrome: the RIFLE-STEACS (Radial Versus Femoral 2011;123:2736-47. Randomized Investigation in ST-Elevation Acute Coronary Syndrome) study. J Am Coll Cardiol 2012;60: 281–89. 16. Goldman S, Zadina K, Moritz T, Ovitt T, Sethi G, Copeland JG, et al. Long-term patency of saphenous vein and left 3. Brueck M, Bandorski D, Kramer W, Wieczorek M, Holtgen internal mammary artery grafts after coronary artery R, Tillmanns H. A randomized comparison of transradial bypass surgery: Results from a department of veterans versus transfemoral approach for coronary angiography & affairs cooperative study. J Am Coll Cardiol 2004;44: angioplasty. JACC Cardiovasc Interv 2009;2:1047–54. 2149-56.

27 Safety and Feasibility of Transradial Approach for Coronary Artery Bypass Graft Intervention Gomes et. al.

17. Verheul HA, Moulijn AC, Hondema S, Schouwink M, 19. Michael TT, Alomar M, Papayannis A, Mogabgab O, Patel Dunning AJ. Late results of 200 repeat coronary artery VG, Rangan BV et al. A randomized comparison of the bypass operations. Am J Cardiol 1991;67:24-30. transradial and transfemoral approaches for coronary artery bypass graft angiography and intervention (the 18. Bundhoo SS, Earp E, Ivanauskiene T, Kunadian V, Freeman RADIAL-CABG trial). JACC Cardiovasc Interv 2013;6: P, Edwards R, et al. Saphenous vein graft percutaneous 1138–44. coronary intervention via radial artery access: Safe and effective with reduced hospital length of stay. Am Heart J 2012;164:468-72. ORIGINAL ARTICLE

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Epidemiological Features of Hospital Acquired Infection in a Tertiary Military Hospital Muhammad Junayed Alam,1 A K M Mustafa Kamal Pasha2

ABSTRACT Background & objective: Hospital Acquired Infections (HAIs) are the major concern in developing countries commonly affecting the ill patients in hospital settings. This study was conducted among the surgical patients admitted in the Combined Military Hospital (CMH), Dhaka to see the prevalence of HAI and factors influencing it. Method: The present cross-sectional study was carried out on patients admitted in the Combined Military Hospital (CMH), Dhaka ORIGINAL ARTICLE between 01 July to 31 December 2018 to find the epidemiological features of Hospital Acquired Infection (HAI). Patients who acquired infection while admitted in CMH in whom the infection was not present at admission or who were incubating pathogenic microorganisms at the time of admission and manifested signs and symptoms after discharge were the study population. However, psychologically abnormal patients were excluded. A total of 200 patients were selected consecutively. The variables included in the study were demographic characteristics, co-morbidity, immunosuppressive conditions, immunosuppressive therapy. Result: Out 200 patients, 24(12%) developed HAI. Analysis of demographic features revealed that age and sex of the patients did not act as determinants of HAI (0.378 and p = 0.635 respectively). Patients dependent on others for most of their day-to-day activities tend to develop HAI more often than those who did not require assistance in their daily activities (p = 0.005). Patients inserted with an invasive device were more likely to develop HAI (14.9%) than those who were not inserted with such devices (7.6%) (p = 0.121). The patients of chronic respiratory disease and diabetes mellitus frequently develop HAI than the patients with other illnesses (p = 0.040). Colostomy tube was the prime source of HAI (50%) followed by gastrostomy tube (33.3%), urinary catheter (20.6%), orthopedic fixation device (20%) and mechanical ventilation (16.7%) (p< 0.001) with longer the use of invasive devices the higher is the chance of HAI (p = 0.001). No association was observed between immunosuppressive condition of the patients and development of HAI (p = 0.558). Association between immunosuppressive therapy and HAI was not found to be significant (p = 0.495). HAI demonstrated their significant presence in patients with emergency operation compared to that in patients with routine operation (p = 0.047). Conclusion: The study concluded that every one in eight patients admitted in CMH may develop HAI. Patients dependent on others for their daily activities and patients inserted with an invasive device more often develop HAI than those who are independent or without an invasive device. Patients of chronic respiratory disease and diabetes mellitus are more prone to develop HAI. Colostomy and gastrostomy tube also act as the main source of HAI. So does the urinary catheter, orthopedic fixation device and mechanical ventilation with longer the use of invasive devices the higher is the chance of HAI. Emergency operation also tends to be associated with HAI. Key words: Hospital Acquired Infections (HAIs), epidemiological factors, Tertyiary Millitary Hospital etc

INTRODUCTION: infections continue to develop in hospitalized patients without any concession. The effects of HAI Hospital Acquired infection (HAI) can be defined as are among the major causes of death and increased an infection occurring in a patient while admitted in morbidity in both developed and developing a hospital or a health care facility in whom the countries resulting in significant burden both for infection was not present at the time of admission. patients & hospital administration. The World Health This includes infections acquired in the hospital but Organization carried out a study in 2002 in 55 appearing after discharge, and also occupational hospitals of the 14 countries and found an average of infections among staff of the facility.1 Despite 8.7% of hospital patients with HAI. The situation is immense progress in public health and hospital care,

Authors’ information: 1 Major (Dr.) Muhammad Junayed Alam, MPH (Hospital Management), DADMS, Head Quarter 10 Infantry Division, Ramu. 2 Brigadier General (Dr.) A K M Mustafa Kamal Pasha, SPP, NDC (National Defence College), MPhil, MPH( Epidemiology), IG Prisons, Bangladesh. Correspondence: Major (Dr.) Muhammad Junayed Alam, Phone: +8801769125098, E-mail: [email protected]

29 Epidemiological Features of Hospital Acquired Infection in a Tertiary Military Hospital Alam et. al.

worst in Eastern Mediterranean and South East Asian due to management of HAIs, most of which is caused region and accounted for figures of 11.8% and 10% by drug-resistant bacterial strains. Increased respectively.2 As these infections occur during mortality and length of hospital stay increases social hospital stay, they cause prolonged stay, disability, and economic burden.2 The present study was, and economic burden.1 therefore intended to determine the epidemiological features of HAI in a Tertiary Care Military Hospital. Although modern medicine practiced in large urban hospitals in the 19th century, opened up many METHODS: avenues of hopes, overcrowding and ignorance This cross-sectional analytical study was conducted added a significant risk of developing HAIs in on patients admitted in Surgical Units [General patients undergoing multiple procedures ranging Surgery, Orthopedics, Urology, Neurosurgery, from child birth to amputation.3 However, in Obstetrics & Gynaecology, Intensive Care Unit (ICU), Bangladesh, a few studies have been conducted in High dependency unit (HDU), Cancer Center, Bone this field. A study in 1990, found rate of HAI in Dhaka Marrow Transplantation Unit and Post-operative Medical College Hospital as 30%. In 2003, the rate of Wards] at Combined Military Hospital Dhaka over a infection in the same hospital was found to be period 6 months from July to December, 2018. The 11.3%. The studies revealed that 38.2% patients study population consisted mostly of military with HAI had to bear the burden of extra cost personnel (Army, Navy and Air Force) and a small (1001-2000 Taka) because of longer hospital stay.4 number of civil employees paid from defense budget. In another study conducted to determine the

ORIGINAL ARTICLE The spouses and children of military personnel and microorganisms responsible for the HAI in different civil employees as well as their parents were also hospitals of Bangladesh found Staphylococcus included in the study. Patients who acquired infection aureus to be the most common pathogen with while admitted in CMH in whom the infection was not majority being resistant to multiple antibiotics.5 A present at admission or who were incubating study carried out in Combined Military Hospital pathogenic microorganisms at the time of admission (CMH), Dhaka in 2007 found HAI to be 8.3%.6 The and manifested signs and symptoms after discharge extent of problems and consequences of HAIs have were the study population. However, psychologically been documented in several studies in USA where abnormal patients and hospital staffs were excluded nearly two million patients are infected each year in from the study. A total of 200 patients were selected the hospital. Of them 90 thousands die each year as consecutively. The variables included in the study a result of complications of HAI. Persons infected were demographic characteristics, co-morbidity, with drug-resistant organisms are more likely to immunosuppressive conditions & immunosuppressive have longer hospital stays and are treated with therapy. second or third line drugs that are less effective, more toxic and expensive.6 A questionnaire and a checklist were prepared and were pre-tested among 10 admitted patients in the The patients with hospital-acquired infection suffer study hospital, for clarity, accuracy, unambiguity and from functional disability and emotional stress to find out the face validity of the questions. Minor leading to disabling conditions and reduced quality of modifications of the questionnaire and the checklist life. The economic costs are also immense. were done following pretesting. After explaining the Hospital-acquired infections add to the imbalance purpose of the study to the respondents, data were between resource allocation for primary and collected by the researcher himself through face- secondary health care by diverting scarce fund to the to-face interview. In addition, patient's medical management of potentially preventable HAIs. records were reviewed and necessary information Prolonged hospitalization of infected patients also was recorded on the questionnaire and check-list. results in decreased availability of hospital facilities Data were analyzed using SPSS (statistical package for other patients with overall negative impact upon for social sciences), version 20. The test statistics hospital practices. The costs of antibiotic increase used to analyze the data were descriptive statistics

30 Ibrahim Card Med J 2019; 9 (1&2): 29-35  Ibrahim Cardiac Hospital & Research Institute

like frequency with corresponding percentage, had surgery after admission; of them 80(81.6%) mean, median and standard deviation from the underwent routine surgery and the rest 18(18.4%) mean. Factors influencing HAI were analyzed using emergency surgery (Table V). Chi-square (χ2) or Fisher’s Exact Test. The level of significance was et at 5% and p-value < 0.05 was Table I. distribution of patients by their socio-demographic characteristic (n=200) considered significant. Socio-demographic Frequency Percentage RESULTS: characteristic

Age distribution shows that the mean age of the Age (years) respondents was 42.7 ± 17.7 years (range: 15 – 74 15-30 62 31.0 30-50 59 29.5 ORIGINAL ARTICLE years). Approximately 40% of the respondents were ≥ 50 79 39.5 50 or > 50 years old, 31% 15-29 years, 29.5% Sex 30-49 years. The respondents were predominantly Male 142 71.0 male (71%) with male to female ratio being roughly Female 58 29.0 7:3. Over half (52.5%) of the respondents was Education secondary or equivalent level educated, 25% were Primary 21 10.5 higher secondary qualified, another 25% were class Secondary or equivalent 105 52.5 6-10 qualified and 4% were illiterate. A total of Higher secondary or equivalent 50 25.0 63(31.5%) respondents was military personnel, Graduation 14 7.0 followed by 54(27%) retired army personnel, Post-graduation 2 1.0 36(18%) housewife, 19(9.5%) civil employee Illiterate 8 4.0 serving in Armed Forces. The mean monthly income Occupation Military service 63 31.5 of the respondents was taka 14287 ± 10615. Nearly Retired military service 54 27.0 three-quarters (74%) of the respondents were House wife 36 18.0 married. Fifty five percent of the respondents had Civil employee 19 9.5 small family (2-4 members) and 34.5% had larger Students 10 5.0 family comprising of > 4 members (Table I). Others (Farmer, Electrician etc) 18 9.0 The study subjects were mainly taken from the Monthly income (taka) <10000 50 25.0 Departments of Orthopedics (26%) and Gynae 10000-19000 32 16.0 (24.5%) followed by Surgery (14.5%), Urology 20000-29000 64 32.0 (11%), Postoperative ward (7.5%), Critical care unit 30000 and above 17 8.5 (6%) and less commonly from other wards, such as No income 37 18.5 Neurosurgery, BMT, Cancer Center and HUD (Table II). Marital status Out of 200 respondents 121(60.5%) used invasive Married 148 74.0 device. Of the invasive devices, intramuscular canula Unmarried 33 16.5 was most frequently used (39.5%) followed by urinary Others (Widower, Widow, Divorce) 19 9.5 catheter (17%), orthopedic fixation device (7.5%), Family size nasogastric tube (4%). Other less commonly used < 2 21 10.5 devices were mechanical ventilation, gastrostomy 2-4 110 55.0 tube, colostomy tube and others (Table III). > 4 69 34.5 Mean = 42.7 ± 17.7 years; range: 15 – 74 years. Over 80% of the devices were used for 1-9 days duration, 13.2% for 10-19 days and 6.7% for 20 or Eighteen (9%) patients were admitted in ICU >20 days duration (Table IV). Over one-third including Critical Care Center HDU. Table VI depicts (34.5%) had immunosuppressive conditions; the number of patients developed hospital acquired 55(27.5%) were receiving immunosuppressive infection (HAI) and their type. Out of 200 therapy. Nearly half (49%) of the respondents have respondents, 24(12%) developed HAI; of them 6%

31 Epidemiological Features of Hospital Acquired Infection in a Tertiary Military Hospital Alam et. al.

had surgical site infection, 3% had urinary tract Table V. Distribution of operated patients by type of operation (n=98) infection, 2% respiratory infection, 1% blood Type of operation Frequency Percentage stream, skin and soft tissue infection). Aseptic measures taken by the hospital staff were evaluated Routine 80 40.0 using a check-list. Table VII depicts that 25% of the Emergency 18 9.0 hospital staff washed their hand before touching a patient, 50% washed their hands after touching a Table VI. Distribution of respondents by type of HAI (n=200) patient, 7.5% took hand washing after exposure to HAI developed and its type Frequency Percentage body-fluid of patients, and 25% took hand washing Yes 24 12.0 after touching the patients’ surroundings and Surgical site infection 12 6.0 belongings. General cleanliness, cleanliness of the Urinary Tract Infection 6 3.0 patients clothing and isolation of infectious patients were maintained 100% in the wards. Respiratory Infection 4 2.0 Blood stream, skin and soft tissue infection 2 1.0 Table II. Distribution of respondents by admission in di erent wards No 176 88.0 Admission in di erent wards Frequency Percentage Orthopedics 52 26.0 Table VII. Evaluation of aseptic measures adopted by the hospital sta Gynae 49 24.5

Urology 29 14.5 e r o f ORIGINAL ARTICLE

Surgery 22 11.0 e t b n

e g i t Post -operative 15 7.5 Ward n i a

h s a Critical care 12 6.0 g p n w

i

h d c Neurosurgery 7 3.5 n u a o Hand washing before washing Hand aseptic procedure body after washing Hand exposure fluid after washing Hand a patient touching t BMT 5 2.5 H touching Hand washing after patient surrounding medical of use Safety equipment cleanliness General patients’ Cleanliness of clothing waste Bin of Presence infectious Isolation of patients Cancer center 5 2.5 1.Surrggeer ryy NO YE S YE S NO NO YE S YYEES S YYEES S YYEES S YE S HDU 4 2.0 2.BMT T YE S YE S YE S YE S YE S YE S YYEES S YYEES S YYEES S YE S

3.Urroolloogg yy NO YE S YE S YE S NO YE S YYEES S YYEES S YYEES S YE S

Table III. Distribution of respondents by type of invasive devices used 4.ICU YE S YE S YE S YE S YE S YE S YYEES S YYEES S YYEES S YE S Invasive devices used Frequency Percentage 5.Gynnaa ee NO YE S YE S YE S NO YE S YYEES S YYEES S YYEES S YE S Yes 121 60.5 6.Neuurroo ssuurrggeeryry NO YE S NO NO NO YE S YYEES S YYEES S YYEES S YE S Intravascular Cannula 46 39.5 7.Canncceerr cceennteterr NO YE S YE S NO NO YE S YYEES S YYEES S YYEES S YE S

Urinary Catheter 34 17.0 8.Orrtthhooppeed dicic NO YE S YE S NO NO YE S YYEES S YYEES S YYEES S YE S Orthopedic Fixation Device 15 7.5 Nasogastric Tube 8 4.0 Table VIII. Association between demographic features and HAI Mechanical Ventilation 6 3.0 HAI Gastrostomy Tube 3 1.5 Demographic p-value features Present Absent Colostomy Tube 2 1.0 (n = 24) (n = 176) Others 7 3.5 Age (years) No 79 39.5 15 – 29 6(9.7) 56(90.3) 30 – 49 10(16.9) 49(83.1) 0.378 Table IV. Distribution of respondents by duration of use of invasive > 49 8(10.1) 71(89.9) devices (n = 121) Sex Duration of invasive Frequency Percentage Male 16(11.3) 126(88.7) devices used (in days) 0.635 Female 8(13.8) 50(86.2) 1-9 97 80.1 10-19 16 13.2 Figures in the parentheses denote corresponding %. Data were ≥ 20 08 6.7 analyzed using Chi-square (χ2).

32 Ibrahim Card Med J 2019; 9 (1&2): 29-35  Ibrahim Cardiac Hospital & Research Institute

Table IX. Association between HAI and functional status of the patients Table XIII. Association between HAI and immunosuppressive condition of the patients HAI Functional Hospital Acquired Infection Present Absent p-value status Immunosuppressive p-value (n = 24) (n = 176) condition Present Absent (n = 24) (n = 176) Self help 5(5.2) 91(94.8) 0.005 Yes 7(10.1) 62(89.9) Require Assistance 19(18.1) 85(81.9) 0.558 No 17(13.0) 114(87.0) Figures in the parentheses denote corresponding percentage. Figures in the parentheses denote corresponding percentage. χ2 Data were analyzed using Chi-square ( ). Data were analyzed using Chi-square (χ2). Table X. Association between HAI and invasive device application Table XIV. Association between HAI and immunosuppressive therapy ORIGINAL ARTICLE HAI Invasive device Hospital Acquired Infection Present Absent p-value Immunosuppressive p-value application Therapy Present Absent (n = 24) (n = 176) (n = 24) (n = 176) Yes 18(14.9) 103(85.1) 0.121 Yes 8 (14.5) 47 (85.5) 0.495 No 6(7.6) 73(92.4) No 16 (11.0) 129 (89.0) Figures in the parentheses denote corresponding percentage. Figures in the parentheses denote corresponding percentage. Data were analyzed using Chi-square (χ2). Data were analyzed using Chi-square (χ2).

Table XI. Association between type of underlying illnesses and HAI Table XV. Association between Hospital Acquired Infection and type of operation HAI Type of p-value Hospital Acquired Infection underlying illness Present Absent Type of (n = 24) (n = 176) p-value operation Present Absent Cerebrovascular Disease 0(0.0) 6(100.0) (n = 24) (n = 176) Routine 11(13.8) 69(86.2) Coronary Heart Disease 3(25.0) 9(75.0) 0.047 Chronic Genitourinary disease 2(7.1) 26(92.9) Emergency 6(33.3) 12(66.7) Endocrine Disease 3(50.0) 3(50.0) Figures in the parentheses denote corresponding percentage. χ2 Malignancy 1(7.7) 12(92.3) 0.040 Data were analyzed using Chi-square ( ). Chronic Respiratory Disease 2(66.7) 1(33.3) Analysis of demographic features revealed that age Gastrointestinal Disease 3(13.0) 20(87.0) of the patients did not act as a determinant of HAI Musculoskeletal Disease 6(10.7) 50(89.3) (0.378). Also, there was no significant association Gynaecological Disease 4(8.3) 44(91.7) between gender and hospital acquired infection ENT Disease 0(0.0) 5(100.0) (p = 0.635)(Table VIII). Respondents who required Figures in the parentheses denote corresponding percentage. assistance for most of their daily activities tend to Data were analyzed using Chi-square (χ2). develop HAI more often than those who did not take Table XII. Hospital Acquired Infection by type of invasive devices used assistance in their daily activities (p = 0.005) (Table HAI IX). The patients inserted with an invasive device Name of device Present Absent p-value were more prone to develop HAI (14.9%) than those (n = 24) (n = 176) who were not inserted with such devices (7.6%) Gastrostomy Tube 1(33.3) 2(66.7) (p = 0.121) (Table X). The patients of chronic Nasogastric Tube 0(0.0) 8(100.0) respiratory disease and diabetes mellitus were more Intravascular Cannula 3(6.5) 43(93.5) likely to develop HAI than the patients with other Urinary Catheter 7(20.6) 27(79.4) < 0.001 illnesses (p = 0.040) (Table XI). Colostomy tube was Orthopedic Fixation Device 3(20.0) 12(80.0) Mechanical Ventilation 1(16.7) 5(83.3) the main source of HAI (50%) followed by Colostomy Tube 1(50.0) 1(50.0) gastrostomy tube (33.3%), urinary catheter Others 2(28.6) 5(71.4) (20.6%), orthopedic fixation device (20%) and Figures in the parentheses denote corresponding percentage. mechanical ventilation (16.7%). Association Data were analyzed using Chi-square (χ2). between duration of use of invasive device and HAI

33 Epidemiological Features of Hospital Acquired Infection in a Tertiary Military Hospital Alam et. al.

was statistically significant (p = 0.001) (Table XII). than that from the present study. Out of 24(12%) No association was observed between cases of HAI, 50% were surgical site infection (SSI), immunosuppressive condition of the patients and 25% urinary tract infection (UTI), 16.7% respiratory development of HAI (p = 0.558) (Table XIII). tract infection (RTI), 4.1% skin and soft tissue Association between immunosuppressive therapy infection (SSTI), 4.1% blood stream infection (BSI), and HAI was not found to be significant (p = 0.495) pneumonia 12%, skin and soft tissue infection (Table XIV). HAI demonstrated their significant (SSTI) 10%, blood stream infection (BSI) 9%. The presence in patients with emergency operation difference in the findings might be due to the fact compared to that in patients with routine operation that different hospitals, even variation among countries, there are wide variety of practices with (p = 0.047) (Table XV). regard to clean surgical procedures, use of invasive DISCUSSION: devices and knowledge & practices among hospital staffs for aseptic patient handling. People come to health facilities to be cured from disease and injuries. Many of their diseases are The present study found no association between caused by microorganisms. Therefore, health socio-demographic factors and development of HAI. facilities are places with a high incidence of Patients who underwent surgery had a higher disease-causing micro- organisms which are easily incidence of HAI (17.3%) than those who did not spread from patient to patient and by the staff and undergo surgery (p = 0.023). The present study equipment and other materials used for patient care. conformed to the findings of Afroz et al.11 where ORIGINAL ARTICLE The present study aimed at describing the state of association between surgery and development of hospital-acquired infection in CMH, Dhaka, HAI was found statistically significant (p <0.05). The Bangladesh and factors influencing it. As the study study also demonstrated that patients who used was conducted in CMHs, a sizable portion of the invasive device tend to be associated with HAI, patients was admitted with musculoskeletal diseases which is further strengthened by the fact that more due to their exposure to rigorous physical activities. the duration of invasive device use, the more is the Overall, the study found that HAI constituted a major chance of HAI bearing consistency with the findings avoidable health problem in the hospital which of Afrozet al11. The study found type of operation to causes significant economic sequel, patients be associated with HAI with emergency operation sufferings & administrative inconveniences. The HAI being more frequently associated with the was commonly found in ICU (41.7%), followed by development HAI. Emergency surgical intervention BMT ward (20%), General Surgery (17.2%), Urology usually involves inadequate aseptic preparation by ward (13.6%), Orthopedics ward (9.6%). the surgical team and the patients needing surgical interventions are usually more vulnerable to develop In the present study, hospital-acquired infection HAI. The finding is consistent with the finding of (HAI) at the time of data collection was 12% and the Amin & Nahar6 number of people at risk of HAI were 200 which is where 34.8% of emergency operation developed HAI. However, immunosuppressive close to the findings of Sridhar et al.7 (10%), Khan et condition of the patients or patients receiving al.8 (11.3%) in Dhaka Medical College Hospital. immunosuppressive therapy were not associated However, Hussain9 in Dhaka Medical College Hospital with the HAI which bears consistency with result of demonstrated HAI to be much higher(30%). The Afroz et al.11 difference may be due to the fact that military Respondents who require assistance for hospitals had a sound administration to take care of most of their daily activities tend to develop HAI the risk factors for HAI and appropriate application of more frequently than those who did not require assistance in their daily activities (p = 0.005) which aseptic practices. Andersen et al.10 in their study is in line with the findings of Amin and Nahar,6 showed that in Norway, the overall hospital acquired where 40% of the HAI developed in those who needed infection rate to be 6%. Amin and Nahar6 in Dhaka assistance for most activities. CMH showed the prevalence of HAI (8.3%) to be less

34 Ibrahim Card Med J 2019; 9 (1&2): 29-35  Ibrahim Cardiac Hospital & Research Institute

CONCLUSION: 6. Amin ZA, Nahar N. Hospital Acquired Infection in a Tertiary Military Hospital in Dhaka, Bangladesh. International The study concluded that every one in eight patients Journal of Infectious Diseases and Therapy 2017;2 admitted in CMH may develop HAI. Neither age nor (2):35-39. doi: 10.11648/j.ijidt.20170202.12 sex of the patients determines the development of 7. Sridhar MR, Boopathi S, Lodha R et al. Standard HAI. Patients dependent on others for their daily precautions and post exposure prophylaxis, for a activities more often develop HAI than those who are preventing infections. Pediatr J 2004;71:617-626. independent. Patients inserted with an invasive 8. Khan HM, Miah AK. Outcome of acquired infections in a device and patients of chronic respiratory disease hospital of Dhaka city. Journal of Preventive and Social and diabetes mellitus are more prone to develop Medicine (JOPSOM) 2003;22(2):45. ORIGINAL ARTICLE HAI. Colostomy and gastrostomy tube also act as the 9. Hussain T, Fazal MA, Ahmed A et al. nosocomial infection-A main sources of HAI. So does the urinary catheter, cross-sectional study in the surgical wards of Dhaka orthopedic fixation device and mechanical ventilation Medical College Hospital. Journal of Preventive and Social with longer the use of invasive devices the higher is Medicine 1991;10(2):10-13. the chance of HAI. Immunosuppressive condition of 10. Andersen BM, Rasch M. Hospital-acquired infections in the patients and immunosuppressive therapy Norwegian long-term-care institutions. A three-year development were not found to be associated with survey of hospital-acquired infections and antibiotic treatment in nursing/residential homes, including 4500 HAI. Emergency operation also tends to be residents in Oslo. J Hosp Infect 2000;46(4):288-96. associated with HAI. Findings suggest that measures need to be taken to increase awareness of hospital 11. Afroz H, Fakruddin M, Masud MR, Islam K. Incidence of and risk factors for hospital acquired infection in a tertiary staffs during any aseptic procedure for effective care hospital of Dhaka, Bangladesh. Bangladesh Journal of control of HAI. The findings might be useful for the Medical Science 2017;16(3):358-369. hospital managers and policy-makers to develop policy and strategy to contain the incidence of HAIs. The researcher suggests further in-depth study to find out the causes of increasing HAI in different wards to get a real picture of HAI.

REFERENCES:

1. WHO. Bulletin of the World Health Organization. 2011; 89(10): 701-776. doi: 10.2471/BLT.11.088179

2. World Health Organization. Prevention of hospital acquired infection. A practical guide. Bull World Health Organ [Internet]. 2002 [cited 2015 Jan 101. 1 p. Available from: http://apps.who.int/medicinedocstdocuments/sl6355e/ sl6355e.pdf

3. Breathnach SA. Nosocomial Bacterial Infection. Medicine International 2001;01(3): 88-90.

4. Shahida SM, Islam A, Dey BR, Islam F, Venkatesh K, Goodman A. Hospital acquired infections in low and middle income countries: root cause analysis and the development of infection control practices in Bangladesh. Open Journal of Obstetrics and Gynecology 2016;6 (01):28.

5. Rahman ASMM. Organisms causing nosocomial infections and their antibiogram isolated from patients of ICU. ICDDR'B, Centre for Health and Population Research, 2002.

35 Ibrahim Card Med J 2019; 9 (1&2): 36-41  Ibrahim Cardiac Hospital & Research Institute

Evaluation of Outcome of Treatment of Intertrochanteric Fracture with Dynamic Hip Screw (DHS) Jonaed Hakim,1 Afrina Jahan,2 Mahbubur Rahman Khan,3 Md. Humayun Reza,4 Rasel al Zilani, 5 Muhammad Shahiduzzaman,6 MKI Quayyum Choudhury 7

ABSTRACT Background & Objective: Intertrochanteric femur fractures are becoming increasingly common as our population ages. Effective treatment strategies that result in high rates of union of these fractures and low rates of complication are important. This study was designed to evaluate the clinical outcome of intertrochanteric fracture treated with dynamic hip screw, among many other fixation techniques available to fix intertrochanteric fractures.

Methods: This prospective interventional study was done in the Department of Orthopaedics & Traumatology Department of Dhaka Medical College Hospital, Dhaka between June 2013 to November 2014. A total of 30 patients having intertrochanteric femur fracture were treated with Dynamic Hip Screw (DHS) after doing all necessary investigations for anesthetic fitness. Regular follow up was done up to six months after each operation and was observed for fracture healing, stability, complications and functional outcome by the prescribed scoring system (Harris Hip Score).

Result: Nearly one third (30.0%) of the patients belonged to 7th decade and male to female ratio was 1:1.3. According to Harris Hip Score, 13(44.82%) patients were rated as excellent, 9 (31.03%) good, 5(17.24%) fair and 2(6.89%) poor.

Conclusion: Dynamic hip screw (DHS) is a reliable method of fixing the stable intertrochanteric femur fractures. The reliability and long-term effect of dynamic hip screw used to treat intertrochanteric fractures of unstable variety are

ORIGINAL ARTICLE unsatisfactory and not up to the mark.

Key words:Hip Fractures, Infection, Dynamic Hip Screw, Fracture Fixation, Harris Hip Score

INTRODUCTION: of either high-energy trauma is rare; mostly seen in young male patients, but simple low-energy falls are Intertrochanteric fractures of femur are still a big common and seen in elderly female patients.5 A truly challenge in traumatology. The number of hip stable intertrochanteric fracture is one, which when fractures is estimated to increase from 18,338 in reduced, has a cortical contact without a gap medially 2010 to 50,421 in 2035 because of aging of the and posteriorly. Whereas in unstable intertrochanteric population.1 Intertrochanteric hip fractures represent fracture there is comminution of greater trochanter almost half of all fractures of the proximal femur.2,3 and there is no contact between proximal and distal Several factors may be associated with hip fracture fragment because of displaced posteromedial fragment. incidence such as age, gender, and race/ethnicity.4 The importance of displaced lesser trochanter Intertrochanteric fractures occurring as consequences

Authors’ information: 1 Dr. Jonaed Hakim, Junior Consultant, Department of Orthopaedics & Traumatology, BIRDEM (Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders) General Hospital & Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Dhaka-1000, Bangladesh 2 Dr. Afrina Jahan, Registrar, department of Orthopaedics & Traumatology, BIRDEM (Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders) General Hospital & Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Dhaka-1000, Bangladesh 3 Dr. Mahbubur Rahman Khan, Junior Consultant, National Institute of Traumatology, Orthopaedics & Rehabilitation (NITOR), Agargaon, Dhaka 4 Dr. Md. Humayun Reza, MS (Orthosurgery) Assistant Professor, Orthosurgery, Sahid M. Mansur Ali Medical College, Sirajgonj 5 Dr. Rasel al Zilani, Registrar, Kishoreganj Medical College, Kishoreganj 6 Dr. Muhammad Shahiduzzaman, Professor & Head, Department of Orthopaedics & Traumatology, Dhaka Medical College, Dhaka 7 Prof. MKI Quayyum Choudhury, Professor & Head, Department of Orthopaedics & Traumatology, BIRDEM General Hospital & Ibrahim Medical College, Dhaka. Correspondence: Dr. Jonaed Hakim, Phone: +880 1975701631 E-mail: [email protected]

36 Evaluation of Outcome of Treatment of Intertrochanteric Fracture with Dynamic Hip Screw (DHS) Hakim et. al.

fragment, its size & displacement are a key to decide type and the degree of displacement and lastly the the instability of intertrochanteric fracture.6 surgeon’s skill to operate. Treating stable and unstable intertrochanteric fractures by dynamic hip Non-surgical treatment of intertrochanteric hip fractures screw (DHS) is the oldest method among many is usually reserved for patients with co-morbidities available options to manage such fractures. It had that place these patients at unacceptable risk from been applied in Dhaka Medical College Hospital for anesthesia, the surgical procedure, or both.7 When long. This study was aimed to evaluate the outcome surgery is the choice of treatment for both stable and of stable and unstable intertrochanteric fracture by unstable intertrochanteric fractures, the surgical Dynamic Hip Screw (DHS). goal is to achieve and maintain a stable fracture reduction to allow early patient mobilization. METHODS: ORIGINAL ARTICLE Achieving this goal is dependent on a number of This study was done in Dhaka Medical College factors, including the fracture pattern, the stability of Hospital from June 2013 to May 2014. Prior the reduction, and the method of fixation. The first permission was taken from Ethical Review group of implants to be used successfully was the Committee, Dhaka Medical College Hospital, Dhaka, fixed-angle nail plate devices, such as the Jewett Bangladesh to conduct the study. During the study nail. Although these devices provide fixation of the period, 67 patients of intertrochanteric fractures proximal fragment and fixation to the shaft, they do were admitted in Dhaka Medical College Hospital, not allow fracture impaction. If impaction does not through emergency and out-patient Department occur and there is lack of bone contact, increased (OPD). Patients older than 18 years having loads on the device often resulted in either breakage intertrochanteric fractures (Evan’s Classification, of the device at the nail-plate junction or separation modified by Jensen) treated with Dynamic Hip Screw of the plate and screws from the shaft, particularly in (DHS) were enrolled in this study (Table:I). However, unstable fractures. This gave rise to sliding nail-plate patients with pathological fractures, open fractures, devices (Massie nail, Ken-Pugh nail), consisted of a intertrochanteric fractures with ipsilateral femoral nail that provided fixation in the proximal fragment shaft fractures were excluded from study. Of the 67 and a side plate and barrel that allowed the nail to patients, 2 patients died due to diseases of old age telescope within the barrel. This mechanism allowed before operation, 6 patients transferred to medicine controlled fracture impaction. Impaction provided unit for treatment of medical co-morbidities and not bone-on-bone contact, which encouraged osseous returned to orthopaedics, 3 patients were treated healing and decreased the stress on the implant, conservatively in the form of traction, 1 patient had thereby decreasing the incidence of implant failure. open fracture, 3 patients were found to have The sliding nail-plate devices were followed by the pathological fracture, 1 patient had ipsilateral sliding screw-plate devices, in which the nail portion femoral shaft fracture and so 51 patients of was replaced by a blunt-ended screw with a large intertrochanteric fracture were left to be treated outside-thread diameter. This modification resulted operatively. Among these 51 patients, 8 patients in improved proximal fragment fixation and were operated by Proximal Femoral Locking Plate decreased the possibility of cutting out superiorly by (PFLP), 2 patients were operated by Dynamic removing the sharp edges found on the nails. Today, Condylar Screw (DCS), 4 patients were treated with the sliding hip screw, such as Dynamic Hip Screw is Proximal Femoral Nail (PFN) and 37 patients were the device most commonly used for fixation of treated with Dynamic Hip Screw (DHS). Among intertrochanteric fractures.7 these 37 patients, 7 patients did not give consent for In a developing country like Bangladesh, management the study and 1 patient died on 3rd post-operative of intertrochanteric fractures is based on individual day. So finally, the study was done on 29 patients. patient factors, such as preinjury ambulatory status, Informed written consent was taken from each age, comorbidities, the financial status of the patient before intervention. All the patients were patient, and on fracture factors, including fracture evaluated by detail history, investigations like

37 Ibrahim Card Med J 2019; 9 (1&2): 36-41  Ibrahim Cardiac Hospital & Research Institute

complete blood count, random blood sugar, serum fractures, 6(85.7%) had excellent and only creatinine, chest X-ray (PA view), ECG, blood 1(14.3%) had poor outcome. None of the 11 cases of grouping and cross matching, Echocardiogram type-4 fractures came out with excellent result, (where available). 7(63.6%) with good, 3(27.3%) with fair and only 1(9.09%) with poor result. Both of the two cases of Following intervention and discharge from the type-5 fractures had fair result (100%) (Table III). hospital, regular follow up was done for each patient after operation to assess the functional outcome by During the initial follow up almost all patients the prescribed scoring system (Harris Hip Score). Six complained of mild to moderate pain. But at final months follow up was targeted to evaluate the final follow up 13(44.8%) had painless hip, 9(31%) functional outcome. Patients were followed up at complained of mild pain on walking for a distance, out-patient department on 6 weeks (1st follow up), 3 5(17.2%) had moderate pain and needed analgesics months (2nd follow up) and 6 months after operation to get relief of the pain. In 2(6.9%) patients, any (3rd follow up). All information was collected in a bodily movement caused pain and they were on pre-designed structured data collection sheet. analgesics and rest (Table IV). Over half (51.7%) of Statistical analysis was done by SPSS using the patients regained unlimited walking ability, descriptive statistics like frequency & corresponding nearly one-quarter (24.1%) needed one cane or percentage. walking stick (at the end of six months) to walk longer distance, 17.2% one crutch or stick and 6.9% RESULTS: two crutches or non-ambulatory (Table: V). Mean ORIGINAL ARTICLE The mean age of the study subjects was 58.3 years. time from operation to sit in a chair was 3.26 days Males affected more frequently in 31-40 years age (range: 1 to 5 days). The rigid protocol of sitting in a group (4:1), whereas, females affected more often chair or bedside on the 1st postoperative day could in 61-70 years (2:7) (Fig: 1). Out of 5 patients in age not be followed in all cases. Some patients failed to group 31-40 years, 2(40%) had excellent outcome, do so on the 1st postoperative day due to pain, 2(40%) good and 1(20%) fair outcome. Age group headache and discomfort. Over half (51.7%) of the 41-50 years comprised of 5 patients. Of them patients could normally use climb stairs without 3(60%) had excellent, one (20%) good and one using a railing, 7(24.1%) could climb stairs using a (20%) fair outcome. Age group 51-60 years railing, 5(17.24%) could climb stairs in any manners comprised of 6 patients; 3(50%) exhibited excellent and 2(6.9%) were unable to climb stairs (Table VI). and 3(50%) good outcome. Out of 8 patients in age Out of 29 patients, 22(75.8%) regained full range of group 61-70 years, 3(37.5%) demonstrated hip movements. 5(17.2%) had limited range of excellent, 1(12.5) good, 2(25%) fair and another motion of the hip and in 2(6.9%) movements were 2(25%) poor outcome. Out of 3 patients in age restricted due to pain (Table VII). group 71-80 years, 2(66.7%) showed excellent So, in the final analysis of Harris Hip Score, result and 1(33.3%) good result. Two patients were 13(44.8%) patients were rated as excellent, above 80 years of age; of them 1(50%) showed 9(31.03%) patients were rated as good, 5(17.2%) good and 1(50%) fair result. These variations in as fair and 2(6.9%) as poor results. They were results among age groups were statistically wheelchair bound and any movement of the hip significant (p > 0.05)(Table: II). caused pain. One of them had nonunion and lag Out of 29 cases, 2(6.9%) were type-1 fracture, screw cut out of the femoral head superiorly. 7(24.1%) were type-2, another 7(24.1%) were Ultimately it ended up with varus angulation. type-3, 11(37.9%) type-4 and 2(6.9%) were type-5 Another developed deep infection and loosening of fractures. Both of the two cases of type-1 fractures screws, so bed rest, antibiotic and analgesic were demonstrated excellent result (100%). Out of 7 prescribed. All (100%) of the stable (type 1 & 2) cases of type-2 fractures, 5(71.4%) showed fractures had excellent or good result. Out of 20 excellent and 2(28.5%) good result. Out of 7 type-3 cases of unstable fractures (type-3, 4, and 5)

38 Evaluation of Outcome of Treatment of Intertrochanteric Fracture with Dynamic Hip Screw (DHS) Hakim et. al.

13(65%) showed excellent or good result and 7 Table IV. Distribution of patients by criteria of pain (n=29) showed fair or poor result. This difference of result Criteria of pain Frequency Percentage between stable & unstable fractures was significant Free of pain/ Occasional pain, (p < 0.001) (Figure 2). but no compromise of activity 13 44.8 Mild pain 9 31.0 Male Female Moderate pain 5 17.2 10 Serious pain causing limitation s

t of activity/ Pain in any motion 2 6.9 n 8 e a ti

p 6

f 7 Table V. Distribution of patients by walking ability (Support) ORIGINAL ARTICLE o

r 4 1 4 e 3

b Walkingability (Support) Frequency Percentage

m 2 4 2 0 u Regained previous walking ability / N 2 2 2 2 0 1 No support needed 15 51.7 31-40 41-50 51-60 61-70 71-80 >80 One cane or walking stick for long work and most of the time 7 24.2 Figure-1: Age versus sex distribution of 30 patients Walk with crutches / walking stick 5 17.2 Table I. Distribution of Intertrochanteric fracture by modi ed Evans type Two crutches / Non-ambulatory 2 6.9 Type of fracture Frequency Percentage Table VI. Distribution of patients by climbing stairs (n=29) Stable (n= 9) Climbingstairs Frequency Percentage Type- 1 2 6.7 Type- 2 7 23.3 Normally without using rallying 15 51.7 Unstable (n= 21) Normally using a rallying 7 24.2 Type- 3 7 23.3 In any manner 5 17.2 Type- 4 12 40.0 Unable to use stairs 2 6.9 Type- 5 2 6.7 Table VII. Distribution of patients by hip mobility (n=29) Mobility of hip Frequency Percentage Table II. Distribution of patients by age group and results (n=29) Full range of motion 22 75.8 Age group Final Outcome p-value Limited range of motion 5 17.2 (years) Excellent Good Fair Poor Movements not possible due to pain 2 6.9 31-40 2(40.0) 2(40.0) 1(20.0) 0(0.0) 41-50 3(60.0) 1(20.0) 1(20.0) 0(0.0) Poor 51-60 3(50.0) 3(50.0) 0(0.0) 0(0.0) 0.05 2 (6.9 %) Excellent Fair 13 (44.8 %) 61-70 3(37.5) 1(12.5) 2(25.0) 2(25.0) 5 (17.3 %) 71-80 2(66.7) 1(33.3) 0(0.0) 0(0.0) >80 0(0.0) 1(50.0) 1(50.0) 0(0.0)

Table III. Distribution of cases by fracture types and results (n=29) Good Results Fracture 9 (31.0 %) types Excellent Good Fair Poor Type- 1 2(100) 0(0.0) 0(0.0) 0(0.0) Figure 2: Pie chart shows final result of the study patients Type- 2 5(71.5) 2(28.5) 0(0.0) 0(0.0) Type- 3 6(85.7) 0(0.0) 0(0.0) 1(14.3) DISCUSSION: Type- 4 0(0.0) 7(63.7) 3(27.3) 1(9.0) Achieving the goal for two parts stable intertrochanteric Type- 5 0(0.0) 0(0.0) 2(100.0) 0(0.0) fracture is no longer a problem now-a-days. For

39 Ibrahim Card Med J 2019; 9 (1&2): 36-41  Ibrahim Cardiac Hospital & Research Institute

unstable comminuted intertrochanteric fracture, it were type 5 unstable fracture. Among the remaining remains a challenging but common problem.8,9 This 3 (10.3%) patients, 1 had bilateral Colle’s fracture, 1 series included 30 cases of intertrochanteric fractures had contralateral ankle injury and in 1, fixation of the in adult and elderly; out of them, one diabetic fracture was not satisfactory. So these patients were patient died on 3rd postoperative day in BIRDEM allowed partial weight bearing 8 weeks after General Hospital. Remaining 29 patients were evaluated operation. Full weight bearing in 3 months was with a follow up of 6 months. The outcome was observed in 28 patients. Full weight bearing was satisfactory (good to excellent) in more than 75%, never possible in one patient due to pain and cases. The result is comparable to that of the study unacceptable radiological healing and position of lag reported by Adams et al10, where the average Harris screw. Finally, at the end of six months, 7(24.1%) Hip Score at 6 months of follow up was 66.4, though patients needed one cane for walking and 2(6.9%) they did not categorize the patients based on the were non-ambulatory. Among them, 1 patient had Harris Hip Score. Stable intertrochanteric fractures unacceptable radiological healing and nail position in are commonly treated with dynamic hip screw femoral head, so failed to bear weight. Another fixation with failure rate of less than 2%. The patient, though walked full weight bearing in 3 treatment of unstable intertrochanteric fractures is months, could not continue it due to pain and deep more controversial. Unstable intertrochanteric fractures infection was suspected. They had no definite cause treated with Dynamic Hip Screw have considerable but probably it may occur due to contracture of hip failure rate, ranging from 4 to 15%.11 capsule and surrounding musculature as a

ORIGINAL ARTICLE consequence of delayed and prolonged surgery. The average operation time in the present study was longer than that of Setiobudi et al11 study (mean So, in the final analysis of Harris Hip Score, operation time 58 ± 18 minutes) for 61 stable 13(44.8%) patients were rated as excellent. They intertrochanteric fractures. Another study by Adams regained excellent range of motions and restored et al10, showed average operation time of 61.3 normal functional and walking ability without any minutes (58.2—64.4 minutes) in 197 patients limp and pain. They needed no support for walking. operated with Dynamic Hip Screw. In the present Radiologically, there were bony unions in good series, in 1(3.4%) case only, the lag screw was cut alignment and all of them were satisfied with out of the femoral head with varus angulation and operative treatment and returned to their previous resulted in nonunion. This case was considered as job. Nine (31.0%) patients were rated as good. All of mechanical failure. Satisfactory radiological healing them regained full range of motion. They had with acceptable alignment occurred in the remaining occasional mild pain and noticeable limp. They used 28(95.5%) cases. a cane for walking. Radiologically the union was good and alignment was acceptable. Five (17.2%) Full range of painless hip movement is a prerequisite patients were rated as fair. They had a limited range for leading a normal life. Out of 29 patients, of motion, moderate pain, needed analgesic with 2(6.89%) patients had pain while having any noticeable limp and needed crutches for walking. But motion. In one it was due to lag screw cutout of the their radiological union was sound. Two patients femoral head and in another due to deep infection. were rated as poor and they were wheelchair bound Another 5(17.2%) patients had moderate pain and and any movement of the hip caused pain.12,13 limited range of hip mobility and needed crutch support for walking, 17(58.6%) could wear their Wound infection occurred in 5(16.6%) patients, shocks and shoes with ease. Nearly 45% patients among them 3(10%) had just stitch infection and had no or minimum limp, 48.3% had noticeable limp 2(6.6%) had deep infection. Causative organism was and 6.9% were unable to bear any weight on the Staphylococcus aureus in all cases and it was found operated limb. Over 75% were reported to walk with sensitive to both flucloxacillin and clauvulonic acid. crutch with partial weight bearing. In walking frame Stitch infection was controlled within 5 days of within 3 months, 2 of these cases were type 4 and 2 antibiotic therapy, but the antibiotic was continued

40 Evaluation of Outcome of Treatment of Intertrochanteric Fracture with Dynamic Hip Screw (DHS) Hakim et. al.

up to 2 weeks. The deep infection was managed by 7. Kaplan K, Miyamoto R, Levine BR, Egol KA, Zuckerman JD. open drainage and secondary closure associated Surgical management of hip fractures: an evidence-based review of the literature. II: intertrochanteric fractures. J with antibiotic therapy for 3 weeks. Am Acad Orthop Surg 2008;16(11):665-73.

The study population was selected from the 8. Medoff RJ, Maes K. A new device for the fixation of unstable Department of Orthopaedics & Traumatology, Dhaka pertrochanteric fractures of the hip. J Bone Joint Surg Am Medical College & Hospital, Dhaka and therefore, 1991;73(8):1192-99. lacks generalization. The operating surgeons were 9. Larsson S, Friberg S, Hansson LI. Trochanteric fractures. not the same in all cases which might have resulted Mobility, complications, and mortality in 607 cases treated in operator dependent variation in outcome to some with the sliding-screw technique. Clin Orthop Relat Res extent. The purposive sampling was used in 1990;(260):232-41. ORIGINAL ARTICLE selecting study population and the entire sample was 10. Adams CI, Robinson CM, Court-Brown CM, McQueen MM. collected from the patients operated after admission. Prospective randomized controlled trial of an This sampling bias further limits the generalization of intramedullary nail versus dynamic screw and plate for the findings. intertrochanteric fractures of the femur. J Orthop Trauma 2001;15(6):394-400.

CONCLUSION: 11. Setiobudi T, Ng YH, Lim CT, Liang S, Lee K, Das De S. From the findings, it can be concluded that, Dynamic Clinical outcome following treatment of stable and unstable intertrochanteric fractures with dynamic hip Hip Screw is a reliable and standard method of fixing screw. Ann Acad Med Singapore 2011;40(11):482-7. the stable intertrochanteric femur fractures. In case of fixing the unstable intertrochanteric femur fractures 12. Peyser A, Weil YA, Brocke L, Sela Y, Mosheiff R, Mattan Y, Manor O, Liebergall M. A prospective, randomised study with Dynamic Hip Screw, its reliability and long-term comparing the percutaneous compression plate and the effect are unsatisfactory and not up to the mark. compression hip screw for the treatment of REFERENCES: intertrochanteric fractures of the hip. J Bone Joint Surg Br 2007;89(9):1210-17. 1. Chen IJ, Chiang CY, Li YH, Chang CH, Hu CC, Chen DW, 13. Whitelaw GP, Segal D, Sanzone CF, Ober NS, Hadley N. Chang Y, Yang WE, Shih HN, Ueng SW, Hsieh PH. Unstable intertrochanteric/subtrochanteric fractures of the Nationwide cohort study of hip fractures: time trends in femur. Clin Orthop Relat Res 1990;(252):238-45. the incidence rates and projections up to 2035. Osteoporos Int 2015;26(2):681-88. doi: 10.1007/ s00198 -014-2930-z.

2. Koval KJ, Zuckerman JD. Hip Fractures: II. Evaluation and Treatment of Intertrochanteric Fractures. J Am Acad Orthop Surg 1994;2(3):150-156.

3. Cooper C, Campion G, Melton LJ 3rd.Hip fractures in the elderly: a world-wide projection. Osteoporos Int 1992;2 (6):285-9.

4. Brauer CA, Coca-Perraillon M, Cutler DM, Rosen AB. Incidence and mortality of hip fractures in the United States. JAMA 2009;302(14):1573-79. doi: 10.1001/jama. 2009.1462.

5. Dhanwal DK, Dennison EM, Harvey NC, Cooper C. Epidemiology of hip fracture: Worldwide geographic variation. Indian J Orthop 2011;45(1):15-22. doi: 10.4103/0019-5413.73656.

6. Babhulkar, SS. Management of trochanteric fractures. Indian Journal of Orthopaedic, 2006;40(4):210-218.

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Perception About the Use of Over-the-Counter Antibiotics Among Patients Attending Outpatient Department of a Tertiary Care Hospital of Bangladesh Md. Ashraf Uddin Ahmed,1A.S.M. Morshed,2 Farzana Yasmin,3 Dwijraz chakraborty4

ABSTRACT Background & objective: Antibiotics are considered among the most commonly sold drug classes in the developing countries. The irrational and overuse of antibiotics result not only in the emergence of resistant bacterial strains but also adverse reactions and economic burden on national health system. This study was carried out with the focus to assess the awareness, attitude and practice of patients visiting Outpatient Department (OPD) of Bangladesh Institute of Research & Development in Endocrine & Metabolism (BIRDEM) General Hospital. towards antibiotic usage and development of its resistance

Methods: This cross-sectional study was done in the OPD of BIRDEM General Hospital from June 2017 to July 2017. Patients presented at OPD were selected by convenient sampling. The total number of respondents was 100. A semi-structured questionnaire was used to collect information from the respondents. Data were analyzed using statistical package for social sciences (SPSS) version 20.0 and descriptive statistics were used to analyze the data.

Results: Of all the participants who took part in the study, 46% had no knowledge and 36% were unaware of ill-effects of antibiotic resistance. Over half (54%) of the patients showed confusion between antibiotic and

ORIGINAL ARTICLE antiviral drugs. Investigating patients’ practice about antibiotics revealed that 50% patients used to take incomplete antibiotic course and 30% patients shared their antibiotics with other sick family members. During emergencies, 16% patients used the previously left-over antibiotics without seeing the expiry date. Nearly half (46%) of the patients had a practice of taking previously prescribed antibiotic again for the similar nature of illness without consulting a doctor, 6% patients sought antibiotics prescription whenever they consult a doctor.

Conclusion: Although the results of this study cannot be generalized to all adult Bangladeshi, indiscriminate use of antibiotic and unawareness of antibiotic resistance and poor attitude towards the antibiotic usage can be a concern for antibiotic resistance in Bangladesh. It highlights the need of educational interventions to increase awareness of people about the consequences of antibiotic misuse and also to develop healthy attitude to practice antibiotic usage.

Keywords: Antibiotic usage, antibiotic resistance, health education

INTRODUCTION in most developing and many developed countries. The irrational and overuse of antibiotics Antibiotics have been pivotal in treating and results not only in the emergence of resistant preventing common infections, but their overuse bacterial strains but also imposes an economic and misuse have contributed to an alarming burden on national health system.1 Several increase in antibiotic resistance worldwide. studies have shown that antibiotic-resistant Antibiotic resistance has been a low-priority area infections are associated with increased morbidity

Authors’ information: 1 Dr. Md. Ashraf Uddin Ahmed, Resident physician, BIRDEM General Hospital, Dhaka, Bangladesh 2 Dr. A. S. M. Morshed, Assistant Professor, Sirajul Islam Medical College, Dhaka, Bangladesh. 3 Dr. Farzana Yasmin, Resident medical o cer, Department of Paediatrics, BIRDEM General Hospital, Dhaka, Bangladesh. 4 Dr. Dwijraz Chakraborty, MD resident, Critical care medicine, BIRDEM General Hospital, Dhaka, Bangladesh. Correspondence: Dr. Md. Ashraf Uddin Ahmed, Phone: +880 1819272977, Email: [email protected].

42 Perception About the Use of Over-the-Counter Antibiotics Among Patients Attending Outpatient Department of a Tertiary Care Hospital of Bangladesh Ahmed et. al.

and mortality as compared with antibiotic- questions were set to assess the attitude and susceptible infections.1 The World Health Report practice of the respondents about antibiotics. Data 2007 stressed antibiotic resistance as one of the were analyzed with the help of SPSS (Statistical major threats to public health security in the 21st Package for Social Sciences) version 20.0. The century.1 There are cross-sectional studies on the test statistics used to analyze the data were people’s perception about antibiotic use;2,3 descriptive statistics only. however, very few studies have assessed the RESULTS: patients’ level of awareness about antibiotic uses as a contributing factor for development of A total of 100 questionnaires were distributed;all antibiotic resistance.4,5 of whom completed the questionnaire. The mean ORIGINAL ARTICLE age of the participants was 35.8±11.9 years (Fig In developing countries like Bangladesh, where 1). Majority (82%) of the participants was male most of the people is not health conscious, with male-to-female ratio being roughly 4:1. particularly about antibiotic use and resistance, Educational level of the participants varied from educational intervention to raise their awareness high school (58%) to graduate and above (42%). on the issue is essential. Thus, the present study Questions are set to assess patients, awareness was aimed at assessing the patients’ awareness, about antibiotic usage and development of its attitude and practice towards antibiotic usage in resistance (Table 1). Of all the participants who Bangladesh could be useful to plan for educational took part in the study, only 42 had heard about intervention. antibiotic resistance. Nearly half (46%) of the METHODS: participants was not aware about the seriousness of the issue and 12% participants did not know This was an observational study, carried out in about antibiotic resistance. Outpatient Department (OPD) of Bangladesh Institute of Research and Rehabilitation in More than half of the participants (54%) knew Diabetes, Endocrine and Metabolic Disorders about development of bacterial resistance to (BIRDEM) General Hospital, Dhaka over a period antibiotics and that could be fatal to themselves of two months from June 2017 to July 2017. Adult and even to their family members. About three people aged ≥18 years attending at OPD who had quarters (72%) agreed that, usage of antimicrobials used antibiotic within last one year were the study without doctor’s advice is harmful. While 26% population. Participants who were in medical, participants believed that, self-medication or taking paramedical profession or who had their relatives medication on advice of medical shopkeeper, any in such profession or person who were unaware non-medical person (Relatives/Friends/Neighbors) about the term “Antibiotic” were excluded. Based or even by seeing advertisement on Internet/ on the predefined eligibility criteria, a total of 100 Television/ Newspapers are not harmful. respondents of both sexes (82 males and 18 Nearly half (46%) of the participants was aware females) participated in the study. A structured about basic difference between antibiotic and questionnaire, both in English and Bangla, was antiviral drugs and their usage. Less than one given to the respondents. Ethical approval for the quarter (20%) participants believed that, there is study was obtained from Ethical Approval no such difference between usage of antibiotics Committee of Bangladesh Diabetic Association and antivirals. More than one-third (34%) of the (BADAS) prior to commencing data collection. participants did not know about the development A total of 14 variables were included in the of resistance due to misuse of antibiotic in place of questionnaire; 8 of them were set to assess the antivirals without doctor’s advice. More than patients’ awareness about antibiotic resistance three-quarters (76%) of the participants believed and its adverse effects on public health. Another 6 that, promiscuous use of antimicrobials is harmful

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while 22% participants felt such use to be safe Table I. Questions to assess patient’s awareness about antibiotic and 2% were not aware about the consequences usage & development of its resistance (n=100) of indiscriminate use of antibiotics. Questions & Response Frequency Percentage

Fifty percent participants agreed that, they stop A.1 Heard about antibiotic resistance. taking prescribed antibiotics when start feeling Yes 42 42.0 better; among them 30% stop antibiotic No 46 46.0 frequently, 14% sometimes and 6% stop Don’t know 12 12.0 antibiotic very rarely. Another 50% participants complete the full regimen prescribed by the doctor A.2 Antibiotic resistance could be fatal to me or my family. (Table 2). Nearly one-third (30%) of participants Yes 54 54.0 have a habit of sharing their antibiotics with a sick No 36 36.0 family member. While 70% participants do not Don’t know 10 10.0 practice sharing of their antibiotics with anyone. Sixteen percent of participants keep antibiotic A.3 Antibiotic self-medication is harmful. stock at home and use it without seeing the expiry Yes 72 72.0 date during emergencies, while 84% participants No 26 26.0 Don’t know 2 2.0 check for the expiry date and discard the left over antibiotics. A.4 Usage of antibiotic by advice of non-medical relative ORIGINAL ARTICLE Nearly half (46%) participants used to take is harmful. previously prescribed antibiotics again for the Yes 72 72.0 similar nature of diseases subsequently without No 26 26.0 consulting a doctor, while 54% participants would Don’t know 2 2.0 like to consult a doctor before taking any antibiotic even for the similar illness. Only 6% participants A.5 Usage of antibiotic by seeing advertisement on Internet/ would like to consult another doctor to prescribe Media/Newspapers is harmful. antibiotic if the former disagreed to do so. Yes 66 66.0 No 30 30.0 Majority (94%) of the participants disagreed to Don’t know 4 4.0 have such expectations from the doctor during consultation. More than one-third (36%) A.6 Usage of antibiotic by advice of Medical Shopkeeper participants admitted that they gave antibiotic to is harmful. their children for common cold, while 64% Yes 66 66.0 participants said they usually used cough No 32 32.0 remedies instead of antibiotics. Don’t know 2 2.0

51-60 <20 10% 2% A.7 Using antibiotics for viral infections can increase its 21-30 resistance. 41-50 38% 16% Yes 46 46.0 No 20 20.0 Don’t know 34 34.0

A.8 Indiscriminate use of antibiotic can cause more harm than good 31-40 34% Yes 76 76.0 No 22 22.0 Fig: 1 Distribution of patients by their age Don’t know 2 2.0

44 Perception About the Use of Over-the-Counter Antibiotics Among Patients Attending Outpatient Department of a Tertiary Care Hospital of Bangladesh Ahmed et. al.

Table II. Patients’ antibiotic behavior related to antimicrobial non-prescription antibiotics has become a major resistance. (n=100) public health problem. This is one of the very few cross-sectional studies in Bangladesh that Response & Questions Frequency Percentage attempted to identify & examine the perceptions B.1 Stop taking prescribed antibiotics when feeling better. of antibiotics in the general population. never do 5 5.0 very rarely 6 6.0 Over-the-counter medication with antibiotics by general population is high in low income countries Sometimes 14 14.0 like Srilanka, Vutan, Africa, Pakistan, India, Frequently 30 30.0 Nizeria etc. This finding is in agreement with a B.2. Share antibiotics with sick family members. similar studies which showed that the commonest ORIGINAL ARTICLE never do 70 70.0 groups of medication prone to self-medication very rarely 2 2.0 include antimalarials and antibiotics.7 Though Sometimes 8 8.0 awareness programs are carried out by WHO, Frequently 20 20.0 58% (46% don’t know and 12% don’t B.3. Take antibiotic without seeing the expiry date. understand) participants seeking primary care in never do 84 84.0 BIRDEM General Hospital, Dhaka, were found to very rarely 4 4.0 have no knowledge that antibiotic resistance is a Sometimes 6 6.0 major threat, while only 9% of Chinese people Frequently 6 6.0 were unaware of “antibiotic resistance” term.3 B.4. Take previously prescribed antibiotic again for the similar These variations may be attributed to the patient’s incidence. level of awareness, education, standard of living, never do 54 54.0 economy of the country, and also to the very rarely 6 6.0 non-calibration of the sample size. Sometimes 14 14.0 The level of knowledge about the consequence of Frequently 26 26.0 antibiotic resistance was found to be 54% among B.5. Consult another doctor to prescribe antibiotic if rst doctor the participants. On the contrary, high level of disagreed to do so. knowledge (80.7%) in this regard was found in never do 94 94.0 the study done by Andre et al.8 Nearly one-third very rarely 6 6.0 (36%) of the participants of this survey did not Sometimes 0 0.0 agree that, antibiotic resistance is a Frequently 0 0.0 life-threatening problem which is almost B.6. Use antibiotic for child suering from common cold consistent with the findings of Vanden et al9 who never do 64 64.0 showed that 42% of the participants were very rarely 4 4.0 unaware about the possible health dangers of sometimes 12 12.0 antibiotic resistance. In a descriptive study in Frequently 20 20.0 Hong Kong in which patients were asked how much they knew about the therapeutic and DISCUSSION: side-effects of the medications they used, 69% knew at least some of the therapeutic effects Antimicrobial resistance is one of the most serious while 31% did not know any of the therapeutic public health threats of the twenty-first century. effects, so rendering themselves at risk from Globally, about 700,000 people die due to inappropriate use of drugs.3 Furthermore, the vast AMR-related illnesses every year. It is estimated majority (93%) of the patients were totally that by 2050 these deaths will reach 10 million, unaware of the possibility of side-effects in that costing US$100 trillion.6 The development of study. Such unawareness and misguided beliefs antimicrobial and antibacterial resistance related could be potential danger to public health. to misuse of antibiotics and irrationalized use of

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In the present study, 72% participants agreed antimicrobial drugs is more harmful, whereas that usage of antimicrobials without doctor’s nearly 60% of respondents of Penang state prescription or by any other ways is harmful. believed so.14 This inconsistent result is probably Similar level of awareness (70%) was also found due to level of education which is much higher in among the students of Portugal.5 In our study, a Malaysia than Bangladesh. So improved literacy significant number of participants believed that, can change the condition. self-medication or taking medication by advice of Of all the participants who took part in the study, non-medical person is not harmful. Among them 50% used to practice incomplete antibiotic course 26% think that taking antibiotic by advice of when they start feeling better (30% frequently non-medical person (Relatives/Friends/ Neighbors) stop, 14% sometimes stop and 6% very rarely are not harmful, while this number from medical stop antibiotic when they feel better). Likewise, shopkeeper was 32%. Over half (51.8%) of about 50% of adults of Changhua were Jordanians used antibiotics on advice of their non-compliant.15 Kardas and colleagues16 in his relatives.10 Alghanim11 showed that the systematic review and meta-analysis found an commonest source of information was the private even higher percentage (62.2%) of non-compliance sector pharmacy salesmen (including pharmacists), with prescribed antibiotic regimen.16 A 2015 reported by about three-quarters of the survey by the WHO in 12 countries across the six respondents (74.0%). This was followed by WHO regions provides a useful information of the respondents’ experiences or knowledge from general public’s knowledge over the appropriate

ORIGINAL ARTICLE previous episodes (50.8%). Health staff was the use of antibiotics. Over a third of the nearly least common source of information (9.6%). In a 10,000 survey respondents had taken antibiotics study of United Arab Emirates prevalence of in the past month. Nearly two thirds (64%) antibiotic use with and without a prescription was mistakenly believed that viral infections such as high (40%). The pharmacy was the main source, influenza or colds could be treated with where the majority (>90%) obtained antibiotics.12 antibiotics, and nearly a third (32%) thought that Like other studies8,10 54% participants of our stopping antibiotics when they felt better rather study showed confusion regarding effectiveness of than completing a course as prescribed was the antibiotics against bacteria or viruses, (20% don’t appropriate behavior.17 Abasaeed18 found that know and 34% don’t understand the difference self-medication with antibiotics may increase the between antiviral and antibiotic). In other studies, risk of inappropriate use and the selection of 27% and 19% of people believed that, intake of resistant bacteria in Abu Dhabi. Eight hundred antibiotics during common cold made them to feel sixty questionnaires were completed, with a better more quickly and 32% of them felt that it response rate of 86%, consisting of 66% males prevented the occurrence of more serious and 34% females. These types of irrational and illness.10 Around 80% people of Bangladesh live in incomplete use of antibiotics might cause rural areas and their access to quack or village antibiotic resistance. Nearly one-third (30%) of doctors or traditional healers are quite common, the participants of our study reported sharing who actually prescribe not only irrational their antibiotics with other sick family members antibiotics, but also the newest regimens, like whereas this antibiotic behavior was only 8% in ceftriaxone or meropenem every now and then. Hong-Kong population.19 Several factors, like gross dispensing of Less than one-quarter (16%) participants antibiotics, unethical promotion, self-medication reported they keep antibiotics in stock and use without prescription, irrational use of antibiotics in them without seeing the expiry date during prescriptions by professionals, animal agricultural emergencies while 28.5% of Jordanians and 6.6% antibiotic use are endangering the situation in the of Chinese had kept antibiotics at home for country.13 In the present study, 22% participants emergency.3,10 Nearly half (46%) had a practice of believed that the indiscriminate use of

46 Perception About the Use of Over-the-Counter Antibiotics Among Patients Attending Outpatient Department of a Tertiary Care Hospital of Bangladesh Ahmed et. al.

taking previously prescribed antibiotic again for 3. Wun YT, Lam TP, Lam KF, Ho PL, Yung WH. The public's the similar illnesses without consulting a doctor. In perspectives on antibiotic resistance and abuse among other studies, 86% and 49% of respondents used Chinese in Hong Kong. Pharmacoepidemiol Drug Saf 2013;22:241-9. left over antibiotics without physician’s consultation.4,20 In a study of rural area of 4. Gualano MR, Gili R, Scaioli G, Bert F, Siliquini R. General Barabanki showed that the important sources of population's knowledge and attitudes about antibiotics: information for self-medication were previous a systematic review & meta-analysis. Pharmacoepidemiol Drug Saf 2015;24(1):2-10. prescription of doctors (72.6%), friends and neighbors (52.4%) and chemists (38.1%).21 In 5. Väänänen MH, Pietilä K, Airaksinen M. Self-medication

developing countries like Bangladesh due to withantibiotics–does it really happen in Europe? Health ORIGINAL ARTICLE poverty and insufficient knowledge of parents and Policy (Amst, Neth) 2006;77:166—71. children themselves perform irrational use of 6. Adeyi OO, Baris E, Jonas OB, Irwin A, Berthe FCJ, Gall drugs.22 In our study, only 6% participants asked L, et al. final report [Internet]. The World Bank; [cited their doctors to prescribe antibiotic (Injection/ 2018 May 17] Report No.: 114679. 2017:1–172. Tablet) for their illnesses, whenever they consult 7. Afolabi, A. Factors influencing the pattern of with them. These participants would like to self-medication in an adult Nigerian population. Annals consult another doctor to prescribe antibiotic if of African Medicine 2008;7(3):120.

their physicians disagreed to do so. In other 8. André M, Vernby A, Berg J, Lundborg CS. A survey of studies, similar antibiotic behaviors were public knowledge and awareness related to antibiotic 15-48%.17,19,23 In contrast, 87% of respondents of use and resistance in Sweden. J Antimicrob Chemother Sweden had higher trust in doctors for not 2010;65:1292-6. 8 prescribing an antibiotic. Such inconsistent 9. Vanden Eng J, Marcus R, Hadler JL, Imhoff B, Vugia DJ, results show the importance of education and Cieslak PR et al. Consumer attitudes and use of indicate the need of educational interventions to antibiotics. Emerg Infect Dis 2003;9:1128-35. create awareness among participants regarding 10. Shehadeh M, Suaifan G, Darwish R M, Wazaify M, Zaru antibiotics and its judicious use. L, Alja’fari S. Knowledge, attitudes and behavior CONCLUSION: regarding antibiotics use and misuse among adults in the community of Jordan- A pilot study. Saudi Motivation of people to understand the different Pharmaceutical Journal 2012;20:125–33.

facets of antibiotic and modifying their behavior 11. Alghanim SA; Alomar BA. Frequent use of emergency towards its rational usage is vital in reducing the departments in Saudi public hospitals: Implications for antibiotic resistance. Although antibiotics are primary health care services. Asia-Pacific Journal of prescription only drugs in Bangladesh, the results Public Health 2011;27(2): 2521–30.

of this study express that antibiotic 12. Sharif SI, Bugaighis LMT, Sharif RS. Self-medication self-medication is rampant in Bangladesh. It is the practice among pharmacists in UAE. Pharmacology & duty of the government especially Drug Pharmacy 2007;06(09):428–435. Administration Authority of Bangladesh to 13. Faiz MA, Basher A. Antimicrobial resistance: Bangladesh implement the regulatory controls on the experience, Regional Health Forum 2011;15(1):1-8. distribution and selling of antibiotics following the 14. Ling Oh A, Hassali MA, Al-Haddad MS, Syed Sulaiman guidelines of National Drug Policy-2005. SA, Shafie AA, Awaisu A. Public knowledge and REFERENCES: attitudes towards antibiotic usage: a cross-sectional study among the general public in the state of Penang, 1. World Health Organization. Antimicrobial resistance: Malaysia. J Infect Dev Ctries 2011;28(5):338-47. global report on surveillance 2014. Geneva: WHO. 15. Chen C, Chen YM, Hwang KL, Lin SJ, Yang CC, Tsay RW 2. Kotwani A, Wattal C, Joshi PC, Holloway K. Irrational use et al. Behavior, attitudes and knowledge about of antibiotics and role of the pharmacist: an insight antibiotic usage among residents of Changhua, Taiwan. from a qualitative study in New Delhi. J Clin Pharm Ther J Microbiol Immunol Infect 2005;38:53-9. 2012;37:308-12.

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16. Kardas P, Devine S, Golembesky A, Roberts C. A 20. Desai AJ, Gayathri G.V, Mehta D.S. Public’s Perception, systematic review and meta-analysis of misuse of Knowledge, Attitude and Behavior on Antibiotic antibiotic therapies in the community. Int J Antimicrob Resistance, A survey in Davangere City, India. Journal Agents 2005;26:106-13. of Preventive Medicine and Holistic Health 2016; 2(1):17-23. 17. World Health Organization. Antibiotic Resistance: Multi-Country Public Awareness Survey. Geneva, 21. Keshari SS, Kesarwani P, Misra M. Prevalence and Switzerland: WHO, 2015. pattern of self-medication practices in rural area of barabanki. Indian Journal of Clinical Practice 2015; 18. Abasaeed A, Vlcek J, Abuelkhair M, Kubena A. 25(7):635-9. Self-medication with antibiotics by the community of Abu Dhabi Emirate, United Arab Emirates. J Infect Dev 22. Pereira FSVT, Bucaretchi F, Stephan C, Cordeiro R. Ctries 2009;3(7):491-7. Self-medication in children and adolescents, Jornal de Pediatria 2007;83(5):453–58. 19. You JH, Yau B, Choi KC, Chau CT, Huang QR, Lee SS. Public knowledge, attitudes and behavior on antibiotic 23. Bennadi D. Self-medication: a current challenge. J Basic use: a telephone survey in Hong Kong. Infection Clin Pharm 2013;5:19-23. 2008;36:153-7. ORIGINAL ARTICLE

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State of Working Slum Children in Dhaka City Md. Nurul Amin1, Shayela Farah2, Mohoshina Karim3, Farhana Rahman,4 Shitil Ibna Islam5

ABSTRACT Background & objective: Rapid urbanisation in the 20th century has been accompanied by the development of slums. Nearly one-third of the world’s population and > 60% of urban populations in the least developed countries including hundreds of millions of children live in slums. Slums are areas of broad social and health disadvantage to children and their families due to extreme poverty, overcrowding, poor water quality and sanitation,

substandard housing, limited access to basic health and education services. The objective of this study was to ORIGINAL ARTICLE assess the demographic and nutritional status of working slum children in Dhaka city.

Methods: This descriptive cross-sectional study was conducted at Moghbazar slum, situated in Dhaka city from July to December, 2013. A total of 200 slum children aged 6 to18 years whose parents’ (either father or mother) voluntarily consented to allow their children participate in the study.

Result: Out of 200 slum children, 57(28.5%) were in the age group of 12-14 years, among them 110(55.0%) were male. More than 50% never attended any kinds of formal school. Forty five percent children lived with their parents. Over half (26%) of the slum children were engaged in beggary, 23% were van/rickshaw puller, 22% were rag-picker (Tokai), 10% were cooli. Three-quarters of the children had medium work-load and 80% did 5-8 hours work per day sixty percent of the children had monthly income of Taka 1000-1500. In terms of BMI, one-third (33.5%) was severely under-nourished, 55% were of normal BMI and 11.5% were overweight and obese.

Conclusion: The study presented a gloomy picture (in terms of nutritional status) of working children in a selected slum within Dhaka city. Therefore, health related programmes should focus to improve the overall wellbeing of the working slum children.

Key words: Nutritional status, working slum children, occupation.

INTRODUCTION: which is caused by social deprivation.2 Many children find works, like collecting the waste Children constitute a large segment of the world's papers, cleaning cars or working as shoe shiners. population and, therefore, form a significant Some engage in begging, pick-pocketing or sex component of all human societies.1 There is a pervert while others end up as drug addicts, who general tendency in society to view slum children use cheap and easy accessed inhalants which as criminals, victims, or as sub-human figures but cause irreversible brain damage. Furthermore, a significant portion of disadvantaged children live they have less access to basic amenities, such as, in the slums on account of acute impoverishment

Authors’ information: 1 Dr. Md. Nurul Amin, Assistant Professor, Department of Community Medicine, Rajshahi Medical College, Rajshahi & Executive Editor, Ibrahim Cardiac Medical Journal, Ibrahim Cardiac Hospital & Research Institute, Shahbag, Dhaka. 2 Dr. Shayela Farah, MBBS, MPH (DU), Assistant Professor, Department of Community Medicine, Dhaka Community Medical College, Moghbazar, Dhaka-1217 3 Dr. Mohoshina Karim, MBBS, MPH (DU), Lecturer, Department of Community Medicine, Dhaka Community Medical College, Moghbazar, Dhaka.-1217 4 Dr. Farhana Rahman, Assistant Professor (Pediatrics), Delta Medical College, Dhaka. 5 Shitil Ibna Islam, MS in Environmental Science (KU) & Health Economich (DU), Research O cer, Ibrahim Cardiac Hospital & Research Institute, Shahbag, Dhaka, Bangladesh. Correspondence: Dr. Shayela Farah, Phone:+8801716143491 E-mail: [email protected]

49 State of Working Slum Children in Dhaka City Amin et. al.

health, education or food.3 Bangladesh is a country study duration was six months from July to of South Asia with 1, 47,570 sq. km of geographical December, 2013 to assess the situation of working area and 146.6 million people making it world’s slum children in Dhaka city. A house-to-house seventh most densely populated country.4 survey was conducted and a total of 200 working children aged 6 to 18 years were enrolled using Dhaka is the capital city of Bangladesh and one of purposive sampling technique. Consent regarding the most densely-populated & rapidly expanding their participation in the study was, however, mega-cities in the world. Unfortunately, the taken from their parents. The children were expansion and growth are not well planned. It is interviewed and information regarding the age, estimated that every year 300,000 to 400,000 education, occupation, monthly family income, new migrants come to city from different parts of working conditions and nutritional status of their the country. As a result, every ten years the children were collected both from the parents and population of Dhaka is doubling. Many slum children. Height was measured without shoes to dwellers are illiterate, live in unhygienic the nearest centimeter using a ruler attached to conditions, eat unhealthy food and drink unsafe the wall, while weight was measured to the water. These conditions create many health nearest 0.1 kg on a manually-adjusted scale with problems. Overcrowding & unsanitary conditions the subject wearing school ordinary dress and no facilitate the transmission of disease-including shoes. Then data were collected from the pneumonia and diarrhoea, the two leading killers respondents by face-to-face interview using a of children (younger than 5 years) worldwide.

ORIGINAL ARTICLE semi-structured questionnaire (Research Instrument Outbreaks of measles, tuberculosis and other or Tool). Using weight and height data, body mass vaccine preventable diseases are also more index (BMI) was calculated with the help of frequent in these areas, where population density formula BMI = (weight in kg)/ (height in sq-meter). is high and immunization levels are low.5

It has been recognized that infants, children and women of the reproductive age constitute the most vulnerable group from the stand point of nutrition. Malnutrition is the outcome of many complex biological and social processes. The roots of malnutrition run deep into its social soil and it is a cause of concern.6 Since children have the rights to survival, adequate health care and a standard of living that supports their full development. Research on urban slum dwellers, specially, on nutrition is very relevant and deserve in-depth studies. This could help explain many of the interrelated variables which come into play in explaining the prevailing situation amongst the urban slum dwellers. The purpose of the study was to assess the demographic and nutritional situation of working slum children in slum environment in Dhaka city. METHODS:

This descriptive cross-sectional study was conducted at Moghbazar slum situated near the Fig. 1 : Body mass index-for-age percentiles Dhaka Community Medical College Hospital. The (Adapted from CDC, Atlanta)

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As BMI of children and adolescents is age- and Table II. Socio-demographic characteristics of slum children (n=200) sex-specific, calculated BMI were plotted on Socio-demographic characteristics Frequency Percentage Growth-chart [developed and recommended by Age (years) Centre Disease Control (CDC), Atlanta] to find the 6-8 45 22.5 percentile. Then the nutritional status of the 9-11 40 20.0 individual respondents was determined as follows: 12-14 57 28.5 15-17 42 21.0 Table I. Nutritional status based on BMI-for-age percentiles >17 16 8.0 (Adapted from CDC, Atlanta) Sex

Male 110 55.0 ORIGINAL ARTICLE Nutritional status Percentile range Female 90 45.0 Underweight < 5th Percentile Education Never attended any school 102 51.0 Normal 5th to < 85th Percentile Primary incomplete 60 30.0 Overweight 85th to < 95th Percentile Primary complete 33 16.5 Secondary incomplete 05 2.5 Obese ≥ 95th Percentile Living with Data were processed and analysed using SPSS, Both Parents 90 45.0 Mother Only 54 27.0 version 23. All analyzed data were presented in Father Only 02 1.0 the form of frequency and percentages. Alone 44 22.0 RESULTS: Others 10 5.0 Family members Out of 200 slum children, 57(28.5%) were in the <3 14 7.0 age range 12-14 years, 45(22.5%) in 6-8 years 3-5 166 83.0 and 42(21.0%) were in 15-17 years. Among them >5 20 10.0 110(55.0%) were male and the rest female. More than 50% children never attended in school, 30% Table III. Working status of the slum children (n = 200) had incomplete primary level education and Work-related variables Frequency Percentage 16.5% completed primary level. Forty five percent Occupation children lived with their parents, 27% lived with Beggary 52 26.0 their mothers only and 22% lived alone. Majority Domestic help 15 7.5 (83%) had 3-5 family members (Table II). Rag-pickers (Tokai) 44 22.0 Day labour 15 7.5 The children were found to be engaged in a wide Sex work 08 4.0 range of activities, which included among others Rickshaw/van-pulling 46 23.0 Tokai (rag-picker) (22%), van/rickshaw puller Transport work/help (Cooli) 20 10.0 (23%), beggar (26%), Cooli (10%) at the railway Work-load station or ‘launch ghat’ etc. Seventy five percent Normal 34 17.0 of the children had medium work-load and 80% Medium 150 75.0 did 5-8 hours work per day. Sixty percent had Heavy 16 8.0 Working hours monthly income of Taka 1000-1500, 30% Taka < 5-8 160 80.0 1000 and 10% Taka > 1500 (Table III). In terms > 8 40 20.0 of nutritional status (BMI), one-third (33.5%) was Personal income (TK) severely undernourished, 55% were of normal < 1000 60 30.0 nutritional status, 9% were overweight and 2.5% 1000-1500 120 60.0 obese (Fig 2). >1500 20 10.0

51 State of Working Slum Children in Dhaka City Amin et. al.

UNICEF estimates that around 16% of children 55.0 aged 5-14 years in developing countries are 60 involved in child labour.10 ILO estimates that 50 around 215 million children under 18 work around 33.5

e 40 the world; many of them being full-time. In g a t

n Sub-Saharan Africa 1 in 4 children aged 5-17

e 30 c r

e works, compared to 1 in 8 in Asia-Pacific and 1 in P 20 9.0 10 in Latin America are engaged in child-labour.11 2.5 10 Even though the prevalence of child labour is 0 falling in recent years everywhere, apart from Under weight Normal Over weight Obese Sub-Saharan Africa,12 it continues to harm the Nutritional status physical and mental development of children and adolescents and interfere with their education.10

Fig. 2: Distribution of children by their nutritional The slum children were found engaged in a variety status (n = 200) of activities, which mong others include DISCUSSION: rag-picking, van/rickshaw pulling, beggary, assisting passengers in carrying their luggage in Growth of urban population is always accompanied “railway station” or “launch-ghat” (cooli) etc. by the growth of slums, which poses threat to the Working children are involved in many different ORIGINAL ARTICLE health of urban population, particularly, the health types of work, often for little or no pay. Some of the children.7 In the present study out of 200 children work within their own homes, engaged in slum children, 57(28.5%) were in the age range of domestic chores and small family businesses. 12-14 years, 45(22.5%) in the range of 6-8 years Others work outside their homes, in small shops, and 42(21.0%) were in 15-17 years which bears factories, restaurants, tanneries, waste-dumps and consistency with the findings of Ahmad8 (31% on the streets. Most working children are employed were 8-10 years, 34% 11-13 years and 35% for an average 8 to 12 hours a day. Many children 14-18 years of age). involve working in hazardous conditions that endanger their physical or mental health and moral The present study demonstrated that over half development through unsafe environments, (51%) of the children never attended in any kinds dangerous duties or overly- long working hours.13 of formal education & 15(33.0%) had incomplete primary education. Khatun & associates2 conducted Three-quarters (75%) had medium work-load and a study in Khulna city where one-fourth (25%) of 80% of them did 5-8 hours work per day and most the children were illiterate, 57% completed up to of their income was 1000-1500 Tk per month Grade-III and only 3% completed up to Grade- which is in line with the results of Khatun et al2. VIII. Forty five percent children lived with their Malnutrition makes a central contribution (up to parents, 27% with mothers only and 22% alone. 56%) to child mortality worldwide and is a These findings are consistent with the findings of recognised problem in informal settlements.14 In “The Chetona Bikash Kendra (CBK)” where 45% the present study, (33.5%) children were severely live with their parents, 18% maintained contact under-nourished, 55% were normal and 11.5% with parents and 24% had no contact with overweight or obese. Compared with their urban parents.8 Majority of children lived with 3-5 family counterparts, children in slums are more likely to members with average family member being 5.9 be undernourished and stunted 15,16 which might Conception goes that population explosion rate is be due to prolonged or recurrent episodes of high in slum. But the study found that they prefer hunger or specific nutritional deficiencies (e.g., to have small-family like other non-city slum caloric, protein, micronutrient), and also might be dwellers for better living. due to persistent or recurrent ill-health.17

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In countries where a large proportion of the urban 10. UNICEF 2011 State of the World’s Children. Adolescence landscape is covered with slums, the rates of An Age of Opportunity United Nations Children’s Fund (UNICEF). February 2011. malnutrition and mortality amongst children are high, particularly in sub-Saharan Africa and South 11. Saltillo United Nations Simulation [Internet]. Suns 2013 Asia. This is clearly linked to inequalities in access [cited 14/06/2016 12:14 PM]. Available able from: http://colamsuns2013.wix.com/suns-2013?_escaped_ to shelter, health care, employment & education. fragment_=background-papers-unicef/c1q4y In most of the developing countries, 2 out of 5 slum children are malnourished, a ratio that is 12. UNICEF. 2015 http://www2.unicef.org:60090/protection/ 57929_58009.html twenty times higher than that of developed countries.18 13. Education_for_Working_Children_(BEHTRUWC). pdf.. ORIGINAL ARTICLE Availableat:https://www.scribd.com/document/13511 CONCLUSION: 0509/ Education-for-Working-Children-BEHTRUWC

The findings of this cross-sectional study 14. Swaminathan H, Mukherji A. Slums & malnourishment: presented a gloomy picture (in terms of evidence from women in India. Am J Public Health 2012;102:1329–35. demographic and nutritional status) of working children in a selected slum in Dhaka city. A 15. Fotso JC. Child health inequities in developing countries: large-scale study addressing the variables of differences across urban and rural areas. Int J Equity Health 2006;5:9. interest is desirable for gaining further insight. 16. Sverdlik A. Ill-health and poverty: a literature review REFERENCES: on health in informal settlements. Environ Urban 2011; 1. Pagare D, Meena GS, Singh MM, Saba R. Risk factors of 23:123–55. substance use amongst street children from Dehli. 17. Bhutta ZA, Chopra M, Axelson H, Berman P, Boerma T, Journal of the Indian Academy of Pediatrics 2004;41 Bryce J, Bustreo F, et al. Countdown to 2015 decade (3):221-25. report (2000–10): taking stock of maternal, newborn, 2. Khatun MT, Jamil H. Life Style of the Street Children. and child survival. Lancet 2010;375:2032–44. Bangladesh Research Publications Journal 2013;9(1) 18. Urban Features: Children, Slums’ First Casualties, :50-56. UN-HABITAT. Available from: www.unhabitat.org. 3. Ahmed S. Bangladesh: Moving towards universal birth registration. The IRIN (e newspaper) [Internet]. DHAKA, 15 July 2008 [Cited 14/06/2016 11:51 AM] Availablefrom:http://www.irinnews.org/report/79258/ bangladesh-moving-towards-universal-birth-registration.

4. BBS. Statistical Pocket Book. Bangladesh Bureau of Statistics. 2009.

5. SOW 2012-Main Report_EN_13 Mar 2012.

6. Haque M, Bhuiyan R, Naser MA, Arafat Y, Roy SK, Khan ZH. Nutritional Status of Women Dwelling in Urban Slum Area. J Nutr Health Food Eng 2014;1(3):00014. Availablefrom:http://dx.doi.org/10.15406/jnhfe. 2014.01 .00014.

7. Kavitha N. Are Slum Children at High Risk of Under Nutrition, Anemia and Childhood Morbidity? Evidence from India. Ind J Comm Health 2014;26(2):124–31.

8. Ahmad M: Education For Street Children: A Case Study of Chetona Bikash Kendra; Community Development Library (CDL), Annual Activity Report 2003. Dhaka.

9. Democracywatch. A Study on Situation of Girl Children of Slums in Dhaka City, 2010.

53 Ibrahim Card Med J 2019; 9 (1&2): 54-59  Ibrahim Cardiac Hospital & Research Institute

Pattern of Drugs Use in Selected Paediatric Diseases in Outpatients Departments of Public and Private Teaching Hospitals in Bangladesh Tasnin Afrin,1 Rumana Afroz,2 Shahin Sultana,3 Kamrunnesa,4 Mahbuba Jahan Lotus5

ABSTRACT

Background & objective: Appropriate use of drugs are important in any diseases in any population. It is particularly so in children. To evaluate whether drugs are properly utilized in terms of efficacy, safety, convenience and economic aspects at all levels in the chain of drug use, periodic studies addressing the utilization of drugs in different health care setting are essential. Various drug utilization studies have been carried out all over the world but there are limited studies addressing drug use patterns in pediatric population in Bangladesh. The present study is one such step to evaluate the pattern of drug use in different pediatric diseases among patients attending at pediatric out-patient department (OPD) in two selected medical college hospitals.

Methods: This cross-sectional study was conducted in the paediatric OPD of two tertiary care hospitals, Sir Salimullah Medical College & Mitford Hospital (SSMC & MH) (a public hospital), Dhaka and Dhaka National Medical College (DNMC) & Hospital (a private hospital). A total of 600 children (300 from each of the two Medical College Hospitals) were selected as study subjects. Three hundred prescriptions audited in SSMC & MH contained a total 946 drugs and 300 prescriptions audited in DNMC contained 990 drugs in total. Patients got admitted during out-patient department visit were excluded from the study. The age and sex of the patients

ORIGINAL ARTICLE and medications use-related variables like dose, frequency, duration and route of administration of the drugs were noted. Pattern of drug use in the hospitals for pediatric population was evaluated.

Results: The study subjects of the two tertiary hospitals were almost identical in terms of age and sex (p = 0.181 and p = 0.369 respectively). Use of three drugs per encounter was commonly observed in both the hospitals. Around one-third of the prescriptions contained four drugs. Prescription of five drugs was rare in both the hospitals. Prescription with two drugs was higher in SSMC & MH than that in DNMC Hospital (p = 0.043). Majority of the prescriptions from SSMC (83.1%) contained drugs within essential drug list (EDL) compared to that from DNMC (73%) (p< 0.001). The highest prescribing drug was antibiotic, both in SSMC (22.7%) and DNMC (23.2%) (p = 0.417) followed by analgesic (18% in SSMC and 17.7% in DNMC), anti-diarrhoeal. The less commonly used drugs were gastric acid suppressant, antispasmodic, anthelmintic, antiemetic, while rarely prescribed drugs were antihistamines, antiasthmatic and nasal drops. Pattern of drugs prescribed in two hospitals were similar (p > 0.05).

Conclusion: The study concluded that the rate of antibiotics prescribed in both public and private hospitals is higher. Further studies teaching hospitals etc. are required for the monitoring of drug utilization pattern and formulation of Standard Treatment Guidelines (STG) for the physicians is essential.

Key words: Pattern of drug use, Pediatric diseases, Outpatients department, Public & private teaching hospitals etc.

Authors’ information: 1 Dr. Tasnin Afrin, Assistant Professor, Department of Pharmacology & Therapeutics, Dhaka Community Medical College. Dhaka. 2 Dr. Rumana Afroz, Assistant Professor, Department of Pharmacology & Therapeutics, Dhaka Medical College. Dhaka. 3 Dr. Shahin Sultana, Assistant Professor, Department of Pharmacology & Therapeutics, Mymensingh Medical College, Mymensingh. 4 Dr. Kamrunnesa, Assistant Professor, Department of Pharmacology & Therapeutics, Shahabuddin Medical College, Dhaka. 5 Dr. Mahbuba Jahan Lotus, Assistant Professor, Department of Pharmacology & Therapeutics, Dhaka Medical College, Dhaka. 6 Prof Dr. Ferdous Ara, Department of Pharmacology, Delta Medical College, Dhaka Correspondence: Dr. Tasnin Afrin, Cell Phone: +88 01726138327, E-mail: [email protected]

54 Pattern of Drugs Use in Selected Paediatric Diseases in Outpatients Departments of Public and Private Teaching Hospitals in Bangladesh Afrin et. al.

INTRODUCTION: prescribing practices and characterizes the early signals of irrational drug use. With the help of WHO Pediatrics is the branch of medicine dealing with the prescribed drug use indicators and concept of defined development, diseases and disorders of children.1 daily doses it is possible to compare drug utilization Drug therapy is considered to be the major patterns between different settings.13 Appropriate component of pediatric management in health care drug utilization studies are, therefore, important tools settings like hospital. The use of antimicrobial agents, to evaluate whether drugs are properly utilized in specially antibiotics has become a routine practice for terms of efficacy, safety, convenience and economic the treatment of pediatric illness.2 However, there are aspects at all levels in the chain of drug use.14 Various also reports of an irrational use of antibiotics,3 which drug utilization studies have been carried out all over may even lead to infections worse than originally ORIGINAL ARTICLE the world but there are limited studies addressing drug diagnosed ones. Inappropriate prescribing is a use patterns in pediatric population in Bangladesh. recognized worldwide problem of the healthcare delivery system.4 The rational prescribing can be Therefore, the present study was undertaken to assessed with the help of conducting prescription evaluate the pattern of drug use in different pediatric audit on continuous basis. In recent years, drug diseases. Out-patient Department of two tertiary utilization studies are found to be useful tool to level hospitals in Bangladesh, which may help facilitate rational use of drugs in health care delivery clinicians to take appropriate measure for the systems. It truly reflects the status of health care improvement of prescribing pattern and use of system. Various indicators have been developed by essential drugs to prevent prescribing errors and thus International Network for the Rational Use of Drugs promote rational use of drugs. (INRUD) to allow for assessment of drug use practices METHODS: and suggesting remedial measures.5 Many studies point to major misconceptions & misuse of medicines. This cross-sectional descriptive study was carried out The design of drug use indicator studies, however in the pediatric out-patient department (OPD) of two varies from settings to settings. While a large number tertiary care hospitals. The study population included of drug utilization studies are available for adults all children attending at Paediatrics OPD in Sir over the world,6,7 a few studies provide information on Salimullah Medical College & Mitford Hospital, Dhaka drug use patterns in pediatrics. and Dhaka National Medical College & Hospital. A total of 600 children (300 from each of the two Pediatrics is among the most vulnerable population selected Medical College Hospitals) were selected as group in terms of disease acquisition. Besides, study subjects. However, patients got admitted pharmacodynamic and pharmacokinetics are different during out-patient department visit were excluded in children, which often make them more susceptible from the study. The study population were classified to various adverse drug reactions.8,7 Additionally, the as low income group (monthly income<10000/ impact of maternal drug intake on neonates is also month), middle income group (monthly income relevant in this context. Such issues therefore call for 10000-20000/ month) and high-income group close monitoring of drug prescribing trends in (monthly income >20000/month). The demographic neonates and infants.9,10 Besides, due to economic characteristics like age and sex of the patients and and ethical issues, children do not often participate in medications use-related variables like dose, clinical trials and specific knowledge about effect of frequency, duration and route of administration of drugs in children is often inadequate.11 Another drugs were recorded. Pattern of drug used in the common problem encountered in children is failure to selected hospitals for pediatric population was comply with therapeutic regimen due to either evaluated with the help of World Health inconvenient dosing schedule and/or large number of Organization’s Core Drug Indicators to Investigate medicines prescribed.12 Study of drug utilization Drug Use in Health Facilities as follows (Table I): pattern in a particular setting gives an idea about the

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Table I. World Health Organization Core Drug Indicators to (83.1%) contained drugs within EDL compared to that Investigate Drug Use in Health Facilities from DNMC (73%) (p< 0.001) (Table IV). The highest WHO core drug use indicators prescribing drug was antibiotic, both in SSMC Prescribing indicators (22.7%) and DNMC (23.2%) (p = 0.417) followed by 1. Average number of drugs per prescription analgesic (18% in SSMC and 17.7% in DNMC) and 2. Percentage of drugs prescribed by generic name anti-diarrhoeal (10.5% in SSMC and 10.1% in DNMC). 3. Percentage of encounters with an antibiotic prescribed The less commonly used drugs were gastric acid 4. Percentage of encounters with an injection prescribed suppressant, antispasmodic, anthelmintic, antiemetic, 5. Percentage of drugs prescribed from Essential Drug List or formulary while rarely prescribed drugs were antihistamines, antiasthmatic and nasal drops. Pattern of drugs Patient care indicators* prescribed in two hospitals were almost similar (p > 6. Average consultation time 0.05) (Table V). 7. Average dispensing time 8. Percentage of drugs actually dispensed Table II.Distribution of age of study subjects in the two study areas 9. Percentage of drugs adequately labeled 10. Patient’s knowledge of correct dosage Study Area Age(years) SSMC DNMC *p-value Facility indicators (n = 300) (n = 300) 11. Availability of copy of Essential Drug List or formulary 0 – 1 84(28.0) 63(21.0) 12. Availability of key drugs 1 – 6 124 (41.3) 128(42.7) Some additional indices 0.181 REVIEW ARTICLE 6 – 10 82(27.3) 94(31.3) 13. Percentage of encounters with other drugs 10 – 12 10(3.3) 15(5.0) *Number 6-10 were not included in current study *Data were analyzed using Chi-squared (χ2) Test and were presented as n(%). Figures in the parentheses denote corresponding percentage. The total number of drugs prescribed for 300 patients of SSMC & MH was 946 and that prescribed for 300 Male Female patients of DNMC was 990. The most commonly 54 52.7 prescribed drugs were noted. The number of drugs prescribed from essential drug list of Bangladesh was 52 51.0

also studied. Data were analyzed using SPSS and the e 50 49.0 a g test statistics used to analyze the data were t n 47.3 e 48 2 c descriptive statistics and Chi-squared (χ ). Level of r e significance was set at 5% and p-value < 0.05 was P 46 considered significant. 44 SSMC DNMC Sex RESULT:

The pediatric patients included from the two tertiary Figure 1: Distribution of sex by patients admitted in hospital hospitals were almost similar in terms of age Table III.Number of drugs prescribed per prescriptions distribution with 1-6 years age group was the Study Area predominant (p = 0.181) (Table II). The sex Prescriptions containing number SSMC DNMC *p-value distribution was also identical between the study of drugs (n = 300) (n = 300) groups (p = 0.369) (Fig. 1). Use of three drugs per Two 60(20.1) 40(13.3) encounter was commonly observed in both the Three 140(46.6) 145(48.4) hospitals. Around one-third of the prescriptions 0.043 contained four drugs. Prescription of five drugs was Four 94(31.3) 100(33.3) rare in both the hospitals. Prescription with two drugs Five 6(2.0) 15(5.0) was higher in SSMC than that in DNMC (p = 0.043) *Data were analyzed using Chi-squared (χ2) Test and were presented as n(%). (Table III). Majority of the prescriptions from SSMC Figures in the parentheses denote corresponding percentage.

56 Pattern of Drugs Use in Selected Paediatric Diseases in Outpatients Departments of Public and Private Teaching Hospitals in Bangladesh Afrin et. al.

Table IV. Drugs prescribed from essential drug list (EDL) of Bangladesh the average number of drugs per prescription was significantly higher than recommended by WHO/ Study Area INRUD. Trade names were used more often and EDL drugs SSMC DNMC *p-value (n = 300) (n = 300) generic prescribing was remarkably lower at private Drugs included within EDL 786(83.1) 723(73.0) sector. <0.001 Drugs excluded from EDL 160(16.9) 267(27.0) Essential medicines and rational use of medicines are *Data were analyzed using Chi-squared (χ2) Test and were two sides of a coin – inseparable from each other and presented as n(%). mutually dependent. Increase in the use of essential Figures in the parentheses denote corresponding percentage. medicines makes the medication therapy more rational.15 In this study, 83% of the medicines could ORIGINAL ARTICLE Table V. Group of drugs used in the diseases of pediatric age group be considered as essential in Sir Salimullah Medical during the study College & Hospital and 73% could be rated as Most common Study Area essential in Dhaka National Medical College & pharmacological SSMC DNMC *p-value group (n = 300) (n = 300) Hospital. A study conducted in three tertiary hospitals of Delhi reported 96, 94 and 74% of essential Analgesic and antipyretic 170(18.0) 175(17.7) 0.866 medicines prescribed16 indicating that prescribing Antibiotic 215(22.7) 230(23.2) 0.792 behavior in India for pediatric age-group is better Expectorants & bronchodilators 78(8.2) 88(8.9) 0.613 than that in our country. One reason for this could be Antihistamines 33(3.5) 35(3.5) 0.955 an effective and successful implementation of NEML Antiasthmatics 22(2.3) 26(2.6) 0.671 (National Essential Medicine List) in government Nasal drops 32(3.4) 36(3.6) 0.762 hospitals of Delhi. There is a pressing need for studies into how medicines are being prescribed to children in Anti-diarrheal 100(10.5) 100(10.1) 0.734 various settings and populations. Studies that have Antiemetic 63(7.4) 55(5. 5) 0.310 investigated prescribing in populations have found Gastric acid suppressants 80(8.4) 86(8.7) 0.856 high prescribing rates although a limited formulary of Antispasmodic 83(8.7) 84(8.5) 0.821 medications is used.17 More medicines increase the Anthelmintic 70(7.4) 75(7.5) 0.883 risk of drug interactions, adversely affecting the patient compliance and hike the cost of treatment.18 *Data were analyzed using Chi-squared (χ2) Test and were presented as n(%). Indiscriminate or prolonged prophylactic use of new Figures in the parentheses denote corresponding percentage. antibiotics has been shown to contribute to the emergence of multi-resistant strains in the hospital DISCUSSION: settings. Like antibiotics, it is difficult to justify the use The present study was intended to assess the of analgesics on such a large scale, taking into prescribing pattern of drugs for paediatric patients at account that prolonged and excessive use of the tertiary level hospitals. The tertiary level hospitals analgesics may cause potential hazards.19 In have been chosen because the prescribing patterns of Bangladesh doctors more often prescribe drugs the out patients department of tertiary level hospitals irrationally to give quick relief of the patients without are often copied by community practitioners and taking into consideration of the patient's disease health workers. Irrational use of drugs is common in condition and age.16 Data obtained from the study, developing countries with a high rate of poly- however, do not support the claims that the private pharmacy, overuse of antibiotics, use of off-level sector hospitals are more efficient and accountable in drugs and drugs with improper efficacy. Several rational prescribing of medications than the public studies have documented prescribing practice in sectors do.20,21 different countries. But there is still dearth of Inappropriate drug prescribing is a global problem.22 information on the prescribing pattern of drugs in Misuse of drugs occurs in all countries. The irrational paediatrics. In the present study it was observed that prescribing behavior is especially common and costly

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in developing countries. Such practices include REFERENCES polypharmacy, use of wrong or ineffective drugs, 1. Ghai OP, Paul VK, Rational drug therapy in pediatric underuse and incorrect use of effective drugs, use of practice. Indian Pediatr 1988;25:1095-1109. combination products which are often more costly and 2. Summers RS, Summers B, Drug prescribing in pediatrics. offer no advantage over single compounds and Ann Trap Paediatr 1986;6:129-33. overuse of antimicrobials and injections.23 Affordable 3. Principi N. Control of antibiotic therapy in pediatric patients. medicine prices are an important prerequisite for Developmental Pharmacology and Therapeutics 1981;2: ensuring access to essential drugs in the public and 145-55. private sectors. High drug prices lead to barrier 4. WHO, Report of a conference of experts, Nairobi, November. towards affordability.24 It is one of the specific (1985). The rational use of drugs. Geneva, 1987:24-29. objectives of the National Medicine Policy, which emphasize on access to equitable availability and 5. Laporte JR, Porta M, Capella D. Drug utilization studies: a tool for determining the effusiveness of drug use. Brnk J affordability of essential medicines to those who need Clin Pharmacol 1983;16:301-304. them.25 When the drug-price is high, the consumers often purchase them, in small quantities, rather than 6. Guyon AB, Barman A, Ahmed AU, Alam MS. A baseline survay on use of drugs at the primancy health care level in in therapeutic amounts. The widespread prescription Bangladesh. Bull WHO 1994;72:265-271. and sale of non-essential drugs means that 7. Vallano A, Montene E, Arnau JM, Vidal X. Medical specialty households, especially poor households, are not and pattern of medicines prescription. Eur J clin Pharmacol 26 getting the best health care for their money. 2004;60:725-730.

ORIGINAL ARTICLE Despite resource constraint in health sector, 8. Ginsberg G, Hattis D, Sonawane B, Russ A. Evaluation of particularly in drug supply, specific improvements in Child/Adult Pharmacokinetic Defferences from a database management of drugs, could reduce wastage and derived from the therapeutic Drug Literature. Toxicol Sci 2002;66:185-200. irrational use, which in turn, will make availability of essential drugs without increasing their expenses.27 9. Takahashi H, Ishikawa S, Nomoto S. Development changes Prescribing pattern need to be evaluated periodically in Pharmacokinetics and Pharmacodynamics of warferin enantiomars in Japanese Children. Clin Pharmacol Ther to increase the therapeutic efficacy, decrease adverse 2000;68:541-555. effects and provide feedback to the prescribers.28 Drug utilization appraisals are useful for obtaining 10. Hanne M, Morten A, Josper H. Drug Prescribing in Danish Children: a population based study, Pharmacoepidemiology information about drug use pattern and their costs.29 and prescription. Eur J Clin Pharmacol 2001;57:159-165. The causes of access gap to essential drugs and the 11. Karande S, Sankhe P, Kulkarne M. Patterns of prescription measures which are needed to close the gap is linked and drug dispensing. Ind J Pediatr 2005;72:117-121. to a set of fundamental economic, social and educational factors that lie beyond the health sector 12. Strand, J, Rokstad, K, Heggedal, U. Drug prescribing for children in general practice: A report from the More and system.30 However, it should be borne in mind that Romsdal Prescription study. Acta Paediatrica 1988;89: access to essential medicines helps to reduce disease 218-224. burden.24 13. World Health Organization (WHO). Rational use of medicines; CONCLUSION: India 2003. Available from: http:// www. whoindia.com 14. Clavenna A, Sequi M, Bortolotti A, Morlino L, Fortino I, The study concluded that the incidence of antibiotics Bonati M. Determinants of drug utilization profile in the prescribed in both public and private hospitals seems pediatric population in Italy. British Journal of Clinical to be higher. Periodic studies for monitoring of drug Pharmacology 2009;67(5):565-71.

utilization pattern in different health care settings and 15. Desai S. Essential drugs and rational drug therapy. Bull soc formulation of Standard Prescribing Guidelines (STG) Rational Ther 2001;12:2-7. for the physicians is essential, which will help assuring 16. Biswas NR, Biswas RS, Pal PS. Patterns of prescriptions and rational use of drugs, thereby reducing the drug use in two tertiary hospitals in Delhi. Indian J Physiol unnecessary drug interactions & health expenditure. Pharmacal 2000;44:109-12.

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17. Strand J, Rokstad K, Heggedal U. Drug prescribing for 24. Tettch EK. Provide affordable essential medicines to African children in general practice: A report from the More and households: The missing policies and institution for price Romsdal Prescription study. Acta Paediatrica 1988;89: containment. Soc Sci and med 2008;66:569-581. 218-224. 25. Ahmed H, Ibrahim M, Babar Z. Affordability of essential 18. Mirza NY, Desai S, Ganguly B. Prescribing pattern in a medicines used for treating chronic diseases in Malaysia: An pediatric outpatient department in Gujarat. Bangladesh J academic perspective. The Internet Journal of Third World Pharmacal 2009;4:39-42. Medicine 2009;8:1.

19. Smith AJ, Aronson KJ, Thomas M. Antibiotic policies in the 26. World Health Organization (WHO). How to develop and developing world. Eur J of Clin Pharmacal 1991;41:85-87. implement a rational drug policy 2nd ed. Geneva: WHO, 2001. 20. Rosenthal G, Newbrander W. Public policy and private sector

provision of health services. Int J Health Plann Manage 27. Boston, MA. Managing drug supply: the selection, ORIGINAL ARTICLE 1996;11:203-216. procurement, distribution and the use of pharmaceuticals in primary health care 1981:18-19. 21. Bustreo F, Harding A, Axelson H. Can developing countries achieve adequate improvements in child health outcomes 28. Kumari R, Idris MZ, Bhushan V, Khanna A, Agarwal M, Singh without engaging the private sector. Ball World Health SK. Assessment of prescribing pattern at the public health Organization 2003;81:886-895. facilities ofLucknow district. Indian J Pharmacol 2008; 40:243-247. 22. Enwere OO, Falade CO, Salako BL. Drug prescribing pattern at the medical outpatient clinic of a tertiary hospital in 29. Marshner JP, Thurmann P, Harden S, Rietbrock N. Drug southwestern Nigeria. Pharmacoepidemiol Drug Saf 2007; utilization review on a surgical intensive care unit. Int J Clin 16:1244-9. Pharmacol Ther 1994;32:447-451.

23. Blum NL. Drug Information Development. A Case Study 30. Quick JD. Essential medicines twenty five years on: closing Nepal. Rational Pharmaceutical Management Project. United the access gap. Health policy and planning 2003;18:1-3. States Pharmacopoeia. (Online) 2000. Available from URL: http://www.usp.org/pdf/EN/dqi/nepal Case Study.pdf.

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Variation in Coronary Artery Disease Pattern and Risk Factors among Female Patients of Di erent Age Groups in Bangladesh Shitil Ibna Islam,1 Md. Nurul Amin,2 Sahela Nasrin,3 F. Aaysha Cader4

ABSTRACT

Background & objective: Coronary Artery Disease (CAD) is a devastating life-threatening condition which varies with respect to age and sex. In Bangladesh a large number of patients currently undergoes coronary angiography for a variety of indications. Due to physiological changes after menopause, the females are more prone to develop CAD. So, the risk factors and pattern of CAD in female are subject change with changing ages. The objective of this study was to compare the risk factors and pattern of CAD in female patients of different age groups.

Methods: This cross-sectional analytical study was conducted at Ibrahim Cardiac Hospital & Research Institute (ICHRI), Dhaka, Bangladesh between September 2005 to August 2016. All female patients (n = 7,627) who underwent coronary angiography during the period were included. They were identified from ICHRI dedicated Cath-lab Database. The patients were divided into three groups based on their age (Group-I ≤45 years, Group-II from age 46 to age 60 and Group-III from age 60 years onwards). A stenosis of ≥ 70% in any of the three major coronary arteries like Left Anterior Descending (LAD), Right Coronary Artery (RCA) and Left Circumflex Artery (LCX) was considered as significant stenosis, while a stenosis of ≥ 50% in left main stem (LMS) was considered significant for left main disease. The data pertaining to their risk factors and angiographic profile were compared among the three age groups to find the association of risk factors and angiographic pattern of the CAD at different age groups.

ORIGINAL ARTICLE Result: All the risk factors (diabetes, hypertension, dyslipidaemia and CKD) demonstrated their significant presence in Group II and III compared to those in Group I, while they were almost identical between Group II and III. More than 40% of the patients were overweight in all age groups and around 20% were obese including a negligible proportion with morbid obesity. ST-segment elevation MI, NSTEMI (Non-ST-elevation myocardial infarction), prior MI (Myocardial infarction), and ALVF (Acute left ventricular failure) were significantly higher in Group III than the two other groups had. However, unstable angina was significantly higher in age-group I & II and atypical chest pain in Group I. Incidence of Single vessel disease (SVD) was considerably higher in group II. Double vessel diseases DVD), Triple vessel disease (TVD), LM disease was significantly higher in group III compared to two other groups. Normal CAG (Coronary angiography) finding was higher among group I, although it was not significantly different from other two groups.

Conclusion: The study concluded that the prevalence of conventional risk factors including overweight/obesity is almost similar between middle-aged and elderly women, while they are significantly lower in early middle-aged group. The elderly women usually present with STEMI (ST-elevation myocardial infarction), non-STEMI, stable CAD, ALVF, while middle-aged women commonly present with UA (Unstable Angina) and early middle-aged women with atypical chest pain. Severe CAD including and LM disease is relatively common in elderly women than those in their early middle-aged and middle-aged cohorts. Coronary artery disease advances with advancing age. Health-care providers should not underestimate the cardiac health of women.

Key words: Coronary artery disease, age, female patients, risk factors, angiographic profile

Authors’ information: 1 Shitil Ibna Islam, MS in Environmental Science (KU) & Health Economich (DU), Research O cer, Ibrahim Cardiac Hospital & Research Institute, Shahbag, Dhaka, Bangladesh. 2 Dr. Md. Nurul Amin, MBBS, DMCH & FP (DU), M Phil (PSM, DU), MPH (Mohidul University), Associate Professor & Executive Editor, Ibrahim Cardiac Medical Journal, Ibrahim Cardiac Hospital & Research Institute, Shahbag, Dhaka, Bangladesh. 3 Dr. Sahela Nasrin, MBBS, MCPS (Med), MD (Card), Consultant & Associate Professor, Ibrahim Cardiac Hospital & Research Institute Dhaka, Bangladesh. 4 Dr. F. Aaysha Cader, MBBS, MRCP (UK), Registrar & specialist in Cardiology, Ibrahim Cardiac Hospital & Research Institute, Dhaka, Bangladesh. Correspondence: Shitil Ibna Islam, Cell Phone: 00880 01720262070, E-mail: [email protected]

60 Variation in Coronary Artery Disease Pattern and Risk Factors among Female Patients of Di erent Age Groups in Bangladesh Islam et. al.

INTRODUCTION: estrogen after menopause alters cardiovascular function & metabolism favoring the development Coronary artery disease (CAD) is a global health atherosclerosis and CAD.17 However, existing data problem reaching an epidemic proportion in both regarding the protective role of oestrogen against developed and developing countries and is the coronary artery disease is conflicting. Women leading cause of mortality and morbidity have poorer prognosis and more severe outcome worldwide. It accounts for about one-third of all than men after myocardial infarction, deaths in individuals over the age of 35 years.1-3 percutaneous coronary intervention and coronary By 2030 the world’s population will grow to 8.2 artery bypass grafting. Mortality from CAD among billion and 33% of all deaths will be caused by women is increasing more rapidly than that in coronary artery disease.4 Cardiovascular disease ORIGINAL ARTICLE men. Moreover, for survivors among female is eight times more responsible for female death patients there is higher risk of recurrent MI, heart compared to breast cancer. Previously it was failure or death.18 In Framingham heart study the thought that CAD primarily affects men. Now it is one-year mortality following an MI was 44% in reported that 1 out of 3 women dies of women.19 The overall CAD mortality following an cardiovascular diseases in the United States MI are about 40% higher in women after compared to 1 in 25 who dies breast malignancy.5 adjustment for age and other risk factors.14 The exact prevalence of CAD in Bangladesh is yet Mortality and morbidity related to CAD have risen unknown.6 Some recent data indicated CAD significantly among women of Asian country as prevalence between 1.85%.7 and 3.4%.8 in rural evidenced data from India and China.20-23 That area and 19.6% in urban.6,9,10 Despite marked purpose the present study was intended to disparity in prevalence statistics among different compare the risk factors and angiographic pattern studies, there seems to be a rising prevalence of of CAD in Bangladeshi female patients of different CAD in Bangladesh.6 However, a study from rural age groups. Bangladesh demonstrated a 30-fold increase in METHODS: CVD deaths from 1986 to 2006 (from 16 deaths per 100,000 population in 1986 to 483 deaths per This retrospective study was conducted at Ibrahim 100,000 in 2006) among males and 47-fold (from Cardiac Hospital & Research Institute, Dhaka, 7 deaths per 100,000 to 330 deaths per 100,000) Bangladesh between September 2005 to August in females.6,9,11,12 2016. All female patients who underwent coronary angiogram during the period were consecutively There has been a substantial rise in the proportion included (n = 7627). They were identified from of women undergoing coronary angiography over ICHRI dedicated catheterization laboratory or the last few years.13 The reason for this Cath-lab Database. Consent had been taken from evolutionary change may be multifactorial. The the patients’ near relatives before the procedure, annual mortality rate of women from CAD is also Angiogram with or without Percutaneous coronary going up.14 In Indian populations it has reached intervention (PCI). Complying with the Helsinki epidemic proportion and accounts for 1 out of 3 Declaration of Research Involving Human Subjects women deaths regardless of the race or ethnicity.15 1964, last amended in 2013 prior permission was The large INTERHEART Cohort Study conducted taken from the Hospital Ethical Review Committee. on more than 52000 individuals with myocardial infarction16 demonstrated that CAD is delayed by The patients were divided into three groups based approximately 10 years in females and occurs on their age (Group-I ≤ 45 years, Group-II from most commonly after menopause, although the age 46 to age 60 and Group-III from age 60 years role of menopause on coronary artery disease is onwards). The data pertaining to risk factors and yet not clear. It is believed that withdrawal of angiographic profile were obtained and were compared among the three groups to find the

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associated risk factors and angiographic pattern of artery bypass graft and stenting were significantly the CAD at different age groups. Coronary higher in group III compared to two other groups angiogram was done by right femoral or radial (p < 0.001, p < 0.001, p < 0.001, p < 0.001 & p route. A Joint Committee of Consultants reported < 0.001 respectively). Single-vessel disease was the coronary lesions (stenosis). A stenosis of ≥ identical in all the study groups (p = 0.290) (Table 70% in any of the three major coronary arteries III). (LAD, RCA and LCx) was considere d as significant Table I. Comparison of risk factors in female patients of stenosis, while a stenosis of ≥ 50% in left main di erent age groups stem (LMS) was considered significant for left Group main disease. Single vessel disease, DVD and TVD Risk factors Group I Group II Group III p-value were noted down. (n = 1432) (n = 4052) (n = 2143) Data were processed and analyzed using SPSS Diabetes mellitus 834(58.2) 2865(70.7) 1510(70.5) < 0.001 (Statistical package for social science), version 25 Hypertension 948(66.2) 3233(79.8) 1713(79.9) < 0.001 (SPSS Inc., Chicago, IL, USA). The test statistics Dyslipidemia 363(25.3) 1235(30.5) 614(28.7) 0.001 used to analyze the data were Chi-square (χ2) CKD 17(1.2) 134(3.3) 101(4.7) < 0.001 Test. While the categorical data were compared between groups using Chi-square (χ2) Test, the Figures in the parentheses indicate corresponding %; *Chi-squared Test (χ2) was done to analyzed the data. data presented on continuous scale were compared between groups using Unpaired t-Test.

ORIGINAL ARTICLE Group I (≤45 Group II (46-60) Group III (≥60) The level of significance was set at 0.05 and 50 46.5 43.1 p-value < 0.05 was considered significant. 38.8 41.2 40 34.1

) 31.9

RESULTS: % (

e 30

a g 21.2

t 19.2

The distribution of risk factors among the three n 16 e 20 c r

study groups is illustrated in Table I. All the risk e P 10 2.4 factors (diabetes, hypertension, dyslipidaemia 1.9 2.2 1.5 1.4 1.6 and CKD) demonstrated their significant presence 0 in Group II and III compared to those in Group I Under Normal Over Obese Morbidly obese BMI (kg/m2) (p < 0.001, p < 0.001, p = 0.001 and p < 0.001 respectively), while they were almost between Fig 1: Comparison of BMI among di erent age groups Group II and Group III. More than 40% of the Table II. Comparison of Indication of CAG between the study groups patients were overweight in all age groups and around 20% were obese (p < 0.001) including a Group Indication of CAG Group I Group II Group III p-value negligible proportion with morbid obesity (Fig 1). (n = 1432) (n = 4052) (n = 2143) Provisional cardiac diseases or symptoms for which Coronary Angiogram (CAG) was indicated STEMI 125(8.7) 334(8.2) 252(11.8) <0.001 are depicted in Table II. Comparison of indications NSTEMI 104(7.3) 499(12.3) 372(17.4) <0.001 among the study groups revealed that STEMI, UA (Unstable Angina) 568(39.7) 1622(40.0) 725(33.8) <0.001 NSTEMI, prior MI, and ALVF were significantly SCAD 361(25.2) 1001(24.7) 555(25.9) 0.586 higher in Group III (> 60 years) than the two other groups (p < 0.001, p < 0.001, p < 0.001 Prior MI 59(4.1) 237(5.8) 161(7.5) <0.001 and p < 0.001 respectively). However, unstable Atypical chest pain 30(2.1) 49(1.2) 22(1.0) 0.015 angina was significantly higher in age-group I & II ALVF 64(4.5) 259(6.4) 247(11.5) <0.001 and atypical chest pain in Group I (p < 0.001 and p = 0.015 respectively). Double vessel disease, Figures in the parentheses indicate corresponding %; χ2 TVD, LM disease and past history of coronary *Chi-squared Test ( ) was done to analyzed the data.

62 Variation in Coronary Artery Disease Pattern and Risk Factors among Female Patients of Di erent Age Groups in Bangladesh Islam et. al.

Table III. Comparison of angiographic ndings in Female patients endogenous oestrogen deficiency carry more than between dierent age groups sevenfold increased risk of CAD.28 Oestrogens Age Groups (years) exert a regulating effect on several metabolic Angiographic p-value factors, such as lipids, inflammatory markers and ndings Group I Group II Group III (n = 1432) (n = 4052) (n = 2143) the coagulant system. They also expedite a direct SVD 507(35.4) 1527(37.7) 804(37.5) 0.290 vasodilatory effect through the a and b receptors 29 DVD 152(10.6) 694(17.1) 414(19.3) <0.001 in the vessel wall, which is further fortified by decline in flow-mediated vasoreactivity by TVD 96(6.7) 716(17.7) 514(24.0) <0.001 brachial artery measurements with the time LMD 36(2.5) 144(3.6) 116(5.4) <0.001 elapsed since menopause. Women have similar CABG (Coronary Artery magnitude of atherosclerosis like that of men, but ORIGINAL ARTICLE Bypass Grafting) 8(0.6) 56(1.4) 53(2.5) <0.001 their plaque characteristics and function are Stenting 40(2.8) 160(3.9) 154(7.2) <0.001 known to differ in comparison to males possibly Normal coronary due to estrogen or genetic related reasons.30,31 arteries 426(29.7) 1189(29.3) 592(27.6) 0.275 After menopause atherosclerotic plaque Figures in the parentheses indicate corresponding %; composition changes into more vulnerable lesions * Chi-squared Test (χ2) was done to analyzed the data. with inflammatory factors involved.18 DISCUSSION: These different plaque characteristics and different mechanisms of plaque formation result in The rising incidence of CAD in women is a currently different clinical presentations of CAD in women of a topic of considerable interest, particularly in the different age groups which is well-reflected in our developing countries. The importance & severity of study. The present study demonstrated that the CAD are underestimated in women. Although the elderly women (age > 60 years) generally present process is delayed 7 to 10 years later in women with STEMI, non-STEMI, stable CAD, ALVF, while than in men it is still the major cause of death in middle-aged and late middle-aged women (from 18 women over the age of 65 years. 46 – 60 years) commonly present with UA and In the present study the prevalence of all the early middle-aged women (≤ 45 years) with conventional risk factors was almost similar atypical chest pain. Kandoria and colleague24 also between middle aged (46-60 years) and elderly found premenopausal women more likely to (> 60 years), while they were significantly lower present with atypical chest pain and in early middle aged (45 years or less). The early postmenopausal women more often with STEMI. middle-aged cohort was also more likely to be Two previous studies also reported that young overweight and obese. Kandoria and associates24 women with CAD more frequently present with demonstrated that the risk burden of CAD to be atypical chest pain.24,32,33 As angiographic profile lesser in premenopausal women (mean age 42 ± of the study patients was analyzed, it was evident 4 years) compared to that in postmenopausal that DVD, TVD and LM diseases were frequently women (mean age 59 ± 8 years). Several other common in elderly women than those in their studies also documented increased prevalence of early middle-aged and middle-aged & late-middle risk factors of CAD after menopause.24-27 These aged counterparts. Consequently, the incidences findings indicate that the risk factors of CAD in of receiving coronary artery bypass surgery and women begin to rise from age of 45 onwards, stenting were also common in the elderly women. probably because of withdrawal of protective These findings indicate that as age advances the factor estrogen due to menopause. Estrogen CAD becomes more complex with increase in the withdrawal is considered detrimental to number of vessels affected. Consistent with these cardiovascular function & metabolism.17 Women’s findings previous angiographic studies in women Ischemia Syndrome Evaluation (WISE) study have also noted a rise in DVD and TVD as the age demonstrated that young women with advances.13,24 This can partly be explained by

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Prediction of Perinatal Outcome with Meconium-stained Liquor Monowara Khatun,1 Runa Parvin,2 Samaria Naurin3

ABSTRACT Background & objective: Passage of meconium in the amniotic fluid during labor has long been considered as fetal compromise resulting from fetal hypoxia or increased vagal activity from cord compression. It is also a sign of normal gastrointestinal tract maturation under neuronal control. However, presence of meconium in the amniotic fluid is traditionally viewed as unfavorable perinatal outcome. So, the present study was contemplated to find the association between grade of meconium during labor and perinatal outcome.

Methods: The present prospective study was conducted in the North Bengal Medical College, Sirajganj between ORIGINAL ARTICLE January 2016 – April 2017. Based on predefined criteria, 53 singleton pregnant women with meconium-stained liquor (MSL) on spontaneous or artificial rupture of membrane after 37 completed weeks of gestation were included in the study. Meconium-stained liquor was graded as “Thick” if the fluid was dark green in colour, viscous, tenacious, opalescent or opaque containing large amount of particulate materials and “Thin” if the fluid was translucent, light yellow green in colour without particulate material. The perinatal outcome was evaluated in terms of APGAR score of neonates at 1 and at 5 minutes of birth, NICU admission, resuscitation needed, jaundice and respiratory distress syndrome (RDS) due to meconium aspiration. Asphyxia neonatorum was diagnosed if APGAR at birth and/or at 5 minutes was < 7. All the outcomes were then compared between mothers forming ‘Thick’ and ‘Thin’ meconium cohort.

Result: Of the 53 meconium-stained liquor, nearly half (49%) was with ‘Thick’ meconium and the half (51%) was with ‘Thin’ meconium. Approximately 85% of the neonates were delivered by lower uterine caesarean section (LUCS) and 80% of the neonates were asphyxiated at birth which reduced to 15.1% at 5 minutes. More than three-quarters (75.5%) of the neonates required resuscitation and 28.3% had respiratory distress syndrome (RDS). The incidences of asphyxia neonatorum, resuscitation needed and RDS were significantly higher in ‘Thick’ meconium cohort than those in ‘Thin’ meconium cohort with risks of having these conditions in the former cohort being 6(95% CI = 1.1–31.2), 4.5(95% CI = 1.1–18.9) and 4.2(95% CI = 1.1–15.7) times higher respectively than those in the latter cohort (p = 0.021, p = 0.031 and p = 0.026 respectively).

Conclusion: Majority of the neonates born of mothers with thick meconium cohort are asphyxiated, need resuscitation and/or develop RDS. Asphyxia neonatorum, need for resuscitation and RDS are significantly higher in ‘Thick’ meconium cohort than those in ‘Thin’ meconium cohort with risks of having these conditions in the former cohort being several times higher than those in the latter cohort.

Key words: Prediction, perinatal outcome, meconium-stained liquor etc.

INTRODUCTION: amniotic fluid is considered as a physiological sign of fetal maturity, on one hand and as an ominous Fetal well-being has traditionally been evaluated sign for fetal distress on the other hand.1 Fetal on the basis of fetal activity, fetal heart rate (FHR) distress is defined as alterations in the fetal heart and presence of meconium in amniotic fluid in rate (FHR) more commonly bradycardia and the vertex presentation. Presence of meconium in the passage of meconium in response to hypoxic

Authors’ information: 1 Dr. Monowara Khatun, Associate Professor (Obstetrics & Gynaecology), Thangamara Medical College & Rafatullah Community Hospital, Bogura. 2 Dr. Runa Parvin, Assistant Professor (Obstetrics & Gynaecology), Shaheed Ziaur Rahman Medical College, Bogura. 3 Dr. Samaria Naurin, Registrar (Obstetrics & Gynaecology), Thangamara Medical College & Rafatullah Community Hospital, Bogura. Correspondence: Dr. Monowara Khatun , Cell Phone: 01712681791, E-mail: monowara.m19@ gmail.com.

67 Prediction of Perinatal Outcome with Meconium-stained Liquor Khatun et. al.

insult. Variations in FHR, passage of the effects of meconium staining are not clearly meconium in the amniotic fluid, pathological or known, MSAF is considered as a predictor of abnormal CTG and decreased fetal scalp blood pH maternal and perinatal morbidity and mortality. are strong indicators of fetal distress.2 The present study was carried out to find the maternal and perinatal outcome associated with Aspiration of meconium by the fetus is a common meconium- stained liquor in our institution. cause of perinatal morbidity and mortality, for it is difficult to prevent. The fetus passes meconium METHODS: into the amniotic fluid in 10% of all pregnancies; The present prospective study was conducted in in 5% of these (1:200 of all pregnancies) the North Bengal Medical College, Sirajganj, a meconium is aspirated into the lungs of the peripheral tertiary care center, between January fetuses or the neonates. This can result in severe 2016 - April 2017. Singleton pregnant women who respiratory distress, called meconium aspiration exhibited meconium-stained liquor (MSL) on syndrome (presence of meconium below the vocal spontaneous or artificial rupture of membrane cord).3 Meconium reduces the antibacterial after 37 completed weeks of gestation with property of amniotic fluid by altering the level of cephalic presentation of fetus formed the study zinc in it which leads to intra-amniotic infections. subjects. However, pregnant women with previous In case of hypoxia, gasping of fetus results in cesarean sections, malpresentations of fetus (like meconium aspiration which neutralizes the breech or transverse lie) were excluded. Based on surfactant action and promotes inflammation of ORIGINAL ARTICLE these enrollment criteria, a total of 53 pregnant lung tissues, whereas persistent hypoxia after women on labor were consecutively included in birth, aspirated meconium results in pulmonary the study. Meconium-stained liquor was graded as vascular and pulmonary hypertension.4 “Thick” if the fluid was dark/deep green in colour, Conflicting outcomes have been reported in the viscous, tenacious, opalescent or opaque and labors, complicated by meconium staining of the contained large amount of particulate materials amniotic fluid, varying with the degree of and “Thin” if the fluid was translucent, light yellow meconium staining.5-7 Meconium staining amniotic in colour without particulate material. fluid (MSAF) is associated with higher rate of Intrapartum cardiotocographic tracing was also caesarean delivery, increased need for neonatal taken for assessing fetal hypoxia during labor. resuscitation and meconium aspiration Bradycardia was considered when fetal heart rate syndrome.8 As per previous studies, 5% of was < 110 bpm and tachycardia when fetal heart neonates born through meconium stained rate was > 160 bpm. Delivery was expedited amniotic fluid develop MAS (meconium aspiration when fetal heart rate abnormalities were detected syndrome).9 The MAS can cause or contribute to by the safest mode of delivery either by neonatal death and, in addition, up to one-third of instrumental vaginal delivery or caesarean cases may develop long-term respiratory section. All patients underwent full trial of labor compromise.10 and caesarean section was done only if trial of In contrast many studies, however suggest that labor was unsuccessful or if there were obstetric MSAF is a low-risk obstetrical hazard because the indications including fetal distress. The APGAR perinatal mortality rate attributable to meconium score of neonates, NICU admission, resuscitation is only 1 death per 1000 live-birth. Many needed, jaundice, respiratory distress syndrome researchers have, therefore, disregarded the (RDS) due to meconium aspiration were recorded. significance of MSAF as an indicator of fetal Asphyxia neonatorum was diagnosed if APGAR at distress.1,11 Although the direct and indirect birth and at 5 minutes was < 7.

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Neonates were considered non-asphyxiated and in hypertension, IUGR and UTI (Table II). More than good condition when Apgar score was 7 or more one-quarter (26.4%) of the fetus had normal while they were considered moderately heart rate, 28.3% bradycardia and 45.3% asphyxiated when the score was between 4 to 6 tachycardia. Over half (50.9%) had yellowish and grossly asphyxiated when score was below 4. liquor amni (grade-I), 34% green liquor (grade-II) Resuscitation was considered according to need, and 15.1% thick deep-green, tenacious liquor determined by Apgar scoring and in consultation (grade-III) (Table III). with a neonatologist. Neonates with Apgar 5-6 Outcome: were placed with the mothers and neonates with Apgar < 5 were transferred to NICU for observation. Majority (84.9%) of the neonates was delivered If they developed any sign of complications within by lower uterine caesarean section (LUCS) and ORIGINAL ARTICLE 24 hours were kept in NICU. Data were analyzed approximately 80% were asphyxiated at 1 minute using SPSS (Statistical Package for Social of birth which reduced to 15.1% at 5 minutes. Sciences), version 25.0. The test statistics used to More than three-quarters (75.5%) of the analyze the data were descriptive statistics and neonates required resuscitation. However, only Chi-squared Test. The predictors of neonatal 1(1.9%) neonate needed ICU admission (Table outcome were determined using Chi-squared (χ2) IV). The commonest neonatal complication Test and the risk of having odd outcome was encountered by the neonates was respiratory determined by Odds Ratio (OR) with its 95% distress syndrome (28.3%), followed by neonatal confidence interval. The level of significance was jaundice (9.4%), meconium aspiration syndrome set 5% and p-value <0.05 was considered (7.5%) & neonatal sepsis (3.8%). Only 1(1.9%) significant. neonate died of the complication (Table V). RESULT: Association between grade of meconium during labor and perinatal outcome: Demographic and obstetric characteristics: Analyses of association between grade of Maternal age distribution shows that two-thirds meconium and perinatal outcome revealed that (67.9%) of the mothers were 20-30 years old and incidence of asphyxiated neonates (APGAR1 < 7) 28.3% 30-40 years old with median age of the was significantly higher in thick meconium cohort mothers being 25 years. Over half (56.6%) of the than that in thin meconium cohort (p = 0.021). subjects was multipara. Over one-quarter The risk of having asphyxia neonatorum in thick (28.3%) received regular antenatal care (ANC), meconium cohort was 6-fold (95% CI=1.1–31.2) 43.4% irregular ANC and the rest (28.3%) did not higher than that thin meconium cohort. A receive any care. Approximately 70% were at substantial proportion of (88.5%) of the neonates term (37-39 weeks) pregnancy and 30% were born of mothers with thick meconium during labor full-term pregnant. Nearly half (47.2%) attended needed resuscitation compared to 63% of the present hospital with their own initiative and neonates born of mothers with thin meconium (p the rest were referred by their relatives, doctors, = 0.031) with odds of needing resuscitation in the nurses/midwifes (Table I). former cohort was 4.5(95% CI = 1.1-18.9) times Presence of high-risk conditions or factors: higher. The incidence of respiratory distress syndrome (RDS) was also significantly higher in Over 45% of the mothers presented with cord neonates born of mothers with thick meconium prolapse followed by oligohydramnios (32.1%), with risk of developing RDS in the former cohort preeclampsia (15.1%), prolonged labor (11.3%), was more than 4(95% CI = 1.1-15.7) times PROM (11.3%) and gestational diabetes mellitus higher (p = 0.026) (Table VI). (9.4%). The minor problems were gestational

69 Prediction of Perinatal Outcome with Meconium-stained Liquor Khatun et. al.

Table I. Distribution of patients by demographic and obstetric Table III. Distribution of patients by their examination ndings characteristics (n = 53) (n=53) Obstetric Mean ± SD characteristics Frequency Percentage (range) Examination ndings Frequency Percentage

Age (years)* Foetal heart during perinatal period < 20 01 1.9 Normal 14 26.4 20 – 30 36 67.9 25.0 ± 5.3 (18-43) Bradycardia 15 28.3 Tachycardia 24 45.3 30 – 40 15 28.3 Amount of liquor amni (by USG) ≥ 40 01 1.9 Adequate 15 28.3 Parity Inadequate 22 41.5 Primi 23 43.4 -- Scanty 16 30.2 Multi 30 56.6 -- Meconium staining liquor Gestational age (weeks) Light yellow or light green (G-I) 27 50.9 37-39 weeks (Term) 37 69.8 -- Green (G-II) 18 34.0 40-42 weeks (Full-term) 16 30.2 -- Dark green, tenacious and opaque (G-III) 8 15.1 ANC received Table IV. Distribution of patients by their outcome (n=53) Regular 15 28.3 -- ORIGINAL ARTICLE Irregular 23 43.4 -- Obstetric Mean ± SD characteristics Frequency Percentage (range) None 15 28.3 -- Mode of delivery Referred by SVD 8 15.1 -- Relative 8 15.1 -- LUCS 45 84.9 -- Midwife 4 7.5 -- APGER 1 Doctor 6 11.3 -- < 7 42 79.2 -- Nurse 10 18.9 -- ≥ 7 11 20.8 -- Self 25 47.2 -- APGER 5 < 7 8 15.1 -- Table II. Distribution of patients by presence of associated risk ≥ 7 45 84.9 -- factors (n=53) Resuscitation needed 40 75.5 -- Presence of associated risk factors Frequency Percentage Admission in ICU 1 1.9 -- Birth weight (kg) -- -- 2.9 ± 0.4 (1.9-3.9) Cord around neck 24 45.3 Oligohydramnios 17 32.1 Table V. Distribution of patients by their neonatal Preeclampsia 8 15.1 complication (n=53) Prolonged labour 6 11.3 Neonatal complication Frequency Percentage PROM 6 11.3 Gestational DM 5 9.4 Meconium Aspiration syndrome 4 7.5 Gestational HTN 2 3.8 Respiratory distress syndrome 15 28.3 IUGR 1 1.9 Neonatal jaundice 5 9.4 UTI 1 1.9 Neonatal sepsis 2 3.8 Others 16 30.2 Perinatal death 1 1.9

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Table VI. Association between grade meconium & perinatal outcome MSAF and its fetal outcome in parturients found that asphyxia neonatorum (APGAR 1 < 7), need Grade of Meconium Perinatal p-value Odds Ratio for resuscitation and RDS were significantly higher outcome Thick Thin (95% CI of OR) (n = 26) (n = 27) in ‘Thick’ meconium cohort than that in ‘Thin’ Mode of delivery* meconium cohort with risks of having these NVD 3(11.5) 5(18.5) conditions in the former cohort being 6(95% CI = 0.374 NC# LUCS 23(88.5) 22(81.5) 1.1 – 31.2), 4.5(95% CI = 1.1 – 18.9) and APGAR score at birth** 4.2(95% = 1.1 – 15.7) times higher respectively < 7 24(92.3) 18(66.7) 0.021 6(1.1-31.2) than those in the latter cohort. The major ≥ 7 2(7.7) 9(33.3) complication associated with MSAF was birth APGAR score at 5 min. asphyxia. Most investigators showed there is an ORIGINAL ARTICLE < 7 6(23.1) 2(7.4) 0.113 NC# association of fetal heart rate abnormalities with ≥ 7 20(76.9) 25(92.6) low Apgar scores and low arterial cord blood pH in Resuscitation needed** the presence of meconium stained amniotic Yes 23(88.5) 17(63.0) 0.031 4.5(1.1-18.9) fluid.12 Samiyappa and associates13 in a similar No 3(11.5) 10(37.0) study in India demonstrated that thick meconium ICU admission needed* was associated with low Apgar score, increased Yes 1(3.8) 0(0.0) 0.491 NC# incidence for NICU admission and meconium No 25(96.2) 27(100.0) aspiration syndrome and required prompt RDS** intervention. Incidence of fetal heart rate Yes 11(42.3) 4(14.8) 0.026 4.2(1.1-15.7) abnormalities was higher in thick meconium No 15(57.7) 23(85.2) accounting for increased incidence of operative Jaundice* 14 15 Yes 3(11.5) 2(7.4) deliveries and low Apgar Score. Vaghela et al 0.482 NC# No 23(88.5) 25(92.6) showed APGAR score in first minute to be low (< 7) Sepsis* in 5.2% of neonates with thin meconium as Yes 1(3.8) 1(3.7) compared to 18.5% of neonates with thick 0.745 NC# No 25(96.2) 26(96.3) meconium. Sedaghatian and associates16 found Mortality* similar result in their study. Patil et al.17 observed Yes 1(3.8) (0.0) much higher incidence (26.2%) of low (< 7) 0.491 NC# No 25(96.2) 27(100.0) APGAR score in patients with thick meconium than that in patients with thin meconium (6.7%) Figures in the parentheses indicate column-wise %. *Fisher’s Exact Test was done to analyze the data; **χ2 Test was Type of MSAF certainly influences the mode of done to analyze the data. # if two Categorical variables are not delivery. Several investigators have shown higher associated, Odds Ratio need not to be Computed (NC) rates of LUCS and instrumental vaginal deliveries DISCUSSION: in thick meconium group as compared to thin meconium group.18,19 In the present study, the The significance of meconium in amniotic fluid is a incidence of caesarean delivery although was a bit widely debated subject. Passage of meconium higher in the ‘Thick’ meconium Group than that in may be a normal physiological event reflecting the ‘Thin’ meconium group, the difference did not fetal maturity. It also reflects fetal hypoxia or turn significant. In spite of that the present study increased vagal activity from cord compression. had higher rates of LUCS, because obstetricians The presence of meconium during labor is were more concerned in labors with MSAF as our associated with an increased risk of perinatal center does not have facilities for continuous FHR mortality and morbidity. The present study monitoring and facilities for fetal scalp blood intended to determine the association between

71 Prediction of Perinatal Outcome with Meconium-stained Liquor Khatun et. al.

sampling. Thus, in the absence of these facilities thick meconium cases encounter asphyxia there is an increase in instrumental vaginal neonatorum, need resuscitation and develop RDS. deliveries and caesarean section rate. Asphyxia neonatorum, need for resuscitation and RDS are significantly higher in ‘Thick’ meconium Presence of meconium in the amniotic fluid during cohort than those in ‘Thin’ meconium cohort with labor often causes anxiety in delivery room, for it risks of having these conditions in the former is implicated as a fetal and neonatal wellbeing cohort being several times higher than those in during the intrapartum and postpartum periods the latter cohort. The occurrence of MSAF during respectively. However, MSAF in cephalic labor is associated with increased caesarean presentation is of greater concern even to senior section as well. and experienced obstetricians and midwives. Whereas detection of meconium in breech REFERENCES:

presentation is not much of concern as it is due to 1. Oyelese Y, Culin A, Ananth CV, Kaminsky LM, Vintzileos mechanical compression of fetal abdomen. Fetal A, Smulian JC, et al. Meconium stained amniotic fluid status during labor is usually assessed by across gestation and neonatal acid base status. Obstet Gynecol 2006;108:345. measuring the fetal heart rate abnormalities and checking the colour of the amniotic fluid. It is 2. Wong SF, Chow KM, Ho LC. The relative risk of foetal often assumed that fetal heart rate abnormalities, distress in pregnancy associated with meconium stained liquor at different gestations. AMJ Obstet especially in the presence of meconium stained Gynaecol 2002;22:594-9. liquor indicates hypoxia and acidosis.20 ORIGINAL ARTICLE 3. Ashfaq F, Shah AA, Effect of amnioinfusion for meconium Although 70% of newborns pass meconium by 12 stained amniotic fluid on perinatal outcome. J Pak Med hours of age, many infants pass meconium prior Assoc 2004;54:322-5. to birth as well.21 It has been suggested that the 4. Yamada T, Minakami H, Matsubara S, Yatsuda T. fetus passes meconium in response to hypoxia Meconium stained amniotic fluid exhibits chemotactic activity for polymorphonuclear leukocytes in vitro. J signaling fetal compromise. Alternatively, in utero Reprod Immunol 2000;46:2130. passage of meconium may represent normal 5. Low JA, Pancham SR, Worthington O, Bolton RW. The gastrointestinal tract maturation under neuronal incidense of fetal asphyxia in 600 high risk monitored control. Meconium passage could also follow vagal pregnancies. Am J Obstet Gynecol 1975;121:456- 59.55. stimulation from transient umbilical cord 6. Meis PJ, Hall M, Marshall JR, Hobel CJ. Meconium 22 entrapment. Traditionally meconium has been passage: a new classification for risk assessment viewed as a harbinger of impending or ongoing during labour. Am J Obstet Gynecol 1978;131:509-13.

fetal compromise; however, some investigators 7. Abramovici H, Brandes JM,Fuchs K ,Timor FI.Meconium believe that it is not associated with fetal hypoxia, during delivery, a sign of compensated fetal distress. acidosis or feta distress. The predictive value of Am J Obstet Gynecol 1974;118:251-55. meconium is better when it occurs in high risk 8. Shaikh EM, Mehmood S, Shaikh MA. Neonatal outcome patients and is thick, dark and tenacious. Lightly in meconium stained amniotic fluid-one year stained meconium has a poor association with feta experience. J Pak Med Assoc 2010;60:711-4. hypoxia.23 Summarizing the findings of the study 9. Paul J, Hall M, Marshall JR, Hobel CJ. Meconiumpassage: and those of others compared and contrasted a new. 1978;31:509-13. suggests following conclusions: 10. Steer PJ, Daniethian P. Foetal distress in labour. In: James DK, Steer PJ, Weiner CP, Gonaik B editors. High CONCLUSION: risk pregnancy: management options. 3rd edition. Philadelpia: Elsevier Inc 2006:1450-72. Of the meconium-stained liquor, nearly half is with thick meconium which generally carries 11. Goud P, Krishna U. Significance of meconium staining of amniotic fluid in labour. J Obstet and Gynaecol India unfavourable perinatal outcome. Majority of the 1989;39:523-6.

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12. Oyelese Y, Culin A, Ananth CV, Kaminsky LM, Vintzileos 18. Supriya K, Suchitra T, Prakhar S. Clinical study of A, Smulian JC, et al. Meconium stained amniotic fluid meconium stained amniotic fluid. International Journal across gestation and neonatal acid base status. Obstet of Biomedical & Advance Research 2014;05 (12):612-614. Gynecol 2006;108:345. 19. Shazia Q, Jan S, Chachoo JA. Perinatal and neonatal 13. Samiyappa DP, Ghose S, John LB, Samal R. Maternal outcome in meconium stained amniotic fluid. International and perinatal outcome in meconium stained amniotic Journal of Reproduction, Contraception, Obstetrics and fluid at term: a case control study. International Journal Gynecology 2016;5(5):1400-1405.DOI:http://dx.doi.org/ of Reproduction, Contraception, Obstetrics & Gynecology 10.18203/2320-1770.ijrcog 20161293 Samiyappa DP et al. Int J Reprod Contracept Obstet 20. Perinatology and contraception-Dutta DC. In: Konar H, Gynecol 2016;5(10):3404-3410DOI:http://dx.doi.org/10. editor. Textbook of Obstetrics .6th ed. calcutta: New 18203/2320-1770.ijrcog 20163413 Central Book Agency (p) Ltd; 2004:256.

14. Singh P and Soren SN. A study of perinatal outcome in ORIGINAL ARTICLE 21. Wood CL. Meconium stained amniotic fluid Nurse meconium stained amniotic fluid. Med Pulse Midwifery. J Nurse Midwifery 1994;39(2Suppl): 106S- International Medical Journal 2017;4(1):06-13. 109S. 15. Vaghela HP, Deliwala K, Shah P. Fetal outcome in 22. Cunningham AS, Lawson EE, Martin RJ, Pildes RS. deliveries with meconium stained liquor. Int J Reprod Tracheal suction and meconium:a proposed standard of Contracept Obstet Gynecol 2014;3(4):909-912 http:// care. J pediatr 1990;116(1):153-44. dx.doi.org/10.5455/2320-1770.ijrcog2014120. 23. Ratnam SS, Rao BK, Arulkumaran S. Practical approach 16. Sedaghatian MR, Otheman L, Rashid N,Ramachandran to Intrapartum fetal monitoring in labour. Chapter 12. P, Bener BA. An 8 year study ofmeconium stained Obstetricsand Gynecology for Postgraduates 1992;1: amniotic fluid in differentethnic groups. Kuwait Medical 115-251. Journal 2004;36:266-69.

17. Patil KP, Swamy MK, Samatha K. A one yearcross sectional study of management practicesof meconium stained amniotic fluid and perinatal outcome. Obstet Gynecol India 2006;56:128-30.

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Comparative Study of Management of Intrauterine Fetal Death by Misoprostol versus Oxytocin Lipika Ghosh,1 Fatema Binta Islam,2 Farjana Maksurat,3 Mamata Manjari,4 Rowshan Afrooz 5

ABSTRACT

Background & objective: Management of pregnancy with intrauterine fetal death (IUFD) is always puzzling to the obstetricians and mental agony to the patients. Intravenous oxytocin infusion was previously practiced for termination of pregnancy with IUFD. But recently misoprostol is claimed to be better than oxytocin in terms of its efficacy and safety. This prospective study was carried out to find which of these two drugs is suitable for termination of pregnancy with IUFD.

Methods: Based on predefined criteria,a total of 100 singleton pregnant women with gestational age more than 22 weeks, ultrasonographically confirmed as having dead fetus in utero were included in the study and were randomly assigned to vaginal Misoprostol and Oxytocin infusion groups. The outcome was evaluated in terms of time required for induction of labor, induction to delivery time and complications encountered by each group.

Result: The overall time required for induction to delivery was significantly shorter in Misoprostol group than that in Oxytocin group irrespective of their Bishop’s score (p < 0.001). Even in patients in whom the cervix was unripe (Bishop's score < 6), the mean time required from induction to delivery was much shorter in Misoprostol group (p < 0.001), but in patients in whom the cervix was ripen, the mean time from induction to delivery in

ORIGINAL ARTICLE Misoprostol group was shorter, but the difference did not turn to significant (p = 0.079). Both nulliparous and multiparous women experienced significantly shorter durations of labor in the Misoprostol group than those in the Oxytocin group (p < 0.001 and p = 0.001 respectively). Complications like hyperstimulation, retained placenta and postpartum hemorrhage all were somewhat higher in Misoprostol group than those in Oxytocin group, but the differences were not statistically significant (p = 0.357, p = 0.500 and p = 0.500 respectively).

Conclusion: The use of vaginal misoprostol is more effective than intravenous infusion of oxytocin in induction of labor in patients with IUFD. The time required from induction to delivery is appreciably shorter when Misoprostol is used compared to that needed when oxytocin is used.

Key words: Induction of labor, misoprostol, oxytocin and intrauterine fetal death (IUFD) etc.

INTRODUCTION: beyond 24 weeks is less than 1% of all pregnancies. Etiology of intrauterine fetal death is Intrauterine fetal death (IUFD) is said when the not definitely known in 50% of the cases. fetus dies prior to complete expulsion or Associated conditions include hypertensive extraction from the mother at any time after 22 diseases of pregnancy, diabetes mellitus, weeks of gestation. The incidence of fetal death erythroblastosisfetalis, fetal congenital anomalies,

Authors’ information: 1 Dr. Lipika Ghosh, Assistant Professor (Obstetrics & Gynecology), Colonel Malek Medical College, Manikganj 2 Dr. Fatema Binta Islam, Assistant Professor (Obstetrics & Gynecology), Ad-Din Women's Medical College, Moghbazar, Dhaka. 3 Dr. Farjana Maksurat, Jr Consultant (Obstetrics & Gynecology), UHC, Shibalaya, Manikgonj 4 Dr. Mamata Manjari, Assistant Professor (Obstetrics & Gynecology), Colonel Malek Medical College,Manikgonj. 5 Dr. Rowshan Afrooz, Assistant Professor (Obstetrics & Gynecology), Nightingle Medical College, Dhaka. Correspondence: Dr. Lipika Ghosh, Phone: +880 1715-029206, E-mail: [email protected]

74 Comparative Study of Management of Intrauterine Fetal Death by Misoprostol versus Oxytocin Ghosh et. al.

placental insufficiency, maternal and fetal infection, labor is very costly and only one dose is not post-maturity, umbilical cord accidents, trauma sufficient. etc.1 Misoprostol has been shown to be less expensive Intrauterine fetal death is suspected when mother and more effective than oxytocin in the induction complains of absence of previously perceived fetal of labor. The use of misoprostol for induction of movements. Real-time Ultrasound is the definitive labor in women with IUFD has been endorsed by method for diagnosis, as it directly visualizes the NICE.4 A randomized controlled trial comparing fetal heart. In addition to the absence of fetal intravenous oxytocin alone with intravaginal cardiac activity, other secondary features might misoprostol (a prostaglandin E1 analogue) for be seen: collapse of the fetal skull with induction of labor in women with an IUFD showed ORIGINAL ARTICLE overlapping bones,2 hydrops, or maceration that misoprostol was more effective.7 A recent resulting in unrecognizable fetal mass. Intrafetal study has confirmed that women receiving gas (within the heart, blood vessels and joints) is intravaginal misoprostol have a significantly lower another feature associated with IUFD that might caesarean section rate, shortened interval limit the quality of real-time images.3 Prolonged between start of induction to vaginal delivery, a retention of dead fetus in utero may result in higher incidence of vaginal delivery (about 90%) maternal clotting abnormalities, coagulopathies or within 24 hours of misoprostol application.8 Two disseminated intravascular coagulation (DIC), randomized controlled trials compared oral and which needs prompt delivery. Management of vaginal misoprostol. In the first, the mean intrauterine fetal death could be either expectant induction to birth interval was shorter with vaginal or delivery as early as possible as determined by use by 7.9 hours (p < 0.05) & there was a reduced discussion between doctor and the patient need for oxytocin augmentation.9 In the other, concerned. If the woman is physically well, her there was no difference in mean induction to birth membranes are intact and there is no evidence of interval for gestations of more than 28 weeks.10 pre-eclampsia, infection or bleeding, the risk of Recently, in a closely supervised hospital setting expectant management for 48 hours is low.4,5 with adequate monitoring, oral misoprostol has the potential to induce labor as safely and There is a 10% chance of maternal DIC within 4 effectively as its vaginal analogue.11 Misoprostol weeks from the date of fetal death and an effectively induces labor, with the vaginal route of increasing chance thereafter.6 If the patient is administration having a faster action than the oral treated expectantly clotting studies should be route in equivalent doses.12 The present study repeated weekly. Expectant management usually was, therefore, undertaken to make a comparative results in spontaneous labor in the majority (more evaluation between outcome of induction of labor than 85%) of patients within 3 weeks.4 If in pregnant women with IUFD by vaginal spontaneous labor does not occur, induction of misoprostol and oxytocin to find the suitable labor could be tried with a) intravenous method for termination of pregnancy with IUFD. administration of increasing concentration of oxytocin or, b) orally or vaginally administered METHODS: misoprostol, or, c) PGE2 gel + Oxytocin or, d) intrauterine catheter + Oxytocin. Of them, vaginal This prospective study was conducted over a application or oral administration of misoprostol (a period of 12 months from July 2009 to June 2010 synthetic analogue of PGE1) is considered the in the Department of Obstetrics & Gynaecology, best & appropriate drug for developing countries Dhaka Medical College Hospital, Dhaka. Singleton like ours. Misoprostol is a cost-effective drug pregnant women with history of gestational age whereas dinoprostone which was randomly used > 28 weeks and recent absence of previously previously in cervical ripening and induction of perceived fetal movement, intact membrane with

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no labor pain were provisionally included in the ascending infection. Data were processed and study. Of them who were confirmed as having analyzed using software SPSS (Statistical Package dead fetus in utero by real-time ultrasonography for Social Sciences) version 25.0. The test were finally included in the study. The patients statistics used to analyze the data were were randomly divided into two groups-Oxytocin descriptive statistics, Chi-square (χ2) Test and group and Misoprostol group. The Oxytocin group Student’s t-Test. Quantitative data were presented received 10 units of oxytocin added to a 500 ml of in the form of mean ± SD and qualitative data as Hartman's solution if the patients were frequency and corresponding percentage. The primigravida and 5 units per 500 ml of Hartman's level of significance was set at 0.05 and p-value < solution if patients were multigravida. All infusions 0.05 was considered significant. were started at 15 drop/min, and increasing every 30 minutes by 5 drop/min till effective uterine RESULTS: contraction was achieved (3 to 4 contractions per Baseline characteristics: 10 minutes), or up to a maximum of 60 drop/min. Demographic characteristics: If no effective contractions were noted, a new Majority of the patients in either group was found infusion with double the original dose was reinstituted. If labor was not established within 48 in the age range of 25 – 29 years. The patients in hours of induction, this was regarded as failed the Oxytocin group was comparatively young induction & the drug administration was stopped. (mean age: 24.4 years) than those in the

ORIGINAL ARTICLE This also applied in the misoprostol group. Misoprostol group (mean age: 28.7 years), although the difference was not statistically Vaginal examination was done four hours later or significant (p = 0.147). Housewives were as necessary to assess the Bishop’s score. The predominant in both Oxytocin (64%) and rate, maximum dose and total dose of oxytocin Misoprostol group (72%) with no significant needed were recorded. In the Misoprostol group intergroup difference (p = 0.391) (Table I). (Tab Cytomis or lsovent) "1/4 Tab Misoprostol" (50 µg) was applied on the vagina and the dose was Obstetric characteristics: doubled every 6 hours till effective contractions Nullipara was predominant in both groups (74% in were achieved. The tablet was wetted with a drop Oxytocin and 66% in Misoprostol group), but the of water for injection and was inserted in the difference between the groups was not posterior vaginal fornix using a Cusco's speculum statistically significant (p = 0.382). Nearly and a wooden spatula. Following medication, one-third (30.0%) of the Oxytocin group patients maternal condition regarding temperature, pulse, and 34% of Misoprostol group patients received blood pressure, uterine contraction, postpartum antenatal care regularly and rest of the respective haemorrhage (PPH) was observed closely. groups did not receive ANC. The difference Cervical score was reassessed after 4 hours or as between the groups was not statistically necessary. Majority of patients was delivered significant (p = 0.668) (Table II). within 24 hours. If labor was not established within 24 hours of induction, this was regarded as Medical illnesses: failed induction and the trial was stopped. The Seven (14.0%) patients in the Oxytocin group and outcome was evaluated in terms of time required 5(10.0%) patients in the Misoprostol group had for induction of labor, induction to delivery time hypertension (p = 0.538). Diabetes was reported and complications (like hyperstimulation, retained to be 18 and 14% in Oxytocin and Misoprostol placenta and PPH) encountered by each group. groups respectively (p = 0.585). Anemia was From the very beginning prophylactic antibiotics invariably present in both groups (Table III). were given in both groups for prevention of

76 Comparative Study of Management of Intrauterine Fetal Death by Misoprostol versus Oxytocin Ghosh et. al.

Table I. Distribution of demographic characteristics of patients Induction to delivery interval: between study groups The mean time from induction to delivery was Group dramatically reduced in Misoprostol group than that Characteristics Oxytocin Misoprostol p-value (n = 50) (n = 50) in Oxytocin group irrespective of their Bishop’s score (p < 0.001). In patients with unripe cervix (Bishop's Age (years)* < 20 1(2.0) 2(4.0) score < 6), the mean interval between induction to 20 – 25 10(20.0) 6(12.0) delivery was significantly shorter (p < 0.001). But in 25 – 30 22(44.0) 20(40.0) patients with ripen cervix (Bishop's score of ≥ 6), the 30 – 35 15(30.0) 18(36.0) mean time from induction to delivery was although ≥ 35 2(4.0) 4(8.0) relatively shorter, it did not reach the level Mean ± SD# 24.4 ± 4.9 28.7 ± 5.0 0.147 ORIGINAL ARTICLE Occupation* significance (p = 0.079) (Table V). Housewife 32(64.0) 36(72.0) 0.391 Complications: Service holder 18(36.0) 14(28.0) Complications like hyperstimulation, retained Figures in the parentheses indicate corresponding %; #Data were analyzed using Unpaired t-Test and placenta and postpartum hemorrhage all were were presented as mean ± SD. somewhat higher in Misoprostol group than those 2 *Chi-squared Test (χ ) was done to analyze the data. in Oxytocin group, but the differences were not Table II. Comparison of obstetric characteristics between the statistically significant (p = 0.357, p = 0.500 and study groups p = 0.500 respectively) (Table VI). Group Obstetric p-value Table IV. Comparison of duration labor between the study groups characteristics* Oxytocin Misoprostol (n = 50) (n = 50) Group Duration of Parity p-value labor (hours)# Oxytocin Misoprostol Nullipara 37(74.0) 33(66.0) (n = 50) (n = 50) 0.382 Multipara 13(26.0) 17(34.0) Nulliparous 10.1 ± 5.6 5.3 ± 2.5 < 0.001 Antenatal care (ANC) Multiparous 5.3 ± 4.1 3.0 ± 1.7 0.001 Received 15(30.0) 17(34.0) 0.668 #Data were analyzed using Unpaired t-Test and were Not received 35(70.0) 33(66.0) presented as mean ± SD. Figures in the parentheses indicate corresponding %; *Chi-squared Test (χ2) was done to analyze the data. Table V. Comparison of induction to delivery intervals between the study groups Table III. History of medical illnesses in current pregnancy Group between the study groups Induction to p-value delivery (hours)# Oxytocin Misoprostol Group (n = 50) (n = 50) History medical p-value illness* Oxytocin Misoprostol All patients 23.3 ± 6.5 12.4 ± 3.1 < 0.001 (n = 50) (n = 50) Bishop’s score < 6 29.8 ± 7.3 15.9 ± 3.2 < 0.001 Hypertension 7(14.0) 5(10.0) 0.538 Bishop’s score ≥ 6 9.0 ± 3.8 7.9 ± 2.2 0.079 Diabetes mellitus 9(18.0) 7(14.0) 0.585 #Data were analyzed using Unpaired t-Test and were Anemia 50(100.0) 50(100.0) 0.987 presented as mean ± SD.

Figures in the parentheses indicate corresponding %; Table VI. Comparison of complications between the study groups *Chi-squared Test (χ2) was done to analyze the data. Group Outcome: Complications* Oxytocin Misoprostol p-value Duration of labor (n = 50) (n = 50) Hyperstimulation 3(6.0) 5(10.0) 0.357 In both nulliparous and multiparous women, the Retained placenta 1(2.0) 2(4.0) 0.500 mean durations of labor were significantly shorter Postpartum hemorrhage 1(2.0) 2(4.0) 0.500 in the Misoprostol group than those in Oxytocin group Figures in the parentheses indicate corresponding %; (p < 0.001 and p = 0.001 respectively) (Table IV). *Chi-squared Test (χ2) was done to analyze the data.

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DISCUSSION: their Bishop’s score (p < 0.001). Even in patients in whom the cervix was unripe (Bishop's score < 6), The present study demonstrated that use of the mean time required from induction to delivery vaginal misoprostol is more effective than was staggeringly shorter in Misoprostol group (p < intravenous infusion of oxytocin in induction of 0.001), but in patients in whom the cervix was labor in patients with IUFD. The costs involved and ripen, the mean time from induction to delivery in times required from induction to delivery were Misoprostol group was shorter, but the difference remarkably reduced as compared to induction did not turn to significant (p = 0.079), which are using oxytocin infusion. The drug was easily stored consistent with the findings of Nakintu.7 at room temperature and was easy to administer. The study also showed that small doses of vaginal CONCLUSION: misoprostol effectively induce labor and they are From the findings of the study it can stated that safe for the mothers, although complications like vaginal misoprostol is more effective than hyperstimulation, retained placenta & postpartum intravenous infusion of oxytocin in induction of haemorrhage were more in the misoprostol group. labor in patients with IUFD. The costs involved These findings fairly compare with findings of and times required from induction to delivery Sanchez-Ramos et al13. were remarkably shorter as compared to The mean duration of labor was significantly shorter induction using oxytocin infusion. As misoprostol in the Misoprostol group than that in Oxytocin is cheaper than oxytocin in cervical ripening and group irrespective of their parity (p < 0.001 and induction of labor in patients with intrauterine ORIGINAL ARTICLE p = 0.001 respectively). When the duration of fetal death, its use for induction of labor labor in nulliparous and multiparous women was particularly in intrauterine fetal death will be analyzed separately, the overall duration of labor cost-effective in the management of this obstetric was significantly shorter in the Misoprostol group complication. The drug can also be accessed and compared to that in the Oxytocin group (5.3 vs. tried in the lower levels of health system to 10.1 hours, p < 0.001). Ngai et al14 observed that manage the condition to avoid undue delays and 60% women in the misoprostol group required a referrals to large hospitals. single dose (100 µg), while the remaining 40% REFERENCES: required a second dose (200 µg). The duration of labor was significantly shorter in the misoprostol 1. Confidential Enquiry into Maternal and Child Health (CEMACH). Perinatal Mortality 2007: United Kingdom. group compared to Oxytocin group (p=0.004). A CEMACH:London 2009 [http://www.cmace.org.uk/ significant difference was also seen in both the first getattachment/1d2c0ebc-d2aa-4131-98ed-56bf8 269 and the second stages of labor between the e529/PerinatalMortality-2007.aspx]. misoprostol and oxytocin group (5.0 vs. 9.6 hours, 2. Zeit RM. Sonographic demonstration of fetal death in the p = 0.03 and 0.6 vs. 1.2 hours, p = 0.01 absence of radiographic abnormality. Obstet Gynecol respectively). Although their induction-to-delivery 1976;48(1 Suppl):49S–52S. interval in the nulliparous women was shorter in the misoprostol group, this difference did not 3. Weinstein BJ, Platt LD. The ultrasonic appearance of intravascular gas in fetal death. J Ultrasound Med reach statistical significance. In contrast, Nakintu7 1983;2:451–4. found no significant difference in induction to delivery time between the misoprostol and 4. National Institute for Health and Clinical Excellence. oxytocin group (8.5 vs. 10.5 hours, p = 0.60). Clinical guideline no. 70: Induction of labour. London: National Institute for Health and Clinical Excellence; In the current series the mean time from induction 2008[http://www.nice.org.uk/nicemedia/pdf/CG070NI to delivery was drastically shorter in Misoprostol CEGuideline.pdf].

group than that in Oxytocin group irrespective of 5. Silver RM. Fetal death. Obstet Gynecol 2007; 109: 153–67.

78 Comparative Study of Management of Intrauterine Fetal Death by Misoprostol versus Oxytocin Ghosh et. al.

6. Parasnis H, Raje B, Hinduja IN. Relevance of plasma 11. Hall R, Duarte-Gardea M, Harlass F. Oral versus vaginal fibrinogen estimation in obstetric complications. J misoprostol for labor induction. Obstetrics & Postgrad Med 1992;38:183–5. Gynecology 2002;99(6):1044-48.

7. Nakintu N. A comparative study of vaginal misoprostol 12. Shetty A, Danielian P, Templeton A. A comparison of oral and intravenous oxytocin for induction of labour in and vaginal misoprostol tablets in induction of labour at women with intra uterine fetal death in Mulago term. Br J Obstet Gynaecol 2001;108(3):238-43. Hospital, Uganda. Afr Health Sci 2001;1:55–9. 13. Sanchez-Ramos L, Chen AH, Kaunitz A, Gaudier FL, 8. Wagaarachchi PT, Ashok PW, Narvekar NN, Smith NC, Oelke I. Labor Induction With Intravaginal Misoprostol Templeton A. Medical management of late intrauterine in Term Premature Rupture of Membranes: A death using a combination of mifepristone and Randomized Study. The American Journal of

misoprostol. BJOG 2002;109:443–7. obstetricians and Gynaecologists 1997;89: 909-12. ORIGINAL ARTICLE

9. Nyende L, Towobola OA, Mabina MH. Comparison of 14. Ngai SW, Chan YM, Lam SW, Lao TT. Labour vaginal and oral misoprostol, for the induction of labour characteristics and uterine activity: misoprostol in women with intra-uterine foetal death. East Afr Med compared with oxytocin in women at term with J 2004;81:179–82. prelabour rupture of the membranes. BJOG 2000;107(2):222-227.//doi.org/10.1111/j.1471-0528. 10. Chittacharoen A, Herabutya Y, Punyavachira P. A 2000.tb11693. randomized trial of oral and vaginal misoprostol to manage delivery in cases of fetal death. Obstet Gynecol 2003;101:70–3.

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Health Vulnerabilities and Resilience to Climate Change: An Update of International Progress Mohd. Arifuzzaman1, M. Mizanur Rahman2, Md. Sultan-Ul-Islam3, Md. Nezam Uddin4

ABSTRACT Despite being one of the most important societal challenges of the 21st century, public engagement with climate change currently remains low worldwide. Mounting evidence from across the behavioral sciences has found that most people regard climate change as a non-urgent and psychologically distant risk—spatially, temporally, and socially-which has led to deferred public decision making about mitigation and adaptation responses. Climate change is increasing risks to human health and to the health systems that seek to protect the safety and well-being of populations. Health authorities require information about current associations between health outcomes and weather or climate, vulnerable populations, projections of future risks and adaptation opportunities in order to reduce exposures, empower individuals to take needed protective actions and build climate-resilient health systems. Health authorities from local to national levels badly seek this information by conducting climate change and health vulnerability and adaptation assessments. While assessments can provide valuable information to plan for climate change impacts, they are often not integrated into adaptation decision making, probably because the health sector is not involved in climate change policy-making processes at the national level. Significant barriers related to data accessibility, a limited number of climate and health models, uncertainty in climate projections, and a lack of funding and expertise, particularly in developing countries, challenge health authority efforts to conduct rigorous assessments and apply the findings. This paper reviews the evolution of climate change and health vulnerability and adaptation assessments, including guidance developed from such projects, and implementation of the findings to support health adaptation action. The findings derived from the study will support collaborative efforts to protect health from current and future climate change hazards. Health authorities may benefit from additional resources to ensure that evidence about climate change impacts on health could effectively be translated into needed actions to build health resilience.

INTRODUCTION: predict between a 1.8˚C and 4 ˚C rise in average global temperature, although it could possibly be In recent time climate change is viewed as one of as high as 6.4˚C. Food production will be the most significant global problems which affect particularly sensitive to climate change, because directly or indirectly alter the structure of the crop yields depend directly on climatic conditions environment.1 The world’s climate has always (temperature and rainfall patterns) and could lead been changing between hotter and cooler periods to food yields being reduced by as much as a third due to various factors. Although the basic science in the tropics and subtropics. Meanwhile future of climate change is now clear, the full range of

REVIEW ARTICLE tropical cyclones will become stronger, with faster effects due to human influenced climate change is wind speeds increasing the amount of damage still not fully understood. However, it is known they cause; floods will become more common due that climate change in the next hundred years will to changing rainfall patterns and glacier melt in be significant and by the year 2100 best estimates

Authors’ information: 1 Mohd. Arifuzzaman, Research Fellow, Institute of Environmental Science, University of Rajshahi, Rajshahi-6205 2 Professor Dr. M Mizanur Rahman, Department of Geography & Environmental Studies, University of Rajshahi, Rajshahi. 3 Dr. Md. Sultan-Ul-Islam, Professor & Chairman, Department of Geology Mining, University of Rajshahi, Rajshahi-6205 4 Md. Nezam Uddin, PhD Fellow,Institute of Environmental Science, University of Rajshahi, Rajshahi-6205 Correspondence: Mohd. Arifuzzaman, Mobile: 01710966543 e-mail: [email protected]

80 Health Vulnerabilities and Resilience to Climate Change: An Update of International Progress Arifuzzaman et. al.

the summer; sea-level rise could inundate large are characterized by weak infrastructure & areas of low lying countries; and the changing economic well-being.19 climate may indirectly cause misery by increasing The impacts of global warming and climate the incidence of disease and conflict. change for Bangladesh seems to be most critical Furthermore, biological diversity the source of as large part of the population is chronically enormous environmental, economic, and cultural exposed and vulnerable to a range of natural value will be threatened by climate change.2 hazards. The effects of global warming have To mitigate the adverse consequence of climate already been evidenced in climate variability, change, people’s preparedness is essential. change and extremes. More adverse impacts are However, people’s perceptions of climate change projected for the coming decades, particularly for and the way they respond depend on their low lying coastline and flood plain ecosystems knowledge.3,4 So understanding local community which characterize Bangladesh. To understand how perceptions on impacts, causes, and responses to global warming and climate change will impact climate change is vital for promotion of Bangladesh in future, influence its development community resilience towards climate change. aspirations and chart its roadmap for sustainable Communities perception about how climate is development, three considerations are critical. changing5 and their contribution is useful in The location of Bangladesh is in a deltaic plain of a identifying adaptation strategies. Populations in major river basin, making it susceptible to floods developing countries are more exposed to climate and cyclones. The country is extremely populated change and they have low capacity to react to the in a small area, and one of the most densely related impacts. For example, recurrent changing populated in the world. The country is still a climate in West Africa has led to decrease in low-income country, particularly the people living rainfall since the late 70s.6-12 This resulted in a in the coastal belt and river basin live below reduction of stream flow and wetlands leading to subsistence level, making them already severe droughts.13,14 Yet, instead of being vulnerable. So there is an urgent needto assess proactive, communities are not prepared to react vulnerability of people and assess their plan for ARTICLEREVIEW to the effects of climate change in West Africa.15 adaptation. As this a broader study and Although the observation of global climate change encompasses vulnerability in terms health, has been largely based on meteorological data, agriculture, environment and so on, it is beyond there is paucity of information on how humans use the scope of the present study to present it local ecological knowledge to recognize and comprehensively. The present study would, respond to such changes.16 Adger et al.17 suggest therefore, be a review of the studies to assess that local communities could interpret and vulnerability & adaptation (V&A) measures as part construct climate change trends and local of efforts by governments and experts to better indicators within a cultural setting. The United understand and respond to climate change risks Nations (UN) recognizes the significant role played to health. It provides information on the type of by indigenous knowledge, cultures, and traditional guidance that has been developed for conducting practices in promoting sustainable development, V&A studies and summarizes national and equity, and management of the environment.18 subnational assessments that have been They further argue that since culture is embedded conducted. The importance of this study lies in in societal modes of production, consumption, helping to build the evidence-base of climate lifestyles, and social organization, it should be change impacts on health. Recommendations are recognized in understanding both mitigation and then provided about supporting future V&As, adaptation to climate change. Understanding and establishing local climate change health risks, building upon perceptions, experiences, and IK on vulnerabilities and adaptation activities and climate change can contribute towards applying the knowledge generated to protect the strengthening the resilience of poor societies who health of populations. The study intends to attain

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the following objectives: period, at least consecutive 30 years. Simply it is the “average weather” in a place. It includes 1) Provide an idea about climate and climate change patterns of temperature, precipitation (rain or 2) Highlight the evidences of climate change snow), humidity, winds, cloudiness, sunshine throughout the year, averaged over a series of 3) Assessing People’s vulnerability or adaptive years. Climate change may refer to the change in response or preparedness to the potential average weather conditions or in the time ill-effects climate change on human health, in variation of weather around long-term average the context of Bangladesh conditions. It is measured by variation in METHODS: temperature, humidity, atmospheric pressure, wind precipitation, atmospheric particulate matter To estimate the number of national V&As that count and other meteorological variables over a have been conducted expert knowledge and the prolonged period of time. database of the World Health Organization (WHO) were used. WHO sourced data consisted of the Climate patterns play a key role in shaping natural results from the 2015 WHO Climate and Health ecosystems and their dependent human Country Survey reported through the WHO/United economies and cultures. But the climate that we Nations Framework Convention on Climate have come to expect is not what it used to be, as Change (UNFCCC) Climate and Health Country the past is no longer a reliable forecast of the Profiles,20 the unpublished results of a WHO future. Once, all climate changes occurred commissioned review of assessments, and naturally. However, we started to alter our climate different reports from the WHO Regional Offices and environment through changing agricultural available online. The WHO Climate and Health and industrial practices during the Industrial Country Survey collects global data on a suite of Revolution. Before the Industrial Revolution, indicators measuring global progress on climate human activity emitted very few gasses into the change and health every two years. These environment, but now we are influencing the indicators include the number of countries that mixture of gases in the atmosphere by fossil fuel have conducted a V&A survey. burning and deforestation. With dramatic effects, our atmosphere is rapidly changing, and that An additional semi-structured search of the transition is occurring faster than any changes PubMed and PMC revealed 20 articles with seen in the last 2,000 years.(http://www.epa. discussion of climate change and health V&As. Of gov/globalwarming/emissions/index.html). these 20 articles, 2 werereviewed as abstract only, and 18 received a full-text review. The 2. Highlighting the evidences of climate change: review results supported the WHO data. A review The impact of climate change on the environment REVIEW ARTICLE of the United States Agency for International and human health is far reaching and thus Development (USAID) database revealed a influencing social changes in many aspects. The further 3 V&A studies that have been impact of climate change has seen in numerous conducted-in Uganda, Senegal and Mozambique- aspects, for instance human health, ecosystem with the assistance of USAID’s African and Latin health and biodiversity, food production, economic American Resilience to Climate Change (ARCC) growth, tourism, and water resources.21 Program. As a result of climate change, the world is now LITERATURES REVIEWED: experiencing warming effects from intensive use of fossil fuel with increasing atmospheric 1. Climate and Climate change: greenhouse gases. According to an IPCC22 report, Climateis defined as the weather conditions global surface temperatures have risen by an prevailing in an area in general or over a long average of 0.13 °C per decade since 1950. At the

82 Health Vulnerabilities and Resilience to Climate Change: An Update of International Progress Arifuzzaman et. al.

same time, on the scale of potential GHG health officials to understand and respond to more emissions, global average surface temperatures severe and possibly compounding effects of future can be raised from 1.8 °C to 4 °C by the end of the climate change, such as tipping-point threats and topic of the 21st century. In fact, the atmosphere shock events beyond the range of current in the next few decades will begin to warm.22 experiences.32

Climate change consists of an increase in Changes in climate and the associated atmospheric temperature, melting of glaciers with environmental changes continue to be reported consequent rise in sea level, sinking islands, lack globally.33,34 Such changes have significant and of fresh water with consequent rise in disease, wide-ranging effects, including direct and indirect increased diarrhoeal disease and endemic health and well-being impacts.35,36 While the mortality, increased coastal water temperature health impacts of climate change are projected to associated with proliferation of Vibrio cholerae be felt globally, some communities have been with eventual rise in cholera.23 Every nation in the recognized as being particularly vulnerable to world in one way or another contributes to climate health-related climate change.37-40 The health change phenomena involving industrialisation, impacts of climate change are often localized and fossil fuel burning, deforestation and unlimited dependent on geographic location, biophysical use of resources and energy contributing to GHG factors, social and environmental relationships, emissions.24 cultural practices, and traditional knowledge.41 Local vulnerability assessments support efforts to 3. Impact of Climate Change on Human Health prepare for and adapt to the current and future 3.1 Climate Change & Health: impacts of climate change on Inuit health.42

Accumulated scientific evidence suggests that While many tools are available to direct human climate variability and change pose serious risks health vulnerability assessments to climate change, to people living across the globe.25-27 Extraordinary they all share a common first step: working with improvements to global health made in recent

local communities and national stakeholders to ARTICLEREVIEW decades are at risk of reversal due to the define and explain the most significant climate- anticipated impacts of climate change.28 Countries sensitive health outcomes (i.e. climate-sensitive lacking adaptive potential, vulnerable populations health outcomes and variability) for a population/ (e.g. indigenous peoples, people relying on region in question.43-47 In order to direct health agricultural livelihoods) and certain regions facing research and effectively inform the creation of severe challenges, such as small island developing public health adaptation strategies and initiatives, countries and the Arctic, are more vulnerable to this phase is necessary to identify and recognize its effects.29 Climate change challenges countries ' climate-sensitive health priorities at adult, household, efforts to achieve key sustainable development community and regional scales.48,49 goals (SDGs) under the 2030 Sustainable 3.2 Physical Effects Development Agenda (e.g., SDG 1-No Poverty; SDG 2-End Hunger; SDG 3-Good Health and Climate-sensitive diseases include heat-related Well-being; and SDG 6-Clean Water and Health).30 diseases, water-borne diseases, vector-borne For example, climate change could lead to 100 diseases, air pollution-related diseases, and million more people living in extreme poverty. extreme weather-related diseases such as floods, droughts, wind storms and fires. Endemic diseases Evidence-based information on current and such as malaria and cholera, meningococcal potential future health risks, vulnerable meningitis, dengue, leptospirosis, and rickettsial populations, and effective adaptation options are infections are common transmissible diseases that needed to prepare individuals and communities are prone to climate change. Water-borne for climate change health impacts.31 This includes diseases are mainly transmitted by flood-water identifying innovative adaptations for public

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and cause extreme contamination as rainwater Nevertheless, the IPPC study22 found that human floods the urban metropolis and contributes to behavior and its relationship with the components major pollution of natural water supplies. These of climate change were the least important. catastrophic events occurred in southern Malaysia Nevertheless, evidence appears to emerge that from mid-December 2006 to late January 2007, people are generally concerned about environmental where the flood affected nearly 200,000 people issues and their effect on their physiological along with 16 deaths reported.50 dimension.61

Increased difficulties in accessing quality water Food is known as health's backbone. So if food sources, due to climate change, contribute to the production is hampered by climate change, it will disease burden that ultimately impede the ultimately have a negative impact on our nutrition freedom to live a long and healthy life. Because of and health. Gohari and associates62 assessed the erratic rainfall, water supply and quality will be impacts of climate change on crop production and hampered, which in turn will lead to warmer water quality of four main crops (wheat, barley, climate conditions favoring the multiplication of rice and maize) in the Zayandeh-Rud River Basin aquatic-borne pathogens, particularly cholera and in Iran. Multi-model ensemble simulations are vector-borne diseases, such as malaria and used for the study period (2015-2044) to resolve dengue.51,52 Worldwide warmer temperatures uncertainties in climate change projections. As a contribute to the breeding of mosquitoes that may result of climate change, monthly temperature will carry malaria.53 Higher levels of contamination rise by 1.1 to 1.5 °C on average. For different associated with warmer environments are months of the year, monthly variations for experienced in the environment, leading to a precipitation may be positive or negative. higher risk of mortality from respiratory diseases. However, with climate change, precipitation will Climate change has caused about 5.5 million decrease by 11% to 31% on an annual basis. deaths of human lives in 2000, according to Rodo While warming may shorten the growing period, et al.54 Due to malnutrition, 2.8 million of them crop production and water productivity of all crops were passed; another 1.5 million were thanks to are expected to decrease due to lower diarrhoea, and malaria affected another 1 million precipitation and higher water requirements at lives. However, another 200,000 were lost due to higher temperatures. Rice and maize are more flooding and interestingly, nearly half of all was vulnerable to climate change due to their high lost in the area of East and South Asia. demand for irrigation water among the four crops studied. As a consequence, their continued 3.3 Psychological Effects development under climate change can be Physiological effects due to temperature on the affected. Considering the locally high economic human body are well known as extreme heat or and food importance of these crops in central Iran, REVIEW ARTICLE cold conditions can affect many body functions. this result is particularly important.62 Researchers have found some negative emotional 4. Assessment of people’s vulnerability: reactions in some individuals due to climate change.55 Medical practitioners have also People’s awareness about the effect of climate experienced the increased number of patients change on health as indirect measure of with anxiety, depression.56 vulnerability:

Wide-ranging research has found a strong The impact of climate change is generally relationship between climate change and stress.57 perceived by people from western countries. The Furthermore, researchers also note that the level of awareness on climate change issues in psychologist's consensus has grown tremendously developed countries is appreciably high. For on the impact of environmental issues and their instance, only 1% of the English have not heard of impact on their behavioral aspects.58-60 either 'climate change', 'global warming' or the

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'greenhouse effect'.63,64 In addition, 92% of Intergovernmental Panel on Climate Change Americans are aware of global warming by 76% (IPCC-AR4) states that Bangladesh is predicted to have already viewed climate change caused a experience an increase in average daytime serious problem in all aspects of human life.65 temperatures of 1.0 ˚C by 2030 and 1.4 ˚C by However, the context of perceived awareness on 205077 indicating the effects of anthropogenic the issues like environment, controlling energy climate change. consumption and health related by the young Bangladesh's coastal districts are uniquely segments takes a low priority by previous vulnerable to climate change due to their very low academic researchers.66-69 elevation, with some of the land at sea level, the To reverse global climate change trend needs topography of the deltaic area and the Bay of widespread support for policies and opportunities Bengal (which funnel up seawater) and also to reduce carbon emissions. Although advocating socio-economic and infrastructural factors that carbon neutrality is definitely in the best interests restrict the country's low, though increasing, of the environment, hindering economic growth is capacity to address the effects of climate change.78 not in the material interests of nations or It is well documented that the coastal regions of individuals.70 southwest Bangladesh are already being affected by slow onset of climatic stresses such as rising The success of environmental education programs, temperatures, salinity intrusion into agricultural like Al Gore's The Climate Campaign, testifies to a soil and groundwater, as well as an increase in the perception that increasing awareness can alter occurrence and intensity of sudden shocks such as individual attitudes and encourages activism, but floods, cyclones, storm surges and riverbank there is little real evidence that this is so.71 erosion as a result of climate change.79,80 Although short-term habits frequently alter as a result of educational experiences,72 the resulting 5. Climate Change and Health Vulnerability behavioral changes are usually short-lived.73 and Adaptation Assessments:

Located on an active delta, Bangladesh is Health authorities perform climate change and ARTICLEREVIEW characterized by a high level of instability in the risk assessments and adaptation assessments on atmosphere that presents high exposure to a local, regional or national scale to identify and climate hazards and natural disasters. The country interpret information needed to prepare health annually faces floods, riverbank and coastal systems for climate change impacts. The erosion and is also susceptible to cyclones that participatory design of these studies requires a form in the Bay of Bengal due to the country's number of stakeholders to support efforts to plan funnel shaped coast.74 High incidence of poverty, for climate change. We have a similar set of goals particularly in the coastal belt, further perpetuates and procedures, although the nature of individual socioeconomic vulnerability of local communities studies can vary considerably. Key evaluation and the country as a whole.75 functions include:81

Globally, both the severity and frequency of • Increase knowledge and understanding of disasters have increased significantly, and there is existing correlations between weather/ increasing recognition of the link between climate climate and health outcomes, including the change and extreme events.22 Managing the Risks wellbeing of communities most vulnerable to of Extreme Events and Disasters to Advance these risks; Climate Change Adjustment). In their research, • Provide health and emergency management Sarker et al76 mentions the increasing trend in agencies, stakeholders and the public with temperature in Bangladesh over the past three information on the extent and trend of decades, especially during the moonsoon season. current and future climate variability and The Fourth Assessment Report of the change-related health risks; and

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• Identifying opportunities to integrate climate Direct and indirect health impacts associated with change issues into current policies and climate change are caused by rising programs aimed at managing weather and temperatures, altered patterns of precipitation, climate-related health threats and developing and increasingly severe and recurrent extreme new strategies where possible to mitigate and weather events.22,26,88 Direct health impacts are reduce the severity of potential risks; caused by hazards such as heat waves, droughts and hurricanes, and indirect impacts are caused • Acting as a benchmark study to track future by exposure to disease vectors and air and water risk changes and based policies and pollution. Rising levels of carbon dioxide can also programs; increased the nutrient value in staple crops, • Collaborating with industries such as water & contributing to climate change. This could sanitation to encourage programs aimed at increase food insecurity among certain improving the health of the population in a populations, especially in developing countries.91 changing climate. A number of social factors can either intensify the health effects of climate change's environmental The ultimate objective of an evaluation is to effects or help mitigate them by public health support the implementation of adaptation and risk initiatives. There are gaps in knowledge about the management measures which are effective in effects of climate change on public health, food reducing current and future climate-related risks distribution, hunger, rural communities, indigenous to human health and well-being, including among groups and marginalized people. populations most vulnerable to impacts. In partnership with a wide range of stakeholders With well-designed adaptation steps, many of the within and outside the health sector, V&As create health impacts of climate variability & change can evidence-based adaptation plans or approaches be minimized or prevented.26,84 Health adaptation for health authorities.81 Health National Adaptation refers to "the process of planning, implementing, Plans (HNAPs) and the Building Climate Resilient tracking and reviewing plans, policies and Health Systems Operational Framework (2015) measures to reduce and take advantage of are complementary tools designed by WHO to opportunities related to climate change.92 Public apply V&A information to define strategic goals health officials have decades of experience with and plans to build health resilience to climate well-known, successful measures to mitigate many change. HNAPs may be included as sector-specific climatic and weather-related health threats such adaptation plans.82,83 as air and water pollution, contaminated food, vector-borne diseases, ozone depletion, and DISCUSSION & CONCLUSION: extreme weather events (e.g. heatwaves, floods, droughts, wildfires, ice storms, hurricanes).93

REVIEW ARTICLE Climate change and health vulnerability and adaptation assessments (V & As) are an important Further understanding of the health and well- instrument and process to obtain information for being risks posed by climate change and advice understanding and addressing climate change- available to health authorities for vulnerability 84 related risks. They can also provide the assessment has resulted in more local, regional knowledge needed to realize potentially large and national studies. Assessments on climate health co-benefits from well-designed adaptation change and vulnerability to health and adaptation and greenhouse gas mitigation measures.Over provide valuable information to health authorities the past few decades, the global evidence base on to enhance the resilience of individuals, climate change effects on health has expanded communities and health systems to climate through the publication of reports from the change impacts. They also contribute to Intergovernmental Panel on Climate Change development of the global evidence-base on 85,86 (IPCC), global disease burden analysis from climate change and health needed to inform climate change,87 and related research.88-90

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adaptation and greenhouse gas mitigation perceptions of climate change and conservation measures in the future, ensuring that they benefit agriculture: evidence from Zambia. J Sustain u Develop 2011;4(4):73–85. Doi: 10.5539/jsd.v4n4p73. the well-being of populations. 5. Heijmans A, 2001. Vulnerability: a matter of perception. Expanded initiatives through V&As to continue to Disaster management Working Paper 4. University build this global evidence base and inform the College of London. creation of solutions to protect against that 6. Carbonnel JP, Hubert P. Pluviométrie en Afrique de threats from climate hazards include further l'Ouestsoudano-sahélienne : remise en cause de la development of both quantitative and qualitative stationnarité des séries. In : Le Floc'h E. (ed.), Grouzis evaluation approaches, techniques and guidance Michel (ed.), Cornet Antoine (ed.), Bille Jean-Claude documents.94 This would include, for example, (ed.). L'aridité :unecontrainte au développement : prioritizing adaptation choices, using qualitative caractérisation, réponsesbiologiques, stratégies des sociétés. Paris : ORSTOM, 1992:37-51. (Didactiques). methods to evaluate the future. Improved skills ISBN 2-7099-1068-3 development in environmental health and epidemiology, which requires knowledge and 7. Nicholson SE, Some B, Koné B. An analysis of recent rainfall condition in West Africa, including the rainy expertise to identify health threats in the context seasons of the 1997 El Nino and the 1998 La Nina of environmental and climate change, will help years. J Clim 2000;13:2623–2639. health authorities in V&As. More rigorous metrics 8. Mahé G, L’Hôte Y, Olivry JC, Wotling G. Trends and and methods to quantify adaptive ability and the discontinuities in regional rainfall of West and Central efficacy of existing adaptations, as well as more Africa (1951–1989). Hydrol Sci J 2001;46(2):211–226. climate scenario and modeling knowledge specific Doi: 10.1080/02626660109492817 to national and local scales, will boost the rigor of 9. Savane I, Coulibaly KM, Gioan P. Variabilitéclimatique et assessments. To order to prepare for potentially ressources en eauxsouterrainesdans la asin severe or catastrophic events, increased knowledge semi-montagneuse de Man. Sécheresse 2001;12(4): of systemic, synergistic, cascading or compounding 231–237. health effects from climate change needs to be 10. Tapsoba D, Bobbé B, Lebarbe L. Quelques caractéristiqu REVIEW ARTICLEREVIEW included in V&As. Use V&As as a key tool for esévénementielles des régimes pluviométriques fostering successful adaptation to climate ponctuels Ouest africains au cours des deuxpériodes change's health impacts would benefit from climatologiques contrastées (1951-1970 et1971- 1991). Application de la loicomposéepoisson/ increased cooperation, communication and exponentielle (LCPE) ou du modèle de la loi des fuites learning between health authorities. (LDF) aux pluies. Sécheresse 2002;13(4):95–103. REFERENCES: 11. Application de la loicomposéepoisson/exponentielle (LCPE) ou du modèle de la loi des fuites (LDF) aux 1. United Nations Framework Convention on Climate pluies. Sécheresse 2002;13(4):95–103; Change, 1992; Costello et al., 2009. 12. Kouakou KE, Goula BTA, Savane I. Impacts de la 2. Pender JS. 2014. What Is Climate Change? And How It variabilitéclimatiquesur les ressources en eau de May Affect Bangladesh. Cited: 7/8/2019, available at: surface en zone tropicalehumide: cas du asin versant http://www.greennewsbd.com/?p=307 transfrontalier de la Comoé (Côte d’Ivoire- Burkina-Faso). Eur J Sci Res 2007;16(1):31–43. 3. Adger WN, Hug S, Brown K, Conway D, Hulme M. Adaptation to climate change in the developing world. 13. Madiodio N, Abe A, Abou A (2004) Réduire la Prog Dev Stud 2003;3(3):179–195. Doi: 10.1191/146 vulnérabilité de l’Afrique de l’Ouest aux impacts du 4993403ps060oa; climatsur les ressources en eau, les zones humideset la asin ification. UICN-Union mondiale pour la nature. 4. IFAD (International Fund for Agricultural Development) Cited: 7/8/2019, available at: https://portals.iucn.org/ (2008) Climate change and the future of smallholder library/efiles/documents/Climate-impactsF-prelims.pdf agriculture: How can rural poor people be part of the solution to climate change? Discussion Paper, Round 14. Kouakou KE, Goula BTA. Et Savané I. Impacts de la Table on Climate Change at the Thirty-first Session of variabilitéclimatiquesur les ressources en eau de IFAD’s Governing Council, Rome; Nyanga H, Johnsen surface en zone tropicalehumide:cas du bassin FH, Aune JB, Kalinda TH. Smallholder farmers’

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REVIEW ARTICLE

92 Ibrahim Card Med J 2019; 9 (1&2): 93-95  Ibrahim Cardiac Hospital & Research Institute

A Case Report : Pregnancy with Multiple Sclerosis Shiuly Chowdhury,1 Nilufar Islam,2 Khadiza Nurun Nahar,3 Kaniz Fatema,4 Salma Akter Munmun,5 Sudip Barua 6

ABSTRACT Multiple sclerosis causes disability in young adults and like most autoimmune diseases, affects women more commonly in their child-bearing years. In general, pregnancy does not appear to affect the long-term clinical course of multiple sclerosis and the disease does not affect the course or outcome of pregnancy. In this reportedcase, a pregnant woman with multiple sclerosis showed relapse of the disease in first half of her pregnancy and disease was well controlled in the second half of her pregnancy and postpartum period after taking appropriate measure. Women who have multiple sclerosis and wish to have a family can usually do so successfully with the assistance of their neurologist and obstetrician.

Key words: Multiple Sclerosis(MS), Pregnancy, Delivery, Antenatal, Postpartum, corticosteroids.

INTRODUCTION: pregnancy with IUGR (intrauterine growth retardation), oligohydramnios & PROM (premature Multiple sclerosis (MS) is the most common rupture of membrane) with MS. Multiple sclerosis inflammatory disorder of the central nervous was diagnosed, before pregnancy three years system during young adulthood. Both genetic and back. She had unilateral (hemicranial) headache environmental factors are considered to be and had difficulty in movement of eyeball on the involved in the pathogenesis of MS.1 Unfortunately right side and fatigue. In the Neurology many obstetricians are not usually experienced Department she was diagnosed as a case of with MS. Conversely many neurologists have limited multiple sclerosis. The diagnosis was confirmed knowledge of obstetrics and pregnancy in MS.2 with medical history, presenting symptoms, CASE REPORT: physical examination and investigations with lumber puncture and MRI. She was treated with A 25-year old nulliparous woman presented with a prednisolone, a steroid and anti-inflammatory history of 38 weeks pregnancy with premature drug. But she discontinued taking medicine when rupture of membrane with multiple sclerosis (MS). she got relieved of her symptoms. She got herself admitted in the Department of She attended at OPD early in her pregnancy. In Obstetrics & Gynaecology in Bangabandhu Sheikh very early weeks, her pregnancy was uneventful. Mujib Medical University (BSMMU). On per abdominal She was on regular antenatal checkup at OPD of examination, her uterus corresponded to 32 Obstetrics & Gynaecology Department. Neurologists’ weeks of pregnancy with cephalic presentation of opinion was taken time and again. Initially she foetus. Clinically it was a case of 38 weeks

Authors’ information: 1 Dr. Shiuly Chowdhury, Associate Professor, Department of Obstetrics & Gynaecology, C-Block (7th oor), BSMMU, Shahbagh, Dhaka-1000 2 Dr. Nilufar Islam, Medical Ocer, Department of Obstetrics & Gynaecology, BSMMU, Shahbagh, Dhaka-1000. 3 Dr. Khadiza Nurun Nahar, Associate Professor, Department of Obstetrics & Gynaecology, C-Block (7th oor), BSMMU, Shahbagh, Dhaka-1000 CASE REPORTCASE 4 Dr. Kaniz Fatema, Associate Professor, Department of Obstetrics & Gynaecology, C-Block (7th oor), BSMMU, Shahbagh, Dhaka-1000 5 Dr. Salma Akter Munmun, Medical Ocer, Department of Obstetrics & Gynaecology, BSMMU, Shahbagh, Dhaka-1000 6 Dr. Sudip Barua, Resident of Neurosurgery, NINS, Agargaon, Dhaka Correspondence: Dr. Shiuly Chowdhury, Cell Phone: +8801755527698, Email:[email protected]

93 A Case Report : Pregnancy with Multiple Sclerosis Chowdhury et. al.

was not put on any medication and was asked to of child-bearing age; approximately 10% of review with them after delivery. Two months later, women first present with symptoms with at around 14th weeks of pregnancy, she pregnancy.4 Therefore, pregnancy and delivery experienced headache which was hemicranial and become an important issue for those with MS.5 radiating to the right side of the face, teeth and Previously, MS specialists often advised against had difficulty in movement of eyeball on the right child-bearing because of the possible impact of side and weakness of extremities. Relapse of the disease on pregnancy and delivery.6 Recently, symptoms of multiple sclerosis compelled her to young adults with MS are being encouraged to be admitted in Neurology Department of this raise family.7 university hospital, where she was treated with Fortunately, pregnancy does not appear to speed steroid and other medicines. With improvement of up the course of the disease or worsen the effects symptoms she was released from the hospital of MS. However, it is thought that women who with treatment plan of pulse methylprednisolone have unrecognized MS are more likely to begin at scheduled intervals for rest of her pregnancy having symptoms during pregnancy. Some studies period. In the initial months, total 5 doses of have found that MS symptoms decrease in injectable methylprednisolone were given and pregnancy and increase during the postpartum then three doses every month till delivery. The (after delivery) period.8 It is thought that relapse postpartum treatment plan was also there and it rate is reduced during the late pregnancy because included capsule Imuran daily after delivery. of the effect of pregnancy hormones which Around 24 weeks of pregnancy, she developed suppress the immune system to ensure that the gestational diabetes mellitus which was managed body will carry a growing baby without rejecting with diet and light exercise. In the last trimester, it. Relapse rate after birth may increase because IUGR was diagnosed and the patient was kept of hormonal disturbances, but there is no under closed supervision for the rest of her consensus about this.9 A short course of high-dose pregnancy. At around 38 weeks of pregnancy she corticosteroids to hasten recovery from relapses presented with premature rupture of membrane appears relatively safe during pregnancy, but with meconium stained liquor. Considering the generally should be limited to disabling relapses. safety of both mother and child, delivery by Often there is a possible increased risk of fetal caesarean section was planned. The baby cleft palate associated with corticosteroid developed respiratory distress syndrome after treatment in the first trimester.10 Relapses during delivery, because of meconium aspiration. The pregnancy can be treated with corticosteroids but baby needed NICU support for 5 days. With caution is advised prior to gestational week 12 symptomatic improvement, both mother and baby because of the risk of cleft palate. In the case of were discharged from the hospital. She was severe relapse in the first trimester, the preferred advised to visit Obstetrics and Gynae OPD for treatment is prednisolone as it is inactivated in the postnatal follow up as well as Neurology OPD for placenta.11 follow up of multiple sclerosis. With the continuation of medicine, injection solupred (methylprednisolone) Women in labour may not have pelvic sensation every month and tablet Imuran (Azathioprine, a and may not feel pain with contraction. Delivery of disease modifying drug), 50 mg three times daily the fetus may be difficult. While labour itself is not and scheduled follow up in respective OPD, her affected, the muscles and nerve needed for present health condition is good without relapse. pushing can be affected. This may make caesarean section, forceps and vacuum assisted DISCUSSION: deliveries more likely.8 More frequent prenatal visits may be needed. In this case baby suffered Multiple sclerosis is a T-cell mediating autoimmune from intrauterine growth retardation (IUGR) and demyelinating disorder of the central nervous the mother had gestational diabetes mellitus system (CNS)3 that preferentially affects women CASE REPORT 94 Ibrahim Card Med J 2019; 9 (1&2): 93-95  Ibrahim Cardiac Hospital & Research Institute

during antenatal period. She also had premature rupture of membrane. The safety of both mother 9. www. Mstrust.org.uk/a-z/pregnancy and baby at delivery is paramount in such 10. Park-Wyllie L, Mazzotta P, Pastuszak A, et al. Birth patients. In the present case, delivery by defects after maternalexposure to corticosteroids: caesarean section was done for obstetric Prospective cohort study and meta-analysis of indication. However, medications like steroid may epidemiological studies. Teratology 2000; 62: 385– be used in pregnancy if needed. Breast feeding 392. was not associated with relapse. In the present 11. Kerstin Hellwig: Pregnancy in Multiple Sclerosis. Eur case, there was relapse of the disease in the first Neurol 2014;72(suppl 1):39–42. DOI: 10.1159/ trimester of pregnancy and general health status 000367640. was stable during the third trimester as well as in the postpartum period with the continuation of steroid and immunosuppressive therapy as scheduled.

CONCLUSION:

Pregnant women with MS need close monitoring of the disease for maternal and foetal wellbeing. Clinical course as well as relapse rate in early pregnancy and postpartum period can be reduced if the patient could be kept under close monitoring.

REFERENCES:

1. Compstona, Coles A. Multiple sclerosis. Lancet 2008; 372(9648):1502-1517

2. Borisow N, Paul F, Ohlraun S, Pach D, Fischer F, Dorr J. Pregnancy in Multiple Sclerosis: a questionnaire study. PloS One 2014;9(6):e99106

3. Houchens MK. Pregnancy and multiple sclerosis. Semin Neurol 2007;27:434-441.

4. Bennet KA. Pregnancy & multiple sclerosis. Clin Obstet Gynecol 2005;48:38-47.

5. R Bove T. Chitnis The role of gender and sex hormones in determining the onset and outcome of multiple sclerosis. Mult Scler 2014;20:520-526.

6. Sadovnick AD, EisenK, Hashimoto SA, Farquhar R, Yee IM, Hooge J, etal.Pregnancy and multiple sclerosis. A prospective study. Arch Neurol 1994;51:1120-124.

7. Bove R, Alwan S, Friedman JM, Hellwig K, Houtchens M, Koren G, et al. Management of multiple sclerosis CASE REPORTCASE during pregnancy and the reproductive years: a systematic review. Obstet Gynecol 2014;124(6):1157- 68. doi: 10.1097/AOG.0000000000000541.

8. Multiple Sclerosis and Pregnancy-Stanford Children's Health https://www.stanfordchildrens.org/en/topic/default? id=multiple-sclerosis...pregnancy.

95 Reviewers of Current Issue

Prof. Dr. Khandker Md. Akhtaruzzaman MBBS, DCM, MCPS (Medicine), MD (Cardiology) Medicine & Heart Specialist Professor & Head, Department of Cardiology Sylhet Women's Medical College & Hospital, Sylhet

Prof. Dr. Mashhud Zia Chowdhury MBBS, DTCD, MD (Card), FACC (USA) Clinical & Interventional Cardiology Professor & Senior Consultant Ibrahim Cardiac Hospital & Research institute (ICHRI), Shahbag, Dhaka

Dr. Shiuly Chowdhury Associate Professor (Obstetrics and Gynaecology) BSMMU, Shahbag, Dhaka

Dr. Sahela Nasrin MBBS, MCPS (Med), MD (Card) Associate Professor (Cardiology) Ibrahim Cardiac Hospital & Research Institute (ICHRI), Shahbag, Dhaka

Dr. C M Shaheen Kabir MD, FSCAI, FACC Associate Professor (Cardiology) Ibrahim Cardiac Hospital & Research Institute, Dhaka

Dr. F. Aaysha Cader MBBS, MRCP (UK), MD (Cardiology) Assistant Professor (Cardiology) Ibrahim Cardiac Hospital & Research institute (ICHRI), Shahbag, Dhaka REVIEWERS

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