2022 12 13 06 59

MuMC Mugda Medical College Journal
ISSN (Print): 2958-1281
J o u r n a l
ADVISORY BOARD
Professor Dr. Jubaida Gulshan Ara
Professor Dr. Tahmina Yeasmin
Professor Dr. Salma Ahmed.
Professor Dr. Md. Zulfiqur Hossain Khan
Professor Dr. Sabina Hussain.
Professor Dr. Jebun Nessa
Professor Dr. Asifa sattar.
Professor Dr. Md. Selim.
Professor Dr. Zahidul Ahsan
EDITORIAL BOARD
Chairperson : Prof. Dr. Abul Bashar Md. Jamal, Principal, MuMC.

Co-Chairperson : Prof. Dr. Shamima Parvin, Vice Principal, MuMC
Chief Editor : Prof. Dr. Naila Huq
Executive Editor : Dr. Md. Monjurul Haque
Assistant Editor : Dr. Md. Abdul Hamid
Dr. Dosth Mohammad Lutfur Rahman
Dr. Md. Abu Sayeed Choudhury
Dr. Riffat Rahim
Members : Prof. Dr. Rubina Yasmin
Prof. Dr. Mohammed Shadrul Alam
Dr. Adnan Yusuf Choudhury
Dr. Khandaker Md. Nurus Sabah
Dr. Mohammad Ahsanul Haque
Dr. A H M Mazharul Islam
Dr. Rokanuzzaman Bhuyian
Dr. A.B.M. Zakir Uddin
Dr. Md. Harun-Are - Rashid
Dr. Sumaira Sufrin
Dr. Abu Saleh Md Shirajum Munir
Published by
MUGDA MEDICAL COLLEGE, BANGLADESH
If any query please correspond with
The Chief Editor, Mugda Medical College Journal (MuMc Journal)
Mugda Medical College, Dhaka, Bangladesh
E-mail: [email protected]
Editorial
Histopathological Diagnosis and its Pitfall:

Bangladesh Perspective
Histopathological diagnosis and knowledge of histopathological reports in extremely low costing. As

pathogenic process is the key to modern medicine. a compromise, they practice inadequate grossing and
Despite histopathology being the gold standard in prepares only a few blocks. This results in missing the
available diagnostic techniques, considerable representative areas in the sections and subsequent
variability exists between different laboratories. This errors. Even if the histopathologist provides proper
culminates in confusion and distress for patients diagnosis, commenting on pathological staging or
and clinicians alike. It is of utmost importance to involvement of resection margins is not possible in
address the issue underlying the diagnostic dilemma malignant tumors.
to overcome the situation. To avoid the diagnostic dilemma, some clinicians prefer
In Bangladesh, the errors start from the operation to divide the specimen and send it to different
theatre which have persistent consequences. Lack laboratories which further aggravates the situation. In
of awareness of health service providers about the many cases different laboratories receives different type
importance of fixation in histopathology majorly of tissue from the same specimen manifesting in
contributes to diagnostic difficulties. In a large different and often conflicting diagnosis. It results in
number of cases, specimens are sent in normal saline. both psychological and financial sufferings to the
patients and their family members. As slides and blocks
Use of improper or inadequate amount of fixative,
are available to review in any laboratory in Bangladesh
sending large specimen without slicing results in
or abroad; it is wise to report the whole specimen in one
autolysis of tissue. Especially the hospitals and
laboratory and avail further consultation if necessary.
clinics outside Dhaka can’t provide proper fixation
due to scarcity of material and expertise. Role of histopathology is crucial in the diagnosis and
treatment of disease. A combined, cordial and
Provision of proper clinical information regarding
communicative approach between both clinician and
age, sex, clinical history, relevant investigations and
histopathologist can produce credible results that aid
provisional diagnosis can reduce the diagnostic
in the therapeutic process.
dilemma in a majority of cases.
Absence of reliability results in dependence of
Mugda Med Coll J. 2022; 5(2): 54
clinicians on few selective laboratories and
overburdens those. On the other hand, sending Naila Huq
specimen in the laboratory without proper setup also Professor and Head, Department of Pathology, Mugda
contributes to the diagnostic errors. They provides Medical College, Dhaka.
54
Original Article
Adolescent Pregnancy Outcome in a District

Hospital of Bangladesh
Chowdhury N1, Rahim R2, Khan LN3, Sweety K4, Akther P5
ABSTRACT
Background: Adolescent pregnancy is universally accepted as high risk pregnancy.
Bangladesh has the highest (1 in 10) adolescent fertility rate in South Asia.
Objective: The study was conducted to find out the common problems of adolescent pregnancy.
Methodology: A comparative cross-sectional study was carried out among 100 respondents
(50 adolescents and 50 adults) in Munshigonj General Hospital from 1st January to 31st
December 2018. Respondents were admitted patients who have delivered either vaginally or
by caesarian section. Women aged 15 to 19 years selected as adolescent and those aged 20 to
40 years selected as adult. Socio-demographic characteristics, past obstetric history, antenatal
checkup, antenatal and intrapartum complications, and clinical state on admission were
recorded in a semi structured questionnaire. Obstetrical parameters of adolescent and adult
groups were compared.
Results: Among total admitted patients 11% were adolescent. 70% were from rural area,
68% were poor, 50% didn’t have even primary education, 92% adolescent never use
contraceptive, 56% had no ANC. Anemia (62%) and hypertension (24%) were prevalent
among the pregnant adolescents. Complication rate were more in adolescent group, like
preeclampsia (12%), eclampsia (14%), preterm labor (12%), prolonged labor (14%), obstructed
labor (8%). Caesarean rate was higher (66%) in adolescent pregnancy.
Conclusion: Majority of the adolescents had no ANC, complication rate were more prevalent
in adolescent group. Adverse perinatal outcome was found in adolescent pregnancy.
Key words: Adolescent pregnancy, Pregnancy outcome.
Mugda Med Coll J. 2022; 5(2): 55-59
INTRODUCTION Majority of these births (95.0%) occur in low and

Adolescent pregnancy is a major global problem due middle income countries 1 . The prevalence of
to the wide range of health effects and socioeconomic adolescent motherhood is much higher in low income
consequences both for mothers and their children. countries as compared to high income countries1.
Globally about 17 million adolescent girls give birth Half of all adolescent births occur in just seven
each year comprising 11.0% of all births worldwide. countries: Bangladesh, Brazil, the Democratic
Republic of the Congo, Ethiopia, India, Nigeria and
1. Dr. Nowshafreen Chowdhury, Assistant Professor, Gynae
the United States 1. Bangladesh has the highest
& Obstetric Department, Mugda Medical College, Dhaka.
2. Dr. Riffat Rahim, Assistant Professor, Gynae & Obstetric adolescent fertility rate in South Asia where 1 girl in
Department Mugda Medical College, Dhaka 10, has a child before the age of 15, whereas 1 in 3
3. Dr. Laila Nazneen Khan, Assistant Professor, Gynae & adolescent becomes mother or pregnant by the age of
Obstetric Department, Mugda Medical College, Dhaka
19 2-4 . Despite remarkable progress in human
4. Dr. Kamrunnahar Sweety, Assistant Professor, Gynae &
Obstetric Department, Mugda Medical College, Dhaka development adolescent childbearing is highly
5. Dr. Pervin Akther, Assistant Professor, Gynae & Obstetric persistent in Bangladesh mostly due to the
Department, Mugda Medical College, Dhaka
comparatively higher prevalence of child marriage5,6.
Address of correspondence: Dr. Nowshafreen Chowdhury,
Assistant Professor, Gynae & Obstetric Department, Mugda To a vast majority of adolescent in the developing
Medical College, Dhaka, Phone: 01771468699, Email:
[email protected] world, family planning information and services are
55
MuMC Journal Volume 5, No. 2 July 2022
not accessible. The effect of time on adolescent RESULTS

motherhood can be attributed to the increasing trend Total admitted pregnant women were 780. Among
of female education, labor force participation, women them 86 (11.03%) were adolescent and rest 694
empowerment and knowledge dissemination in (88.97%) were adult.
Bangladesh. In connection with this it is worthwhile
to mention that Bangladesh is one of the few Total Admission
developing countries that has achieved most of the
Millennium Development Goals including reducing 11.03%
poverty, increasing female education, and reducing
gender inequality7,8.
The study was conducted to find out the common
problems of adolescent pregnancy which would help 88.97%
to develop appropriate measures to reduce these and
eventually contribute to ensure quality life of
adolescents and healthy life of mothers and children Adolescent Adult
in particular in Bangladesh.
Fig.-1: Percentage of adolescent pregnancy in total
MATERIALS AND METHODS admission
This comparative cross-sectional study was carried
out in Munshigonj General Hospital, Munshigonj
Table I: Distribution of habitancy
from 1st January to 31st December, 2018. Respondents
were admitted patients who had delivered either Resident Adolescent Adult
vaginally or by caesarian section. Women aged 15 to
n=50 % n=50 %
19 years selected as adolescent and those aged 20 to
40 years selected as adult. A purposive and Urban 15 30 40 80
convenient sampling method was done to obtain the Rural 35 70 10 20
samples, 50 adolescents and 50 adults. After
formulation of aims and objectives of the study, semi- Adolescent pregnancy was higher (70%) in rural
structured questionnaire was made for recording all habitants.
relevant parameters. Information were recorded by
face to face interview of the respondents and from
patient’s hospital file about socio-demographic Table II: Educational status
condition, contraceptive method, antenatal checkup,
antenatal and intrapartum complications, mode of Education Adolescent Adult
delivery, perinatal outcome and clinical state on
n=50 % n=50 %
admission. Antenatal complication like abortion,
molar pregnancy, hyperemesis gravidarum, preterm Illiterate 17 34 13 26
labor, prelabor rupture of membrane, preeclampsia, Can sign only 8 16 9 18
eclampsia, antepartum hemorrhage, malpresentation
were recorded. Intrapartum complication like Primary 21 42 12 24
eclampsia, prolonged labor, obstructed labor or Secondary 4 8 16 32
postpartum hemorrhage were also recorded. Mode
of delivery whether by normal vaginal delivery or by Less literacy rate was observed in adolescent group.
caesarian section and perinatal outcome whether
baby was normal, cried well just after birth or Table III: Distribution of family income per month
asphyxiated or stillborn were also noted. After
Income (Taka) Adolescent Adult
obtaining the data statistical analysis of the results
n=50 % n=50 %
was performed using SPSS (Statistical Package for
the Social Sciences) version 20 software. The <10000 34 68 25 50
obstetrical parameters of the adolescent and adult 10000-15000 9 18 12 24
groups were compared using the z score test. >15000 7 14 13 26
Statistical significance was set at £0.05 level and Most of the adolescent (68%) come from low income
confidence interval at 95% level. group.
56
Table IV: Use of contraceptives

Use Adolescent Adult Test of significance
n=50 % n=50 % Z P
Don’t use 46 92 21 42 9.4071 .00
Irregular 2 4 9 18 3.2323 .00
Regular 2 4 20 40 7.1291 .00
92% adolescent never use contraceptive.
Table V: Antenatal checkup

ANC Adolescent Adult Test of significance
n=50 % n=50 % Z P
Regular 14 28 23 46 2.4425 0.0146
Irregular 8 16 7 14 0.3960 0.6892
No ANC 28 56 20 40 2.8486 0.0044
Most of the adolescent (56%) had no ANC.
Table VI: Clinical state on admission

Parameter Adolescent Adult Test of significance
n=50 % n=50 % Z P
Anemia 31 62 19 38 3.6449 .00
Edema 12 24 11 22 - -
Hypertension 12 24 2 4 9.0011 .00
Proteinurea 6 12 2 4 4.4915 .00
Anemia (62%) and hypertension (24%) were prevalent among the pregnant adolescents.
Table VII: Antepartum and Intrapartum complications

Complication Adolescent Adult Test of significance
n=50 % n=50 % Z P
Hyperemesis 1 2 1 2 - -
Preeclampsia 6 12 1 2 4.5001 -
Eclampsia 7 14 0 0 - -
IUD 1 2 1 2 - -
Preterm labor 6 12 2 4 3.8065 0.423
Malpresentation 5 10 0 0 - -
Prolonged labor 7 14 2 4 4.605 0.424
Obstructed labor 4 8 2 4 1.1533 0.2460
Scar tenderness 0 0 8 16 - -
APH 0 0 0 0 - -
Oligohydramnios 2 4 1 2 1.1533 0.2460
No complication 13 26 31 62 1.1533 0.2460
Complication rate were more in adolescent group, like preeclampsia (12%), eclampsia (14%), preterm labor
(12%), prolonged labor (14%), obstructed labor (8%).
57
Table VIII: Mode of delivery
Mode Adolescent Adult Test of significance

n=50 % n=50 % Z P
NVD 22 44 29 58 4.6162 0.00
LSCS 28 56 21 42 3.5714 -
Caesarean rate was higher (56%) in adolescent pregnancy.
Table IX: Perinatal outcome
Condition Adolescent Adult Test of significance

n=50 % n=50 % Z P
Healthy 28 56 36 72 1.4286 0.1528
Asphyxiated 18 36 10 20 1.5523 0.1212
Stillborn 4 8 4 8 - -
Better perinatal outcome found in adult group.
DISCUSSION women. For instance, in 2014 the prevalence of

Study revealed that most of the adolescent pregnant contraceptive use (any method) among teenage girls
women were hailing from rural area (70%) and of was only 51.2% compared to 67.7% among adult
low socio-economic condition (68%) with poor women. Part of the reason was that in most cases
literacy rate (92%). Similar features were also observed teenage girls take their desired number of children at
in Islam M.M. et al study9 showed teenage girls in the younger ages to fulfill the expectation of husband
poorest wealth quintile were more likely to experience and in-laws or family members despite higher risk of
adolescent motherhood than the richest wealth having children before age of 20 yrs10.
quintile. Adolescents who had no education were
Adolescents are not fully physically developed, at
found to have 2.76 times higher odds of adolescent
menarche a young girls pelvis has not finished
motherhood than their counterparts who had higher
growing. Therefore, pregnancy and birth at a young
than secondary education. Consistent with the
age pose serious risks for both mother and child. The
prevalence of adolescent motherhood among teenage
present study revealed that 62% adolescent were
girls, the rate of childbearing before age 20 was found
anemic whereas only 38% were anemic in adult
to be lower in urban areas than in rural areas.
group. 24% adolescent became hypertensive during
Similarly, the rate of adolescent motherhood among
pregnancy, 12% developed preeclampsia, 14%
women was substantially higher among lower
suffered from eclampsia while in adult group only
educated women. The inverse association between
2% were hypertensive, 2% developed preeclampsia
wealth index and the rate of adolescent motherhood
and no one suffered from eclampsia. Adolescent
is also clearly evident among adult women as well9.
pregnancy culminated in preterm labor in 12%,
Acceptance of contraceptives is very low in prolonged labor in 14% and obstructed labor in 8%
adolescent. In this present study 92% never use any cases. Adult group showed 4%, 4% and 2%
contraceptive, while in adult group this number was respectively. Study conducted by Rahman M. et al11
42% only. A study conducted by United Nations found that maximum adolescents suffered from
Children’s Fund 10 mentioned that though anemia during the time of pregnancy. About 98%
Bangladesh has made considerable progress in adolescent suffered delivery complications like
increasing overall contraceptive prevalence rate eclampsia, prolonged labour, excess hemorrhage, and
(44.6% in 1993–94 to 62.4% in 2014) it was still much delay in delivery of placenta whereas only 16%
lower among married teenage girls compared to adult suffered these complications that were pregnant at
58
age 20 years and later. More than fifty percent 6. Hossain MB, Ghafur T, Islam MM, Hasan
adolescent undergo prolonged delivery and very few MS. Trends, patterns and determinants of marriage
(2%) adolescent delivered babies safely11. Several in Bangladesh. Dhaka: Bangladesh Bureau of
other studies also observed the pregnancy Statistics (BBS), Statistics and Informatics Division
(SID), Ministry of Planning, Government of People’s
complications like hypertension, eclampsia, iron
Republic of Bangladesh: 2015.
deficiency anemia were common among adolescent12-16.
7. Government of Bangladesh. Millennium
Phuong Hong Nguyen 17 study in Bangladesh development goals: Bangladesh progress report-
showed greater risk of anemia, low birth weight 2015. Dhaka; Bangladesh Planning Commission:
affecting the lifelong well-being of a young mother 2013.
and her child. Economic risks also weighed heavily 8. United Nations. The Millennium Development
on younger mothers, who demonstrated higher rates Goals Report 2015. New York; UN: 2015.
of early school dropout which leaves them less
9. Islam MM, Islam MK, Sazzad MH, Hossain MB.
empowered in the long term and thus more vulnerable
Adolescent motherhood in Bangladesh; Trends and
to sustained poverty17. determinants: 2019.
CONCLUSION 10. United Nations Children’s Fund. The state of the
Adolescent pregnancy is universally accepted as high world’s children 2011. Adolescence: an age of
risk pregnancy. Majority of the adolescents had no opportunity. New York; UNICEF: 2011.
antenatal care & complication rate were more 11. Rahman MM, Hasan M, Akter S, Sultana P.
prevalent in adolescent group. Adverse perinatal Adolescent pregnancy complication and wastage
outcome was also observed in adolescent pregnancy. in Bangladesh.
To reduce this problem multiple programme should 12. Sharma AK, Chhabra P, Gupta P, Aggarwal GP
be undertaken on national level targeting firstly the Lyngdoh T. Pregnancy in Adolescent: A Community
adolescents and secondly their parents as well as based study. Indian J. Prev. Soc. Med 2003; 34: 25-32.
community and social leaders. 13. Lyngdoh T. Adolescent pregnancy and its outcome:
A study in a resettlement colony of east Delhi. Thesis
REFERENCES
submitted to the University of Delhi for the degree
1. World Health Organization. Adolescent pregnancy:
of MD (Community Medicine); New Delhi: 2002.
WHO fact sheet 2014 [cited 2017 Nov 11].
14. Sharma AK, Verma K, Khatri S, Kannan AT.
2. United Nations Development Programme. Human Pregnancy in adolescents: A study of risks and
development report 2016. New York; UNDP: 2016. outcome in Eastern Nepal. Indian Pediatr 2001;
3. United Nations Fund for Population. State of world 38(12): 1405-9.
population 2013. Motherhood in childhood. Facing 15. Ananadalakshmy PN, Buckshee K. Teenage
the challenge of adolescent pregnancy. New York; pregnancy and its effect on maternal and child
UNFPA: 2013. health - a hospital experience. Indian J Med Sci 1993;
47(1): 8-11.
4. Government of Bangladesh. Bangladesh Population
Policy-2012. Dhaka; Ministry of Health and Family 16. Padte K, Pal MN, Pavse J. Review of teenage
Welfare: 2012. pregnancy in Goa. J Obstet Gynecol India 1989; 39:
472-4.
5. Islam MM, Gagnon AJ. Child marriage-related
17. Phuong Hong Nguyen. New research shows
policies and reproductive health in Bangladesh: a
heightened risks of adolescent pregnancy in
cross-sectional analysis. Lancet 2014; 384: S8.
Bangladesh. 2017.
59
Original Article
Causes of Graft Dysfunction in Live Related Kidney
Transplantation in a Tertiary Care Hospital
Chowdhury MFH1, Alam MR2, Khan MF3, Rahman MM4, Khanam A5, Anwar MR6, Nath PKD7,
Hossain M8, Saha SK9
ABSTRACT
Introduction: Renal transplantation remains the treatment of choice for end-stage renal
disease (ESRD). Graft dysfunction or adverse events following renal transplantation are
associated not only with short & long term graft outcome, but also with patient survival.
Living kidney donation is a scheduled event that offers the advantage of optimal preparation
for the recipient and donor. Restoration & preservation of renal function post transplant
depends on many factors. Attempts should therefore been made to improve early graft function
by a variety of mechanical, pharmacological and organ allocation strategies.
Objectives: To identify the causes of graft dysfunction in renal allograft recipients.
Method: In this prospective study, a total of 40 renal allograft recipients as well as 40 donors
were evaluated. ESRD patients and kidney donors preoperative details and clinical parameters
were recorded in structured questionnaire. Peroperative variables like induction with antibody,
cold ischemia time, warm ischemia time, peroperative hypotension, peroperative blood
transfusion, peroperative urine production were recorded. Early postoperative clinical variables
like BP, hourly urine production, temperature were monitored and biochemical Hb%, Tc, Dc,
ESR, blood urea, serum creatinine, s. electrolytes, cyclosporin level (C2 level), urine RME &
CS and imaging USG of transplanted kidney and duplex study of renal vessels were done. On
the basis of creatinine reduction ratio(CRR) on post transplant day 7, renal allograft recipients
were divided into IGF and RGF/graft dysfunction group respectively and evaluation and
causes of graft dysfunction were recorded. Data were processed and analyzed using computer
software SPSS (Statistical package for social science) version 12.
Results: The mean age of donors was 39.15±10.09 years with a male female ratio 1:1.7. The
mean age of renal allograft recipients was 32.30±8.85 years with a male to female ratio of 3.5:1.
Among 40 patients, 52.5% recipients had IGF and 47.5% had RGF. At day 7
posttransplantation period mean serum creatinine in IGF group was 130.10±14.45 ìmol/L
and in RGF group was 237.32±123.85 ìmol/L which was statistically strongly significant (p
value <0.0001). Regarding causes of graft dysfunction at day 7 post transplant period, cold
ischemia time (p value 0.043) and postoperative urine production within 6 hours (p value
0.0001) were found statistically significant.
Conclusion: This study showed that 52.5% renal allograft recipient had IGF and 47.5 %
renal allograft recipient had graft dysfunction(RGF). Significant causes of graft dysfunction
were long cold ischemia time in minute and peroperative urine production in ml within 6
hours after anastomosis of vessels.
Keywords: Kidney transplantation, Immediate graft function (IGF), Reduced graft function
(RGF), Graft dysfunction.
Mugda Med Coll J. 2022; 5(2): 60-66
1. Dr. Md. Farhad Hasan Chowdhury, Assistant Professor, Department of Nephrology, Mugda Medical College, Dhaka, Bangladesh.
2. Professor (Dr.) Muhammad Rafiqul Alam, Chairman and Head, Department of Nephrology, Bangabandhu sheikh Mujib
Medical University, Dhaka, Bangladesh.
3. Professor (Dr.) Md. Firoz Khan, Professor and Head, Department of Nephrology, Dhaka Medical College, Dhaka.
4. Professor (Dr.) M. Muhibur Rahman, Professor and Head, Department of Nephrology, National Institute of Kidney Disease
and Urology, Dhaka.
5. Professor (Dr.) Asia Khanam, Professor, Department of Nephrology, Bangabandhu sheikh Mujib Medical University, Dhaka, Bangladesh.
6. Dr. Mohammed Rashed Anwar, Associate Professor, Department of Nephrology, Mugda Medical College, Dhaka, Bangladesh.
7. Dr. Palash Kumar Deb Nath, Assistant Professor, Department of Nephrology, Mugda Medical College, Dhaka, Bangladesh
8. Dr. Momtaz Hossain, Assistant Professor, Department of Nephrology, Mugda Medical College, Dhaka, Bangladesh.
9. Dr. Satyajit Kumar Saha, Assistant Director, Mugda Medical College Hospital, Dhaka, Bangladesh.
Address of correspondence: Dr. Md. Farhad Hasan Chowdhury, Assistant Professor, Department of Nephrology, Mugda
Medical College, Dhaka, Bangladesh. email. [email protected]
60
INTRODUCTION: of mechanical, pharmacological and organ allocation

Renal transplantation remains the treatment of choice strategies7. If suboptimal early graft function could
for end-stage renal disease (ESRD) in regards to be accurately predicted, the success of these strategies
patient survival1. Marked improvements in early may be improved. Hence, the present study was
graft survival, short-term and long-term graft function proposed to identify the causes of graft dysfunction
have translated into kidney transplantation being a in renal allograft recipients.
more cost-effective alternative to dialysis. Post-
transplantation graft function usually divided into METHODS:
immediate graft function (IGF) and poor early graft This prospective observational study was done in
function or delayed graft function (DGF) or reduced department of Nephrology, Bangabandhu Sheikh
function group(RGF). Olwyn Johnston et al. 20062 in Mujib Medical University (BSMMU) over a period of
their study divide graft function in reduced graft 36 months from January 2010 to December 2012. A
function (with or without dialysis) and immediate total of 40 renal allograft recipients as well as 40
graft function. 7 days’ creatinine reduction ratio (CRR) kidney donors were included in this study. ESRD
marked as cut point of difference between immediate patients and kidney donors preoperative details and
graft function (IGF) & reduced graft function (RGF)
clinical parameters were recorded in structured
group. Recipients with a CRR between time 0 of
questionnaire. All patients (except preemptive
transplantation and day 7 post-transplantation of
e”70% had IGF and CRR <70% with or without transplantation) received hemodialysis on the day
dialysis had RGF. RGF may subdivided into DGF before transplantation. Immunosuppressive drugs
where CRR <70% with dialysis and SGF where CRR Cyclosporin and MMF were started 2 days before
<70% without dialysis. transplantation. Inj. Basiliximab 20 mg peroperatively
and Day 4 posttransplantation – if indicated.
Restoration & Preservation of renal function post-
transplant depends on many factors. Long- term Peroperative variables like induction with antibody,
success of renal transplantation depends upon the cold ischemia time, warm ischemia time, peroperative
quality of the donor organ, avoidance of hypotension, peroperative blood transfusion,
peritransplant and early posttransplant damage and peroperative urine production were recorded.
optimal maintenance of graft function after the first All vital signs including BP, hourly urine production,
6-12 months3. Living donation is a scheduled event
temperature were monitored hourly and intake-
that offers the advantage of optimal preparation for
output chart was maintained according to protocol
the recipient and donor. This situation allows for
control of logistics that minimize the organ in post-operative period on the day of operation in
preservation time. Risk factors for DGF in the recipient KT-ICU. During 1-7 days post-operative period, all
include male gender, black race, longer dialysis vital signs were monitored at regular interval, intake-
duration, high panel-reactive antibody (PRA) titer, output chart and fluid balance were maintained
CMV status, number of grafts received and greater according, I.V Methyl prednisolone – 1st & 2nd POD,
degree of HLA mismatching. Donor related risk oral Cyclosporin , oral MMF and oral prednisolone
factors include use of cadaveric donors, older donor were used as immunosuppressive agents. Any
age and longer cold ischemia time4. Most of these symptoms of fever, burning sensation during
variables affect the graft through ischemia- micturation, cough etc. were noted. Foleys cather
reperfusion injury and immunologic mechanisms. removed on 3rd POD. Laboratory investigations were
High dosage of calcineurin inhibitors (CNIs) could
daily Urine routine and microscopic examination,
also prolong or worsen DGF5. Humar A et al.20026 in Hb%, TC, DC, ESR, B. Urea, S. Creatinine, S. Elecrolytes.
their study showed that initial function of the graft
Urine C/S- 3rd POD, Duplex study of the anastomotic
significantly influenced the subsequent risk of acute
vessels on 5th day, C2 level (Blood level of cyclosporine
rejection (at 12 months’ post-transplant, the incidence
2 hours after ingestion) on 7 th day. Other
of AR was 28% for those with IGF, 38% for those with
investigations were done according to need like blood
SGF, and 44% for those with DGF) and graft survival
C/S, USG of the transplanted kidney etc. On the basis
(the 5-yr death-censored graft survival rate was 89% of creatinine reduction ratio(CRR) on post transplant
for recipients with IGF, 72% for those with SGF, and
day 7, renal allograft recipients were divided into IGF
67% for those with DGF). Attempts should therefore
and RGF group respectively and evaluation and
been made to improve early graft function by a variety
causes of graft dysfunction were recorded.
61
RESULT:
Table I: Preoperative characteristics of donors (n=40) Table II: Preoperative characteristics of recipients (n=40)
Parameters Mean±SD Frequency Percentage Parameters Mean±SD Frequency Percentage
Age (years) 39.15±10.09
Age (years) 32.30±8.85
Sex
Sex
Male 15 37.5
Male 31 77.5
Female 25 62.5
Creatinine clearance Female 9 22.5
rate (ml/min) 84.03±17.61 Pretransplant serum

Anti CMV (IgM) creatinine 523.23±109.77
Positive 0 0.0 (mmol/L)
Negative 40 100.0 HLA typing (class I)
Anti CMV (IgG) 4 mismatch 6 15.0
Positive 35 87.5 2 mismatch 33 82.5
Negative 5 12.5 0 mismatch 1 2.5
Anti CMV (IgM)
Positive 2 5.0
Negative 38 95.0
47.5
Anti CMV (IgG)
52.5
Positive 36 90.0
Negative 4 10.0
Fig.1 shows recipients graft status at 7 th

posttransplant day. 52.5% recipients had immediate
Immediate graft function Reduced graft function
graft function and 47.5% had graft dysfunction or
reduced graft function.
Fig.1 Recipients graft status at 7th post transplant day
Table III: Comparison of postoperative serum creatinine level between reduced and immediate graft function groups
Reduced Immediate
graft graft
Serum function function p valuea
creatinine (mmol/L) (n=19) (n=21)
(Mean±SD) (Mean±SD)
At day 7 237.32±123.85 130.10±14.45 0.0001***
aUnpaired Student’s ‘t’ test
ns = Not significant ** = Significant at P<0.01

* = Significant at P<0.05 *** = Significant at P<0.001
62
Table IV: Comparison of recipient peroperative risk factors between reduced and immediate graft function groups
Risk factors Reduced graft Immediate graft p value
function (n=19) function (n=21)
aInduction with antibody 0.301ns
Yes (No./%) 6 (31.6) 10 (47.6)
No (No./%) 13 (68.4) 11 (52.4)
bCold ischaemic time(min)
(Mean±SD) 108.11±123.45 51.57±11.68 0.043*

bWarm ischaemic time(sec)
(Mean±SD) 13.68±3.13 13.76±2.41 0.930ns

cPeroperative hypotension 0.0001***
Yes (No./%) 10 (52.6) 0
No (No./%) 9 (47.4) 21 (100.0)
cPeroperative blood transfusion 0.005**
Yes (No./%) 11 (57.9) 3 (14.3)
No 8 (42.1) 18 (85.7)
bUrine production(ml)
(Mean±SD) 83.84±112.62 354.52±215.84 0.0001***

aChi square test ns = Not significant bUnpaired Student’s ‘t’ test
* = Significant at P<0.05 cFisher’sexact test ** = Significant at P<0.01

*** = Significant at P<0.001
50 RGF IGF Figure 2 shows adverse events at day 7. In RGF group,

40
21.1% patients suffered from postoperative
hypotension. Fever was found in one quarter (26.3%),
Percentage
30
UTI in 15.8% and perinephric collection in 10.5% of
20 patients. 26.3% patients of RGF group had no adverse
10 events. In IGF group, about half of the patients had
no adverse events whereas fever and UTI was
0
None Fever UTI Perinephric Postoperative observed equally in 28.6% patients.
collection hypotension
Fig. 2: Adverse events at day 7
Table V Analysis of risk factors for reduced graft function (n=19) vs immediate (n=21) graft function groups
Reduced graft Immediate graft
Variables function (n=19) function (n=21) RR p value
No.(%) No.(%) (95% CI)
aDonor age 41.05±9.8 37.43±10.26 36.02 42.46 0.262ns
aRecipient age 31.16±8.13 33.33±9.54 29.39 35.10 0.445ns
aDonor creatinine clearance rate 83.47±17.29 84.53±18.31 78.29 89.72 0.851ns
aRecipient pretreatment s. creatinine 513.47±115.72 532.05±106.18 487.25 558.27 0.600ns
aCold ischaemic time 108.11±123.45 51.57±11.68 52.47 107.20 0.043*
aWarm ischaemic time 13.68±3.13 13.76±2.41 12.84 14.61 0.930ns
aUrine production(ml) 83.84±112.62 354.52±215.84 163.19 275.18 0.0001***
bWell matched kidney 18(94.6) 16(76.2) 0.333 (0.025 4.401) 0.404ns
bInduction with antibody 6 (31.6) 10(47.6) 0.625 (0.089 4.400) 0.637ns
bPeroperative hypotension 10(52.6) 0 0.0001 (0.000 0.032) 0.759ns
bPeroperative blood transfusion 11(57.9) 3(14.3) 0.563 (0.061 5.217) 0.613ns
aMultivariate analysis ns = Not significant
bLogistic regression * = Significant at P<0.05
*** = Significant at P<0.001
63
DISCUSSION: Regarding sex of donor and recipient, among the

Renal transplantation improves the patient’s quality donors, 37.5% were male and 62.5% were female and
of life to a greater extent than hemodialysis and the ratio of male and female was 1:1.7. In case of
peritoneal dialysis8. Reduced Graft Function (RGF) recipient, 77.5% of them were male and 22.5% were
is a well-known complication that can affect the female. The ratio of male and female was about 3.5:1.
kidney allograft in the immediate post-transplant Senel FM et al.1998 in their study11, identified recipient
period. Excellent organ quality and ideal transplant sex as a risk factor for DGF. But some large studies
conditions contribute to immediate graft function showed that sex of both donor and recipient had no
(IGF) in a vast majority of living donor kidney effect on graft function14-15. In our study, we did not
transplantations (LDKT). However, poor early graft find any significant effect of sex on graft function (p
function still occurs after LDKT, although less value in case of donor was 0.597 and in recipient was
frequently than after deceased donor kidney 0.431) which supports the recent studies.
transplantation9. Poor EGF following LDKT has a In our study, regarding HLA matching between donor
large impact on long-term graft survival.10 and recipient, 0 mismatch was found in 2.5% cases, 2
For the purpose of the study, immediate graft function mismatch in 82.5% and 4 mismatch found in 15%
(IGF) was defined as return of normal renal function cases. Univariate analysis between RGF and IGF
within 7 days after transplantation or creatinine groups showed no significant difference (p value
reduction ratio (CRR)e” 70% on day 7 after 0.600). Logistic regression showed HLA mismatching
transplantation, delayed graft function (DGF) as the was not a significant cause of RGF (p value 0.404).
requirement for dialysis within the first week after HLA matching was thought to be very important for
renal transplantation and slow graft function (SGF) living donors, given that two-haplotype–matched
as CRR< 70% on day 7 after transplantation without sibling donors have the best outcome. However, in
dialysis. Graft dysfunction or reduced graft function the mid-1990s, results from a large registry analysis
was defined as occurrence of DGF or SGF. In this found that transplants from two-haplotype–
study, at 7 days posttransplantation period mean mismatched siblings or spouses had outcomes similar
serum creatinine in IGF group was 130.10±14.45 to one haplotype– mismatched sibling or parental
ìmol/L and in RGF group was 237.32±123.85 ìmol/ donor transplants. H.S. Park et al. 201214 showed
L which was statistically strongly significant (p value there was no significant effect of HLA matching on
<0.0001). Among 40 patients, 52.5% recipients had early graft function.
immediate graft function and 47.5% had reduced graft Duration of cold ischemia time is a significant risk
function. factor in the etiology of ATN and an increased
Comparing the demographic characteristics between ischemia time in cadaver transplantation is the cause
the study groups, age of both donor and recipient of high incidence of ATN16. The anastamosis time
were found not significant. This is because most of has also been strongly correlated with de-layed graft
the donors and recipients in our study were young function and was identified as the strongest
adult. Mean age of donor was <40 years (39.15±10.09 independent predictor of delayed graft function in
years, range 22-60 yrs) and recipient was <33 years some studies.17 In our study, cold ischemia time was
(32.30±8.85 years, range 15-50 yrs). It has been showed defined as starting of cold solution perfusion after
in different studies that older donor age is a risk factor organ procurement and ends after establishment of
for decrease graft survival. Senel FM et al.199811 and recirculation after anastomosis of vessels in recipient
Cecka JM 199812 in their studies identified donor age which by definition includes the anastomosis time.
>60 years as a risk factor. Fuggle SV et al.201013 Mean cold ischemia time in RGF group was
described the association between donor age older 108.11±123.45 min and in IGF group was 51.57±11.68
than 59 years with poorer outcome after live donor which were statistically significant in univariate
kidney transplantation. But H.S. Park et al. 201214 analysis (p value 0.043). Multivariate analysis
showed there was no significant effect of donor age showed cold ischemia time was an important risk
and recipient age on early graft function. In their study factor for RGF (p value 0.043). In a study by Olwyn
donor mean age was <42 years and recipient mean Johnston et al.20062 revealed that longer CIT are
age<37 years which were almost similar to our study. important risk factors for reduced graft function. Other
64
centres have also shown that longer CIT has an had IGF and 47.5 % renal allograft recipient had graft
inûuence on graft survival.18-20 Our result supported dysfunction(SGF). Significant causes of graft
all of these study result. dysfunction were long cold ischemia time in minute
and peroperative urine production in ml within 6
Intraoperative hypotension and prolonged operative
hours after anastomosis of vessels.
time are independent risk factors for SGF in kidney
transplant patients.21 For good graft function recovery, REFERENCES:
proper blood pressure (10-20mmHg (1mmHg= 1. Wolf, RA, Ashby, VB, Milford, EL, et al.
0.133kPa) above the basic blood pressure) that Comparison between mortality in all patients on
ensures oxygenated blood is necessary. G. Bacchi, et dialysis, patients on dialysis awaiting trans-
al. 201022 also reported that reduced intraoperative plantation and recipients of a first cadaveric
perfusion as measured using CVP monitoring might transplantation.N Engl J Med. 2000;341: 1725-1730.
increase DGF risk. In our study, peroperative 2. Olwyn Johnston, Patrick O’Kelly , Susan Spencer,
hypotension and peroperative blood transfusion was et al. Reduced graft function (with or without
significant in univariate analysis (p value 0.0001 and dialysis) vs immediate graft function—a
0.005 respectively). But in logistic regression analysis comparison of long-term renal allograft survival.
Nephrology Dialysis Transplantation. 2006;21(8):
both of these factors were not significant (p value 0.759
2270-2274.
and 0.613 respectively). This was because
preoperative hypotension was reversed immediately 3. Salvadori M, rosati A, Bock A, Chapman J, et al.
with blood transfusion and other measures. Estimated one- year glomerular filtration rate is
the best predictor of long- term graft function
KDIGO clinical practice guideline for the care of following renal transplant. Transplantation. 2006;
kidney transplant recipients stated that increased 27,81(2):202-6.
urine volume represents the ûrst sign of progressive 4. Gjertson DW. Impact of delayed graft function and
recovery of kidney function, ahead of a decrease in acute rejection on kidney graft survival. Clin
serum creatinine or blood urea nitrogen. High urine Transpl. 2000;18:467-80.
volume during the first posttransplant days is a useful
5. Kamar N, Garrigue V, Karras A, Mourad G,
parameter to predict graft outcome.23,24 Matteucci et Lefrançois N, Charpentier B, et al. Impact of early
al. 199823 also demonstrated a direct relation between or delayed cyclosporine on delayed graft function
serum creatinine and diuresis volume and urine in renal transplant recipients: a randomized,
creatinine after kidney transplantation. According to multicenter study. Am J Transplant. 2006; 6 (1):
urine output criteria and relation with s. creatinine 1042-8.
DGF was defined as rise in serum Cr at 6–8 h post- 6. Humar A, Ramcharan T, Kandaswamy R,
operatively or <300 ml of urine despite adequate Gillingham K, Payne WD, Matas AJ. Risk factors
volume and diuretics.25 Or Urine output <1 L in 24 h for slow graft function after kidney transplants: a
and <25% fall in serum creatinine from baseline in multivariate analysis. Clin Transplant.2002; 16:
first 24 h post-transplant.26 In our study, mean urine 425–429.
output within 6 hours after anastomosis of renal 7. Tahara M, Nakayama M, Jin M, et al. A radical
vessels was 83.84±112.62 ml in RGF group and scavenger, edaravone, protects canine kidneys from
354.52±215.84 ml in IGF group which was ischemia-reperfusion injury after 72 hours of cold
statistically highly significant (p value 0.0001). Lai Q preservation and autotransplantation.
et al.2010 in their study also showed UO had Transplantation. 2005;80:213-221.
significant role in graft function. In that study, urine 8. Port FK, Wolfe RA, Mauger EA, Berling DP, Jiang
output was <500 ml / 24 hrs in 40% of patients of K. Comparison of survival probabilities for dialysis
DGF group and only in 3% patients of IGF group. patients vs cadaveric renal transplant recipients.
JAMA. 1993;15,270(11):1339-43.
CONCLUSION:
9. Terasaki PI, Cecka JM, Gjertson DW, Takemoto S.
Graft dysfunction or adverse events following renal
High survival rates of kidney transplants from
transplantation are associated not only with short &
spousal and living unrelated donors. N Eng J
long term graft outcome, but also with patient survival. Med.1995; 33:333–336.
This study showed that 52.5% renal allograft recipient
65
10. J. Hellegering, J. Visser, H. J. Kloke, A. J. 18. Ojo AO, Wolfe RA, Held PH, Port FK, Schmoulder
Hoitsma, J. A. vander Vliet, M. C. Warlé . Poor RL. Delayed graft function: risk factors and
early graft function impairs long-term outcome in implications for renal allograft survival.
living donor kidney transplantation.World J Uro. , Transplantation.1997; 63:968–974.
2012; 14:95-98. 19. Boom H, Mallat JK, de Fijter JW, Zwinderman AH,
11. Senel FM, Karakayali H, Moray G, et al. Delayed Paul LC. Delayed graft function influences renal
graft function: Predictive factors and impact on function, but not survival. Kidney Int. 2000; 58: 859–
866.
out-come in living-related kidney transplantation.
Ren Fail. 1998;20:589-95. 20. Sola R, Alcarcon A, Jimenez C, Osuna A. The
influence of delayed graft function. Nephrol Dial
12. Cecka JM. The UNOS Scientific Renal Transplant
Transplant. 2004;19(4):32–37.
Registry. In: Cecka JM, Terasaki PM. (Eds): Clini-cal
Transplantation,Los Angeles. UCLA Tissue Typing 21. Sandid MS, Assi MA, Hall S. Intraoperative
Laboratory. 1998; 1-16. hypotension and prolonged operative time as risk
factors for slow graft function in kidney transplant
13. Fuggle SV, Allen JE, Johnson RJ, Collett D, Mason recipients. Clin Transplant. 2006;20(6):762-8.
PD, Dudley C et al. Factors affecting graft and
22. G. Bacchi, A. Buscaroli, M. Fusari, L. Neri, M.L.
patient survival after live donor kidney
Cappuccilli, E. Carretta. The Inûuence of
transplantation in the UK. Transplantation.
Intraoperative Central Venous Pressure on Delayed
2010;89(6):694-701. Graft Function in Renal Transplantation: A Single-
14. H.S. Park, Y.A. Hong, H.G. Kim, S.R. Choi, I.O. Center Experience. Transplantation Proceedings.
Sun, B.H. Chung, et al. Delayed Graft Function in 2010;42: 3387–3391.
Living-Donor Renal Transplantation: 10-Year 23. Matteucci Elena, Mario Carmellini,z et al. Urinary
Experience. Transplantation Proceedings. 2012;44( Excretion Rates of Multiple Renal Indicators after
1): 43–46. Kidney Transplantation: Clinical Significance for
Early Graft Outcome. Renal Failure. 1998; 20(2): 325-
15. Sharma AK, Tolani SL, Rathi GL, et al. Evaluation
330.
of factors causing delayed graft function in live
related donor renal transplantation. Saudi J Kidney 24. M.R. Ardalan, H. Argani, M. Mortazavi et al. More
Dis Transpl. 2010; 21:242. urine is better after renal transplantation.Transplant
Proc.2003;35:2612.
16. Wynen RM, Booster M, Speatgens C, et al. Long
25. Gonwa TA, Mai ML, Smith LB, Levy MF, Goldstein
term follow-up of non-heart-beating donor kidneys:
RM, Klintmalm GB. Immunosuppressions for
Preli-minary results of a retrospective study.
delayed or slow graft function in primary cadaveric
Transplant Proc. 1993;25:1522. renal transplantation. Clin Transplant. 2002;16:144–
17. Halloran PF, Shoskes DA. Early transplant non- 9.
func-tion: Influence on ultimate graft survival and 26. Halloran PF, Hunsicker LG. Delayed graft function:
func-tion. In. Solez K, Racussen LC, (Eds): Acute state of the art, November 10–11, 2000. Summit
renal failure: diagnosis, treatment and prevention. meeting, Scottsdale, Arizona, USA. Am J Transplant.
New York, Mercel Dekkar Inc. 1991;387-397. 2001; 1:115–120.
66
Original Article
A Study on Clinicodemographic Pattern of Infertility
of Male Partner of Infertile Couple Attending For
Infertility Treatment in Sylhet, Bangladesh
Laila NK1, Chowdhury N2, Riffat R3, Sweety K4, Razia B5
ABSTRACTS
Background: Male infertility is influenced by the environment, occupation, socioeconomic
condition, and lifestyle.
Objective: The purpose of the present study was to see the demographic profiles and clinical
characteristics of an infertile couple who attended at the OPD of a tertiary hospital in Sylhet
city.
Methodology: This prospective longitudinal study was carried out in OPD of SOMCH,
from June 2004 to December 2004. All data were taken in the performed questionnaire. Male
partners of the 100 infertile couples attending the above-mentioned places at Sylhet. The
study population was included with the criteria of the male partners of the infertile couples
who had tried unsuccessfully for at least one year. The Exclusion criteria were men who had
undergone a vasectomy. Proper history including occupational, sexual, personal, as well as
medical, and surgical history, was recorded on a predesigned data collection sheet.
Result: In this study, the Majority (66%) of male partners of the infertile couples were
between 30-40 years of age%) and almost98% of couples had primary infertility and the
proportion between primary & secondary infertility is highly significant, among them 45% of
couples reported within 3-5 y.rs. of marriage and 80 % of couples had regular coitus (4-5
times /wk.). In this study, the majority of the male partners had the habits of. cigarette
smoking 8% had the habit of alcohol intake, and most (42%) of the male partners were a
businessman.
Conclusion: In conclusion, there is a significant number of young middle-aged males had
primary infertility which related with life style.
Keywords: Infertility, Primary Infertility, Secondary Infertility.
Mugda Med Coll J. 2022; 5(2): 67-70
INTRODUCTION purpose of. brevity, the guideline developers use the.

Infertility suggests factors that create , absolute term “infertility” but assume that most fertility
inability to conceive whereas subfertility describes problems are relative in severity. This condition may
factors due to relative inability to conceive. For the
be further classified as-primary infertility, in which
1. Dr. Laila Nazneen Khan, Assistant Professor, Gynae & no previous pregnancy has occurred, and secondary,
Obsterric Departmant, Mugda Medical College, Dhaka.
2. Dr. Nowshafreen chowdhury, Assistant Professor, Gynae &
in which a prior pregnancy, although not necessarily
Obsterric Departmant, Mugda Medical College, Dhaka. a live birth, has occurred.
3. Dr.Riffat Rahim, Assistant Professor, Gynae & Obsterric
Departmant, Mugda Medical College, Dhaka. In a study done by Ladimi in 1987, primary infertility
4. Dr. Kamrunnahar Sweety, Assistant Professor, Gynae & was found to be more frequent due to male
Obsterric Departmant, Mugda Medical College, Dhaka.
involvement and secondary Infertility due to female
5. Dr. Razia Begum, Sinior Consultant, Gynae & Obsterric
Departmant, Mugda Medical College, Dhaka. involvement.1 Infertility is a significant & common
Address of correspondence: Dr. Laila Nazneen Khan, Assistant problem, affecting perhaps one couple in six2. The
Professor, Gynae & Obsterric Departmant, Mugda Medical
reported incidence of male infertility varies widely,
College, Dhaka,Tel: 01709395039, Email: [email protected]
67
and the overall incidence is estimated to be 30-50% of RESULTS

sub fertile couptes3. In a study done by WHO in 1989 This study was done to determine male infertility in
over 1000 infertile couples from 33 centers in 25 infertile couples coming for treatment. It was a
countries, a possible cause in a male partner was prospective longitudinal study where the factors
found in a third of the cases, in a female partner in associated with male infertility were sought out. The
25% of cases & in both partners in 25% cases. The In study population was the male partners of 100 infertile
remaining cases, neither partner had a detectable couples attending outdoor of Sylhet Osmani Medical
cause of infertility4. College Hospital. The data was collected from the
The male infertility is influenced by the environment, private chamber and gynae outdoor of SOMCH, during
occupation, socioeconomic condition, stress, sexual the period of July 2004 to December 2004.
behavior, smoking, and drinking habit, as well as The majority (66%) of male partners of the infertile
consumption of illicit drugs Other important factors couples were between 30-40 years of age, followed by
that seems to be occurring is the decline in male
>20 years (22%) When >40 years (12%). The
fertility, is environmental pollution, unfavorable
distribution is not statistically significant. (Table I)
working habit & job in middle-east in the hot
environment seems to be likely cause. According to a
study done by china. in Singapore in 2000, smoking, Table-I : Age distribution of male partner. (n=100)
density of sperm and the viability of sperm were
Age group Primary 2ndary Total no.
found. to be significant predictors for infertility among
(yrs) infertility infertility (%)
men5.
No.(%) n-98 No. (%) n-2 no: 100
The duration of infertility also provides one of the 20-29 22(22.44%) 0 22(22%)
most significant prognostic indicators of male
infertility6, 7. It perhaps surprising that most studies 30-39 60(61.22%) 0 60(60%)
published recently are in. broad agreement on the 40-49 14(14.28%) 1(50%) 16(15%)
prevalence of infertility with a figure of 14% of all 50-59 2 (2.04%) 1(50%) 3(3%)
couples. There is currently no reliable data available
regarding the prevalence of infertility in Bangladesh. X2=248 df=2 P value= <0.5
Finally, people’s expectations for infertility treatment In this study, 98% of couples had primary & 2% of
are steadily rising because of media coverage of newer couples had secondary infertility. Statistically, the
techniques like IVF with ICSI. So, there is a marked proportion between primary & secondary infertility
is highly significant(P<0.0001). In this study, most of
increase in infertility clinic attendance even in
the couples (45%) reported within 3-5 y.rs. of marriage.
developing countries like Bangladesh.
In this study, 80 % of couples had regular coitus (4-5
METHODS: times /wk.). ( Table No II)
This prospective longitudinal study was carried out
in OPD of SOMCH from June 2004 to December 2004. Table II. Infertility type, duration, and frequency of coitus
All data were collected in the performed Type Male partners (%) No. P value
questionnaire. Male partners of the 100 infertile
Primary 98(98%) <0.0001
couples attending the above-mentioned places at
Secondary 2(2%)
Sylhet. The study population was included with the
criteria of the male partners of the infertile couples Duration(years) Number of pt Percentage
who had tried for at least one year. The Exclusion 1-2 21 21%
criteria were men who had undergone a vasectomy. 3-5 45 45%
Proper history including occupational, sexual,
6- 1.0 32 32%
personal, as well as medical, and surgical history,
was recorded on a predesigned data collection sheet. > 10yrs. 2 2%
Data collected for each individual subject were Frequency No. of male participants Percentage
compiled and analyzed using computer-based
Adequate. (4-5, times/wk)80 80%
software, statistical package for social science (SPSS)
for Windows. A, P value <0,05 was considered a Inadequate (<1 time/wk) 20 20%
minimum level of significance. X2=68.42, df=1
68
In this study,.38% of the male partners had the habits known fertility problems was recruited from a
of. cigarette smoking 8% had the habit of alcohol national government laboratory. Regarding age
intake. In this study, most (42%) of the male partners distribution majority of the men with both primary
were a businessman. (Table no-3) (98%) and secondary infertility (2%) were between
30-39 years of age. Rest were either below the age of
30 or above 40 years. Regarding coital frequency, the
Table -III: Particulars of the male partners of infertile
majority (80%) of the couples had regular coitus 4 to 5
couple
times a week Kamal and Shamim also observed
Smoking Male partner Percentage similar frequency. Regarding past medical history,
Yes 38 38% the majority. of men (73%) had no significant past
medical history8-9. Rochebrochard et al11 found that
No 62 62%’
when paternal age was <40 years, with an adjusted
Alcohol intake odds ratio of 2.21 (95% CI, 1.13, 4.33) for delay in
Yes 8 8% pregnancy onset (failure to conceive within 12
No 92 92% months) and of 3.02 (95% CI, 1.56, 5.85) for difficulties
Occupation in having a baby (failure to conceive within 12 months
or pregnancy not resulting in a live birth).11
Service 25 25%
Business 42 42% CONCLUSION
Teacher 8 8% Under conclusion, this study gives an insight into
Abroad,management, labors) 17 17% male partners in of the infertile couples in the Sylhet
region. The study indicates that most primary
Others 8 8%
infertility reported in the early years of marriage. The
DISCUSSION male partners are mostly young middle-aged,
Data were obtained from selected male partners of predominantly businessmen by profession, and of
100 infertile couples attending the outpatient middle to high socioeconomic status. Further large-
department of Sylhet MAG Osmani Medical College. scale studies should be conducted.
hospital, and private chambers of gynecologists and
obstetricians. Out of 100 infertile couples, 98% had REFERENCES
1. Ladimi M, Sellami A., Mebazaa R, Bourisis. Etiologic
primary infertility and 2% had secondary infertility.
factors in .457 consecutive cases of it trine couples.
Kamal in her study showed that 60% had primary
Ill: RaLnam SS; Teoh ES, Anandakumar C, editors.
and 40% had secondary infertility8. Shamin also
Advances in fertility and sterility. 2nd ed. Chennai:
observed that the majority (69%) had primary and
Orient Longman Ltd., 1987: 230-4
only 31% had secondary infertility. In this study, the
majority of the men were businessmen (42%) only 2. Irvine DS. Epidemiology and etiology of male
25% were in service and the rest were abroad or in infertility. Hum Reprod 1998; 13 (Suppl 1): 33-44.
other professions. Regarding the duration of infertility, 3. Pandian N. Male infertility. In: Ratnam SS, Rao BK,
most couples (45%) reported to doctors within 2-5 Arulkumaran C, editors. Obstetrics and gynecology
years of marriage. This early reporting may be due to for postgraduates. Vol. 1, 2nd ed. Chennai: Orient
increased awareness among the infertile couples Longman Ltd., 1999: 277=88
regarding the treatment options available now a
days.62% of the men had no habit of smoking9. On 4. WHO. Biennial report 1988-89. Research in human
reproduction. Geneva World Health Organization,
the other hand, only 8% of men admitted to taking
1989: 35.
alcohol regularly ‘and the majority denied (92%)
taking alcohol. This result may be biased due to social 5. Chia S, Lim. SA, Tay S, Lim S. Factors associated
and religious barriers in our country regarding with male infertility: a case-control study of 218
alcohol intake. Many persons would deny taking infertile and 240 fertile men. Br J Obster Gynaecol
alcohol even if they are social drinkers or regular 2000; 107:55-6.
alcohol takers Eskenazi et al10 A convenience sample 6. De Kretser DM. Male infertility. Lancet 1997;
of 97 non smoking men (aged 22–80 years) without 249(9054):787-90.
69
7. Schmidt L, Munster K. Infertility, involuntary (assertatin), Dhaka Bangladesh College of Physicians

infecundity, and the seeking of medical advice in - and Surgeons, 1989
industrialized countries 1970-1992: a review of
10. Eskenazi B, Wyrobek AJ, Sloter E, Kidd SA, Moore
concepts, measurements and results. Hum Reprod
L, Young S, Moore D. The association of age and
1995; 10:1407-18.
semen quality in healthy men. Human
8. Kamal AM. A study of infertility [dissertation]. reproduction. 2003 Feb 1;18(2):447-54.
Dhaka: Bangladesh College of Physicians and
11. De la Rochebrochard E, Thonneau P. Paternal agee”
Surgeons, 1983
40 years: an important risk factor for infertility.
9. Shamim S. Clinical stud ; of 100 cases of infertility American journal of obstetrics and gynecology. 2003
attending, the infertility clinic at IFGMR, Dhaka Oct 1;189(4):901-5.
70
Original Article
Serum Lactate Variability as Predictor of Mortality
in Septic Shock: An Experience of Intensive Care
Unit of Dhaka Medical College Hospital, Bangladesh
Akter S1, Mohammad T2, Rahman MS3, Miah MAK4, Zunaid M5, Yasmin R6
ABSTRACT
Background: Observation of variability of lactate levels instead of mean lactate level in
critically ill patients with sepsis act as more efficient mortality factor.
Objective: To determine whether lactate levels measured at different intervals can predict
mortality more effectively than that of mean lactate level for septic patients in intensive care
unit (ICU).
Methods: This cross-sectional study was done in the Department of Anaesthesia, Analgesia,
Palliative and Intensive Care Medicine, Dhaka Medical College Hospital, Bangladesh, between
July and December of 2019. Purposively selected 147 septic patients with multiple organ
failure in Intensive Care Unit were observed prospectively. Serum lactate levels at different
intervals were assessed within the first twenty-four hours of recruitment of septic patients.
The assigned patients were divided into three lactate variable groups: Group I (mild variable
group) – when less than 2 values were not within the target lactate level; Group II (moderate
variable group) – when 2-3 values were not within the range; Group III (more variable
group) – when more than 3 values were not within the range.
Results: The mean age of the study participants was 48.3±12.5years. Among them, 82 (55.78%)
were male and 65 (44.22%) were female. Number of survivors and non-survivors in Group I
(mild) were 37(84.09%) and 7(15.91%) respectively, while in Group II (moderate) 48(71.64%)
and 19(28.36%) respectively and in Group III (more) 13(36.11%) and 23(63.89%) respectively.
A highly significant difference (P=0.001) was existed between three blood lactate variability
groups with respect to mortality. Logistic regression analysis demonstrated that more lactate
variability group had predicted higher mortality rate with a P value of 0.007 and an odds ratio of
16.0. Result is significant. On the other hand, significant effect of moderate lactate variability
group on mortality was not found with a P value of 0.665 and an odds ratio of 0.667.
Conclusion: The septic patients having more serum lactate variability were reported to have
higher mortality rate than that of moderate and less lactate variability in Intensive Care Unit.
Our study suggests that serum lactate variability should be included as a future approach to
see prognosis and predict mortality in septic patients.
Keywords: Serum lactate variability, septic shock, multi-organ failure, intensive care unit,
mortality.
Mugda Med Coll J. 2022; 5(2): 71-75
1. Dr. Shamima Akter, Assistant Professor, Department of Anaesthesia, Analgesia, Palliative and Intensive Care Medicine,
Dhaka Medical College Hospital, Dhaka-1000.
2. Dr. Taneem Mohammad, Assistant Professor, Department of Anaesthesia, Analgesia, Palliative and Intensive Care Medicine,
3. Dr. Md. Siddiqur Rahman, Assistant Professor, Department of Anaesthesia, Analgesia, Palliative and Intensive Care Medicine,
4. Dr. Mohammad Abdul Karim Miah, Assistant Professor, Department of Anaesthesia, Analgesia, Palliative and Intensive
Care Medicine, Dhaka Medical College Hospital, Dhaka-1000.
5. Dr. Md. Zunaid, Registrar, Department of Anaesthesia, Analgesia, Palliative and Intensive Care Medicine, Dhaka Medical
College Hospital, Dhaka-1000.
6. Dr. Rubina Yasmin, Curator, Department of Pathology, Mymensingh Medical College, Mymensingh-2206.
Address of correspondence: Dr. Shamima Akter, Assistant Professor, Department of Anaesthesia, Analgesia, Palliative and
Intensive Care Medicine, Dhaka Medical College Hospital, Dhaka-1000. Email: [email protected]
71
INTRODUCTION from the initiation of resuscitation continue to have

Sepsis is very common worldwide resulting in an predictive and prognostic utility 13 . Thus,
estimated 8 million deaths annually; however, a rapid controversies prevail in literature. Moreover, in our
detection and treatment can reduce the number of country, only few reports are available on utility of
deaths1. Sepsis is defined as life-threatening organ lactate levels in prognosis and mortality in sepsis.
dysfunction caused by a dysregulated host response Hence, we proposed this study to measure serum
to infection, as described in the Sepsis-3 definition2. lactate levels at different duration and evaluate the
The mortality rate of patients with sepsis has impact of serum lactate variability as predictor of
decreased during the past several decades; mortality for septic patients in one of the largest
unfortunately, the incidence of sepsis has steadily Intensive Care Unit (ICU) facilities in the country.
increased, and the mortality rate remains e”20%3-5.
METHODS
The situation is worse in low-income countries.6
This cross-sectional study was done in the Department
Sepsis syndromes span a clinical continuum with
of Anaesthesia, Analgesia, Palliative and Intensive
variable prognoses. Septic shock, the most severe
Care Medicine, Dhaka Medical College Hospital,
complication of sepsis, carries high mortality7. The
Bangladesh, between July and December of 2019.
etiopathogenesis of the syndromes is complex – a
Purposively selected 147 septic patients with multiple
dysregulated host response to infection. In response
organ failure in Intensive Care Unit were observed
to any inciting agent, e.g. various viral/bacterial
prospectively. Serum lactate levels at different intervals
components, including LPS, peptidoglycans,
were assessed within the first twenty-four hours of
lipoteichoic acid and sometimes exotoxins, an intense,
recruitment of septic patients. A detailed history of the
potentially lethal host response occurs; pro-
patient’s current illness, previous history of surgery,
inflammatory and anti-inflammatory arms of the
drug allergy, other comorbid illnesses (if present,
immune system are activated in concert with the
treatment they are taking and the severity of the
activation of monocytes, macrophages, neutrophils
comorbidity) were recorded along with baseline vitals.
and/or T cells that interact with the endothelium
Investigations including complete hemogram, serum
through pathogen recognition receptors to release
electrolytes, renal function test and coagulation
high levels of inflammatory response mediators e.g.
parameters were recorded as per standard institute
cytokines, proteases, kinins, reactive oxygen species,
protocol. Sequential Organ Failure Assessment score
and nitric oxide8,9. Those cells play important roles
(SOFA) and Acute Physiology And Chronic Health
in the cascade of events leading to this condition.
Evaluation II (APACHE II) were calculated for each
Until recently, septic shock was diagnosed as of three
patients. ICU monitoring consisted of
components together: systemic arterial hypotension,
electrocardiogram (ECG), oxyhemoglobin saturation
tissue hypoperfusion associated with organ
(SpO2), systolic and diastolic blood pressure (IBP) and
dysfunction, and hyperlactatemia10. However, in
temperature. Arterial blood gas analysis was done to
newer definition, patients with septic shock can be
establish baseline and subsequent lactate levels in each
clinically identified by a vasopressor requirement to
patient. The assigned patients were divided into three
maintain a mean arterial pressure (MAP) e”65mmHg
lactate variable groups: Group I (mild variable group)
and serum lactate level >2 mmol/L (or >18mg/dL) in
– when less than 2 values were not within the target
the absence of hypovolemia2.
lactate level; Group II (moderate variable group) –
The efficacy of serum lactate as a marker for diagnosis when 2-3 values were not within the range; Group III
of sepsis and response to resuscitative therapies in (more variable group) – when more than 3 values were
septic patients has demonstrated a clear association not within the range. Fluid and vasopressor
with clinical outcomes including mortality11. As per management was guided by invasive arterial, central
recommendation of the Surviving Sepsis Campaign venous pressure, blood gas with lactate and point of
guidelines, serum lactate levels should be measured care ultrasound monitoring. Broad spectrum
within 3 hours of admission in the hospital and if antibiotics were initiated at presentation as per
elevated repeated within 6 hours12. That allows for institute protocol and appropriate cultures (blood,
the implementation and evaluation of effective urine, abdominal fluid and tracheal aspirate whenever
hemodynamic management of the septic patient as suitable) were sent. Patients were followed up daily
early as possible, increasing the chances of survival till 28 days or death or discharge from the hospital,
and better prognosis. However, in other literature, it whichever was earlier. Following parameters were
was stated that lactate measurements beyond 24h collected daily for all patients: urine output, serum
72
creatinine, requirement of renal replacement therapy, respiratory rates were 21.3±2.1 and 22.7±3.4 per minute
development of acute respiratory failure, need for respectively, while pulse rates were 103.8±30.3 and
mechanical ventilation, vasopressor requirement, type 108.0±34.2 per minute respectively. Body temperatures
of nutritional support, and the length of ICU stay. were found 37.1±1.4°C and 37.5±1.3°C respectively.
SOFA scores were 10.0 (8.0–13.0) and 13.0 (11.0–16.0),
Student’s t-test, Chi-square test, and multiple logistic
while APACHE II scores were 2.0 (1.0-2.0) and 6.0 (5.0-
regression analysis were performed. The level of
6.0) respectively. Lactate area scores were 38.8 (22.7–
significance was at 95% confidence interval and a P-
58.0) and 57.0 (33.9–98.0) respectively (Table-II).
value <0.05 was considered as significant. Data were
Number of survivors and non-survivors in Group I
analyzed using SPSS (Statistical package for Social
(mild) were 37(84.09%) and 7(15.91%) respectively,
Sciences) version 22.0. The study was approved by
while in Group II (moderate) 48(71.64%) and
the Ethical Review Committee of Dhaka Medical
19(28.36%) respectively and in Group III (more)
College, Dhaka, Bangladesh.
13(36.11%) and 23(63.89%) respectively. A highly
RESULTS significant difference (P=0.001) was existed between
The mean age of the study participants (n=147) was three blood lactate variability groups with respect to
48.3±12.5years. Among them, 82 (55.78%) were male mortality (Table-III). Logistic regression analysis
and 65 (44.22%) were female. However, there is no demonstrated that more lactate variability group had
difference in age and sex of the participants (P>0.05) predicted higher mortality rate with a P value of 0.007
(Table-I). Among survivors (n=98) and non-survivors and an odds ratio of 16.0. Result is significant. On the
(n=49), systolic blood pressure were found 106.1±30.8 other hand, significant effect of moderate lactate
and 107.4±33.4 mmHg and diastolic blood pressure variability group on mortality was not found with a P
65.6±51.6 and 65.9±23.2 mmHg respectively. Mean value of 0.665 and an odds ratio of 0.667 (Table-IV).
Table I: Demographic characteristics of the study population (n=147)

Characteristics Survivor (n=98) Non-survivor (n=49) P value
Age group
18-30 years 12 (66.67%) 6 (33.33%)) >0.05
31-45 years 31 (77.5%) 9 (22.5%))
46-60 years 29 (64.44%) 16 (35.56%)
61 years and above 26 (59.09%) 18 (40.91%)
Mean±SD 48.3±12.5
Sex
Male 56 (66.4) 26 (67.8) >0.05
Female
42 23
Values were presented as mean±SD, and number (%) as applicable.
P value reached from Student’s t-test and Chi-square test respectively.
Table II: Baseline characteristics of the study population (n=147)

Vital signs Survivor (n=98) Non-survivor (n=49) P value
Systolic blood pressure (mmHg) 106.1±30.8 107.4±33.4 >0.05
Diastolic blood pressure (mmHg) 65.6±51.6 65.9±23.2 >0.05
Respiratory rate (rates/min) 21.3±2.1 22.7±3.4 >0.05
Pulse rate (beats/min) 103.8±30.3 108.0±34.2 >0.05
Body temperature (°C) 37.1±1.4 37.5±1.3 >0.05
SOFA score 10.0 (8.0–13.0) 13.0 (11.0–16.0) <0.001
APACHE II 2.0 (1.0-2.0) 6.0 (5.0-6.0) <.0001
Lactate area score 38.8 (22.7–58.0) 57.0 (33.9–98.0) <0.001
Values were presented as mean±SD or median (interquartile range) as applicable.
SOFA: Sequential Organ Failure Assessment. P value reached from Chi-square test.
73
Table III: Status of the patients among lactate variability groups
Lactate variability group Survivor Non-survivor X2 P value
Group I (mild) 37(84.09%) 7(15.91%) 14.56 0.001

Group II (moderate) 48(71.64%) 19(28.36%)
Group III (more) 13(36.11%) 23(63.89%)
Total 98(66.67%) 49(33.33%)
Values were presented as mean±SD, number (%), or median (interquartile range) as applicable.
P value reached from Chi-square test.
Table IV: Effect of Blood lactate variability on mortality insult and hence the result of these interventions
differs between patients.
Lactate variability groups OR P value
Group I (mild) (Reference) 0.004 Our study demonstrated that more lactate variability
had predicted higher mortality in septic patients.
Group II (moderate) 0.667 0.665
Several evidence demonstrated serial serum lactate
Group III (more) 16.000 0.007 measurements at different intervals for >72h in ICU
patients and concluded that the duration of
Multiple logistic regression analysis was done.
hyperlactemia is a reliable indicator of morbidity and
mortality following trauma, which is in congruence
DISCUSSION with our study.21-23 However, Krishna et al. suggested
Severe sepsis and septic shock are the biggest cause that lactate values probably need to be followed for
of mortality in critically ill patients3-6. A simple longer periods of time in critical patients even when
infection can rapidly develop into sepsis a life- they have tided over the present crisis. The utility of
threatening condition which requires on-the-spot regular lactate analysis in those patients depends on
diagnosis and treatment while the condition is still factors such as availability and cost of tests as well,
in its early stages. The major pathways that lead to especially in resource-poor settings21.
sepsis-induced coagulopathy and DIC include Our study has several limitations. It belongs to
activation of coagulation, platelets, and other observational study design and lacks randomization.
inflammatory cells (e.g., neutrophils, lymphocytes) Our sample size is small and a single centre study;
and vascular endothelial injury8,9. Traditionally, therefore, the findings derived from this study hardly
lactic acidosis in sepsis is attributed to anaerobic generalize to the reference population. Moreover, the
glycolysis due to inadequate oxygen delivery. selective biomarker used in this study was only able
However, it has become clear that the mechanism of to show the picture of an adult ICU, as we spared
hyperlactatemia in sepsis is multifactorial and due paediatric group.
to factors beyond hypoxic tissue injury alone15-18.
Evidence have shown that lactate levels are known CONCLUSION
to be predictors of survival or mortality in patients of Our data suggest that variability of lactate levels at
sepsis in ICU settings19-23. A normalization of serum different intervals instead of mean lactate level in
lactate with aggressive treatment within the first 24 critically ill patients with sepsis act as more efficient
hours of the diagnosis has a favourable outcome, as mortality factor. The septic patients having less lactate
shown in several studies19,21. Aggressive treatment clearance predicted mortality more than that of drastic
includes timely resuscitation, antibiotics, surgical lactate clearance therapy in ICU setting. When we
management, vasopressor and inotropic drugs, know about the propensity of death from the serum
ventilatory support, and dialysis as deemed fit. The lactate clearance of septic patients within the first 24
aim of all interventions remains patient survival. hours of detection of sepsis, it will be easy to treat the
However, the patient presents with a pre-existing set patient and easily improve the outcome of sepsis.
of variables of morbidity that affect his response to an However, further studies with larger sample and
74
multi-centre trials along with combination of more Campaign: International Guidelines for
biomarkers are recommended. Management of Sepsis and Septic Shock: 2016.
Intensive Care Med. 2017;43(3):304-77.
REFERENCES
13. Chertoff J, Chisum M, Garcia B, Lascano J. Lactate
1. Dugani S, Veillard J, Kissoon N. Reducing the
kinetics in sepsis and septic shock: a review of the
global burden of sepsis. CMAJ. 2017;189(1):E2-3.
literature and rationale for further research. J
2. Singer M, Deutschman CS, Seymour CW, Shankar- Intensive Care. 2015;3:39.
Hari M, Annane D, Bauer M, et al. The Third
14. Lee SM, An WS. New clinical criteria for septic
International Consensus Definitions for Sepsis and
shock: serum lactate level as new emerging vital
Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-10.
sign. J Thorac Dis. 2016;8(7):1388-90.
3. Kaukonen KM, Bailey M, Suzuki S, Pilcher D,
15. Dettmer M, Holthaus CV, Fuller BM. The impact of
Bellomo R. Mortality related to severe sepsis and
serial lactate monitoring on emergency department
septic shock among critically ill patients in
resuscitation interventions and clinical outcomes
Australia and New Zealand, 2000-2012. JAMA.
in severe sepsis and septic shock: an observational
2014;311(13):1308-16.
cohort study. Shock. 2015;43(1):55-61.
4. Gaieski DF, Edwards JM, Kallan MJ, Carr BG.
16. Andersen LW, Mackenhauer J, Roberts JC, Berg KM,
Benchmarking the incidence and mortality of severe
Cocchi MN, Donnino MW. Etiology and therapeutic
sepsis in the United States. Crit Care Med.
approach to elevated lactate levels. Mayo Clin Proc.
2013;41(5):1167-74.
2013;88(10):1127-40.
5. Brun-Buisson C, Meshaka P, Pinton P, Vallet B;
17. Hunt BJ. Bleeding and coagulopathies in critical
EPISEPSIS Study Group. EPISEPSIS: a reappraisal of
care. N Engl J Med. 2014;370(22):2153.
the epidemiology and outcome of severe sepsis in
French intensive care units. Intensive Care Med. 18. Jobin SP, Maitra S, Baidya DK, Subramaniam R,
2004;30(4):580-8. Prasad G, Seenu V. Role of serial lactate
measurement to predict 28-day mortality in patients
6. Kwizera A, Dünser M, Nakibuuka J. National
undergoing emergency laparotomy for perforation
intensive care unit bed capacity and ICU patient
peritonitis: prospective observational study. J
characteristics in a low income country. BMC Res
Intensive Care. 2019;7:58.
Notes. 2012;5:475.
19. Marty P, Roquilly A, Vallée F, Luzi A, Ferré F,
7. Hotchkiss RS, Moldawer LL, Opal SM, Reinhart K,
Fourcade O, et al. Lactate clearance for death
Turnbull IR, Vincent JL. Sepsis and septic shock.
prediction in severe sepsis or septic shock patients
Nat Rev Dis Primers. 2016;2:16045.
during the first 24 hours in Intensive Care Unit: an
8. Nguyen HB, Rivers EP, Abrahamian FM, Moran observational study. Ann Intensive Care. 2013;3(1):3.
GJ, Abraham E, Trzeciak S, et al. Severe sepsis and
20. Mikkelsen ME, Miltiades AN, Gaieski DF, Goyal
septic shock: review of the literature and emergency
M, Fuchs BD, Shah CV, et al. Serum lactate is
department management guidelines. Ann Emerg
associated with mortality in severe sepsis
Med. 2006;48(1):28-54.
independent of organ failure and shock. Crit Care
9. Iba T, Levy JH. Inflammation and thrombosis: roles Med. 2009;37(5):1670-7.
of neutrophils, platelets and endothelial cells and
21. Krishna U, Joshi SP, Modh M. An evaluation of serial
their interactions in thrombus formation during
blood lactate measurement as an early predictor of
sepsis. J Thromb Haemost. 2018;16(2):231-41.
shock and its outcome in patients of trauma or
10. Vincent JL, De Backer D. Circulatory shock. N Engl sepsis. Indian J Crit Care Med. 2009;13(2):66-73.
J Med. 2013;369(18):1726-34.
22. Herwanto V, Lie KC, Suwarto S, Rumende CM. Role
11. Freund Y, Delerme S, Goulet H, Bernard M, Riou B, of 6-hour, 12-hour, and 24-hour lactate clearance in
Hausfater P. Serum lactate and procalcitonin mortality of severe sepsis and septic shock patients.
measurements in emergency room for the diagnosis Crit Care. 2014;18(Suppl 2):P2.
and risk-stratification of patients with suspected
23. Innocenti F, Meo F, Giacomelli I, Tozzi C, Ralli ML,
infection. Biomarkers. 2012;17(7):590-6.
Donnini C, et al. Prognostic value of serial lactate
12. Rhodes A, Evans LE, Alhazzani W, Levy MM, levels in septic patients with and without shock.
Antonelli M, Ferrer R, et al. Surviving Sepsis Intern Emerg Med. 2019;14(8):1321-30.
75
Original Article
Efficacy of Bath PUVA in the treatment of
Palmoplantar Hyperkeratosis
Ahmed MI1, Hoq AJMS2, Alam AKMM3, Ahamed ARS4, Snigdha KSR5, Hamid MA6,Sayem AS7
ABSTRACT
Background: Palmoplantar hyperkeratosis, or palmoplantar keratoderma, is a combination of
skin conditions that are characterized by excessive thickening of the skin, mainly on the soles
and palms. There are various treatment methods for keratoderma, and one of those methods
are treatment through bathwater PUVA. It is a type of photochemotherapy.
Objective of the study: The aim of the study was to observe the efficacy of bath PUVA
treatment for palmoplantar hyperkeratosis.
Methodology: This randomized clinical trial study was conducted at the Department of
Dermatology and Venereology, Bangabandhu Sheikh Mujib Medical University, Dhaka,
Bangladesh. The study duration was 6 months, from September 2007 to February 2008. A
total of 30 patients presented with with palmoplantar hyperkeratosis were enrolled in this
study through random sampling method following the inclusion and exclusion criteria.
Results: Majority of participant (33.3%) were from the age group of 31-40 years. The mean
±SD age was 38.40±10.89 years, and the age range of the participants was 20-58 years. 70%
of the participants were male, 83.3% were from low socioeconomic class, and 36.7% were
businessmen respectively. Histopathological diagnosis revealed that 52% patients had psoriasis,
33% had nonspecific dermatitis, and 10% patients had chronic inflammatory dermatitis.
Gradual improvement was observed from baseline to 8 weeks follow-up in regards to
palmoplantar surface area involvement, erythema, and hyperkeratosis. 46.7% of the participants
reported skin tenderness, and 93.3% have a burning sensation and no other side effects.
Conclusion: Bath PUVA may be an effective option in the treatment palmoplantar keratosis
particularly of psoriatic patients. A mild form of nonspecific dermatitis may be treated with
bath PUVA.
Keywords: Hyperkeratosis, Keratosis, Keratoderma,PUVA
Mugda Med Coll J. 2022; 5(2): 76-81
1. Dr. Md. Iqbal Ahmed, Assistant Professor, Department of INTRODUCTION

Dermatology and Venereology, Mugda Medical College Palmoplantar hyperkeratosis is a condition in which
Hospital, Dhaka, Bangladesh
2. Dr. Abu Jafar Md. Shahidul Hoq, Assistant Professor,
the palms and soles produce an excessive amount of
Department of Dermatology and Venereology, Mugda keratin. It is a collection of conditions marked by
Medical College Hospital, Dhaka, Bangladesh abnormal thickening of the skin on the palms and
3. Dr. AKM Mahbubul Alam, Assistant Professor,
Department of Dermatology and Venereology, Mugda soles, rather than a single disorder. They have
Medical College Hospital, Dhaka, Bangladesh traditionally been classified as either hereditary or
4. Dr. Abu Reza Sayem Ahamed, Assistant Professor,
Department of Dermatology and Venereology, Mugda acquired, and they were distinguished by mode of
Medical College Hospital, Dhaka, Bangladesh inheritance, presence of transgradiens (defined as a
5. Dr. Kaniz Shahali Reza Snigdha, Assistant Professor, continuous extension of hyperkeratosis beyond the
Department of Dermatology and Venereology, Mugda
Medical College Hospital, Dhaka, Bangladesh palmar and/or plantar skin), co-morbidities with
6. Dr. Md. Abdul Hamid, Assistant Professor, Department other symptoms, and epidermal involvement, which
of Dermatology and Venereology, Mugda Medical College
Hospital, Dhaka, Bangladesh can be diffuse, focal, or punctate[1],[2].
7. Dr Abu Sayed Sayem, Junior consultant, Department of
Dermatology and Venereology, Mugda Medical College Palmoplantar hyperkeratosis is a common disease
Hospital, Dhaka, Bangladesh in dermatological practice. There are three clinical
Address of correspondence: Dr. Md. Iqbal Ahmed, Assistant
patterns of palmoplantar hyperkeratosis; diffuse,
Professor, Department of Dermatology and Venereology,
Mugda Medical College Hospital, Dhaka, Bangladesh. E-mail: focal, and punctate. The palms and soles undergo a
[email protected] high level of physical stress in everyday use. To resist
76
the mechanical traumas, the palmoplantar region is cumulative UVA exposure. Furthermore, it avoids
equipped with highly specialized proteins such as typical variation in large inter-individual differences
keratin[3],[4]. Keratins are a group of proteins that form in the gastrointestinal tract absorption of psoralens.
the intermediate filament cytoskeleton of epithelial A Large Scandinavian study demonstrated that bath
cells which are important for structural integrity. In PUVA with trimethoxypsoralen bears only a low risk
keratoderma, excessive production of normal or after a long time of usage[7] .The present study was to
altered keratin on the palms and soles is found. This determine the efficacy of Bath PUVA in the treatment
excessive production of keratin leads to palmoplantar of Palmoplantar hyperkeratosis, which would
hyperkeratosis (PPH). Palmoplantar hyperkeratosis provide another treatment option for palmoplanter
(PPH) and palmoplantar keratoderma (PPK) are often hyperkeratosis.
used interchangeably in many works of literature,
but some authors define keratoderma as the non- METHODS
hereditary and non-frictional hyperkeratosis.[1] Both This study was conducted at the Department of
hereditary and non-hereditary hyperkeratosis or Dermatology and Venereology, Bangabandhu Sheikh
keratoderma are caused by abnormal gene mutation, Mujib Medical University, Dhaka, Bangladesh. The
specifically in the keratin genes[5]. Keratin 1 mutations study duration was 6 months, from September 2007
have been documented in patients with epidermolytic to February 2008. A total of 30 patients clinically
and non-epidermolytic keratodermas. It is a common diagnosed with palmoplantar hyperkeratosis were
problem in dermatology. selected through a random sampling method
A great number of people in Bangladesh are suffering following the inclusion and exclusion criteria.
from Palmoplantar hyperkeratosis produced by Informed written consent was obtained from each
various kinds of disturbance in the daily activities of participant, and ethical approval was obtained from
an individual. PPH is prevalent globally, but the the ethical review committee of the study hospital.
incidence is higher in third-world countries. PPH The diagnosis was made on a clinical basis and the
may develop in anyone irrespective of age and gender. severity of PPH was measured by assessing the
An exact cause of palmoplantar hyperkeratosis is percentage of the involved body surface, degree of
unknown. It may be associated with many cutaneous erythema, scaling, and induration of the lesion.
and systemic diseases. The treatment modalities of Patient data were recorded in a predesigned
palmoplantar hyperkeratosis are topical (like salicylic structured questionnaire. Information was collected
acid, steroid etc.) and systemic (like retinoid, PUVA by taking a clinical history and clinical examination.
etc.). But little effect is achieved by topical preparation At the baseline visit, a complete clinical history was
and systemic therapy. Though effective in some cases, taken. Patients were instructed to report every 14 days
they need long-time therapy and have various side interval for 8 weeks to observe the efficacy and side
effects like hepatotoxicity, bone marrow suppression effects of bath PUVA.
etc. For these unsatisfactory outcomes, we choose bath
Inclusion Criteria
PUVA (psoralen plus ultraviolet-A radiation), a
• All patients diagnosed with palmoplantar
photo-chemotherapy used as a treatment regimen for
palmoplantar hyperkeratosis. Fischer and Alsins hyperkeratosis irrespective of etiology.
developed the Bath PUVA, in which psoralen • Patients between the age of 10 to 60 years.
derivatives such as trimethoxypsoralen or
methoxsalen are dissolved in a warm water bath.[6]. Exclusion Criteria
Delivery of psoralens by bath prevents systemic • Pregnancy
adverse effects associated with oral PUVA like • Patients with known hypersensitivity to
hepatotoxicity, photocarcinogenesis, cataract ultraviolet rays.
formation and a generalized photosensitization,
• Patients following other medications for PPH
lasting for 24 hrs requiring photoprotection[6]. Bath
PUVA has the advantage of selective and shorter • Affected with other chronic diseases like
photosensitization leading to a significantly lower hypothyroidism.
77
RESULTS Table II: Distribution of the participants by various

Among the participants of this study, majority demographic characteristics (n=30)
(33.3%) were from the age group of 31-40 years. The
mean ±SD age of the participants was 38.40±10.89 Demographical characteristics Frequency Percent
years, and the age range of the participants was 20- Sex
58 years. Male 21 70.0
Female 9 30.0
Socioeconomic status
Table I: Distribution of the participants by Age (n=30)
High 4 13.3
Age(year) Frequency Percent Mean± SD(Range) Middle 25 83.3
Low 1 3.3
20-30 8 26.7 38.40±10.89(20-58) Occupation
31-40 10 33.3 Service 6 20.0
Housewife 9 30.0
41-50 8 26.7
Student 3 10.0
51-60 4 13.3 Retired 1 3.3
Total 30 100.0 Business 11 36.7
Table III: Distribution of participants by palmoplantar surface area involvement at different follow-up periods (n=30)
Observation Period Palmoplantar surface area involvement

None 25-50% 50-75% 75-100%
Baseline - - 24(80.0) 6(20.0)
2 weeks - - 24(86.7) 4(13.326)
4 weeks - 13(43.3) 17(56.7) -
6 weeks - 29(96.7) 1(3.3) -
8 weeks 4(13.3) 26(86.7) - -
At baseline, 80% of the participants had 50-75% of palmoplantar surface area involvement, and 20% had 75-
100% involvement. After the start of treatment, gradual improvement was observed among the participants,
and by the 8th week, 86.7% of the participants had <50% of surface area involvement, and 13.3% had no
palmoplantar surface area involvement.
Table IV : Distribution of participants by erythema at different follow-up periods (n=30)

Observation Period Erythema
None Mild Moderate Severe
Baseline - - 28(93.3) 2(6.7)
2 weeks - 3(10.0) 26(86.7) 1(3.3)
4 weeks - 23(76.6) 7(23.3)
6 weeks 1(3.3) 29(96.7) - -
8 weeks 28(93.3) 2(6.7) -
At baseline, most of the participants (93.3%) had moderate erythema levels, and 6.7% had severe erythema.
This improved gradually, and week 4, 76.6% had mild erythema, 23.3% had moderate erythema and none had
severe erythema. By week 8, most of the participants (93.3%) had no erythema, and only 6.7% (n=2) had mild
erythema. 38.40±10.89
78
Table V : Distribution of participants by hyperkeratosis at different follow-up periods (n=30)
Observation Period Hyperkeratosis

None Mild Moderate Severe
Baseline 26(86.7) 4(13.3)
2 weeks 1(3.3) 26(86.7) 3(10.0)
4 weeks 19(63.3) 10(33.3) 1(3.3)
6 weeks 29(96.7) 1(3.3)
8 weeks 12(40.0) 18(60.0)
At baseline, 13.3% had severe and 86.7% had moderate hyperkeratosis. At week 2, 10% had severe, 86.7% had
moderate and 3.3% had mild hyperkeratosis. By week 8, no participants had moderate or severe hyperkeratosis,
only 60% had mild hyperkeratosis, and 40% had no hyperkeratosis at all.
Table VI : Distribution of the patients by histopathologic types and final prognosis of participants (n=30)
Prognosis Histopathological types

Psoriasis Nonspecific Dermatitis Chronic inflammatory Dermatitis
(n=16) (n=11) (n=3)
Excellent 3(18.8) 1(9.1) 0(.0)
Good 6(37.5) 0(.0) 0(.0)
Poor 7(43.8) 10(90.0%) 3(100.0)
Histopathological diagnosis revealed that 52% DISCUSSION

patients had psoriasis, 33% had non-specific This clinical trial was conducted to observe the
dermatitis, and 10% had chronic inflammatory efficacy of bath PUVA in the treatment of
dermatitis. Among the psoriasis cases, 43.5% had a palmoplantar keratosis. Thirty patients with
poor outcome, 37.5% had good outcome and 18.8% palmoplantar keratosis were treated with Bath PUVA
had excellent outcome at cessation of the study. in this study. Out of all patients 21 (70.0%) were male
Among the 11 non-specific dermatitis cases, 1 had and 9 (30.0%) were female. Male and female ratio was
excellent and 90% had poor outcomes. All 3 patients 7:3. Our finding of sex distribution was comparable
with chronic inflammatory dermatitis revealed poor with a 1997 study.[10] Eight (33.3%) respondents of
outcomes at the cessation of the study. series were within 31 to 40 years age range followed
by 26.7% within 20-30 years, 26.7% within 41-50 years
and 13.3% within 51 to 60 years age range. Mean age
Table VII: Distribution of the patients by side effects of the patients was 38.4 years with a standard
(n=30) deviation of +10.89 years. All patients were within
20-58 years’ age range. The mean age of the study
Side effect Frequency Percent was almost similar to the mean age of Wahab et al.,
Skin tenderness 14 46.7 which was 35.06 years.[11] Within socioeconomic
groups, 25 (83.3%) patients were from middle class
Burning 28 93.3
families, followed by 4 (13.3%) from upper class and
1 (3.3%) from lower class families. Maximum (36.7%)
The present study participants were observed with patients of the present study group were
side effects like marked erythema, pruritus, or businessman, followed by 9 (30.0%) housewives, 6
blistering. 93.3% of the participants reported of (20.0%) service holders, 3 (10.0%) students and 1
burning sensation after completion of the medication, (3.3%) retired. At baseline 24 (80.0%) patients had 50
and 46.7% had skin tenderness. to 75% involvement in palmoplantar surface area and
79
the remaining 6 (20.0%) had 75 to 100.0% CONCLUSION

involvement. After start of bath PUVA treatment, The treatment with bath PUVA may be an effective
gradual improvement was observed from baseline to option in the treatment palmoplantar keratosis
8 weeks onward. At the first follow-up after 2 weeks particularly of psoriatic patients. A mild form of
of being given bath PUVA, 26 (86.7%) patients had nonspecific dermatitis may be treated with bath
50-75% involved surface area and 4 (13.3%) had 75- PUVA. Although improvement was observed in this
study after bath PUVA treatment, this improvement
100% involvement. By the follow-up at 8 weeks, no
was much slower than other global studies’ findings.
palmoplantar surface area involvement was observed
in 4 (13.3%) patients, followed by 26 (86.7%) who Considering the findings of this study compared to
had only 25-50% involvement. At baseline 28 (93.3%) other similar studies further longitudinal studies with
patients had moderate erythema, and the remaining large sample sizes may be conducted.
2 (6.7%) had severe erythema. After 8 weeks of REFERENCES
treatment, 28 (93.3%) patients had no erythema and 1. Patel S, Zirwas M, English JC. Acquired
only 2 (6.7%) had mild erythema. In regards to palmoplantar keratoderma. American journal of
hyperkeratosis, at baseline, 26 (86.7%) patients had clinical dermatology. 2007 Feb;8(1):1-1.
moderate hyperkeratosis and rests 4 (13.3%) had 2. Odom RB, James WD, Berger TG. Disturbances of
severe hyperkeratosis. After 8 weeks of treatment, 12 pigmentation. In: Odom RB, James WD, Berger TG.
(40.0%) patients had no hyperkeratosis and 18 Andrews’ Diseases of the Skin. 9th ed. Philadelphia,
(60.0%) had mild hyperkeratosis. Histopathological PA: W.B. Saunders Company; 2000:1065-1068.
diagnosis was done to determine the histo- 3. McLean WI. Genetic disorders of palm skin and
pathological types of hyperkeratosis. It was observed nails. Journal of anatomy. 2003 Jan;202(1):133-41.
that 16 had psoriasis, 11 had nonspecific dermatitis,
4. Swensson O, Eady RA. Morphology of the keratin
and 3 had chronic inflammatory dermatitis. Ultimate filament network in palm and sole skin: evidence
improvement was calculated by taking baseline and for site-dependent features based on stereological
final follow-up scores. By considering clinical analysis. Archives of dermatological research. 1996
assesment only four (13.3%) patients had excellent Feb;288(2):55-62.
improvement (3 psoriatic and I nonspecific dermatitis
5. Bonifas JM, Matsumura K, Chen MA, Berth-Jones J,
patient), six (20.0%) had good (all were psoriatic Hutchinson PE, Zloczower M, Fritsch PO, Epstein
patients) and 20 (66.7%) (7 psoriatic, 10 nonspecific Jr EH. Mutations of keratin 9 in two families with
dermatitis, and 3 chronic inflammatory dermatitis palmoplantar epidermolytic hyperkeratosis.
patient) had poor improvement. These findings were Journal of investigative dermatology. 1994 Oct
much different from the findings of other studies, 1;103(4):474-7.
where bath PUVA treatment led to much higher rates 6. Schiener R, Brockow T, Franke A, Salzer B, Peter
of excellent outcomes.[10],[12],[13] Hyperkeratotic RU, Resch KL. Bath PUVA and saltwater baths
dermatitis displayed the poorest responding rates in followed by UV-B phototherapy as treatments for
this study. Unwanted side effects such as erythema, psoriasis: a randomized controlled trial. Archives
pain, blistering or patchy hyperpigmentation were of dermatology. 2007 May 1;143(5):586-96.
not observed in any of the patients. Among the 30 7. Schiener R, Gottlöber P, Müller B, Williams S,
patients, 28 (93.3%) had complained of burning Pillekamp H, Peter RU, Kerscher M. PUVA-gel vs.
sensation, and 14 (46.7%) complained of skin PUVA-bath therapy for severe recalcitrant
tenderness during the treatment period. No gross side palmoplantar dermatoses. A randomized, single-
effects such as erythema, tanning, etc. were observed blinded prospective
in the study, which was similar to by Wahab et al.[11] 8. Skaljic M. Keratosis Palmaris et Plantaris [Internet].
The study was conducted in a single hospital with a Overview, Diffuse Hereditary PPK, Focal and
small sample size. So, the results may not represent Striate Hereditary PPK. Medscape; 2021 [cited
2022Apr16]. Available from: https://emedicine.
the whole community.
medscape.com/article/1108406-overview#showall
80
9. Palmoplantar Keratoderma [Internet]. Palmo- Journal of Bangladesh College of Physicians and

plantar keratoderma | DermNet NZ. [cited 2022 Surgeons. 2006;24(1)14-18.
Apr16]. Available from: https://dermnetnz. org/ 12. Der Petrossian M, Seeber A, Hönigsmann H, Tanew
topics/palmoplantar-keratoderma A. Half side comparison study on the efficacy of 8
10. Schempp CM, Muller H, Czech W, Simon JC. methoxypsoralen bath PUVA versus narrow band
Treatment of chronic palmoplantar eczema with ultraviolet B phototherapy in patients with severe
chronic atopic dermatitis. British Journal of
local bath-PUVA therapy. J Am Acad Dermatol
Dermatology. 2000 Jan;142(1):39-43.
1997; 36: 733 - 737.
13. Ratnavel RC, Griffiths WA. The inherited
11. Wahab MA, Amin MN, Khan MAL, Hasan MS. Bath palmoplantar keratodermas. British journal of
PUVA in the treatment of palmoplantar psoriasis. dermatology. 1997 Oct;137(4):485-90.
81
Original Article
Association of serum vitamin-D level with renal
function in a rural population of Bangladesh
Saha SK1, Iqbal MM2, Nath PKD3, Chowdhury MFH4
Abstract
Background: Vitamin D deficiency is an emerging global health problem. Recent studies
have indicated that the prevalence of vitamin D deficiency even in tropical countries is as high
as that observed in Western populations. Vitamin D deficiency has high impact on renal
disorders which are leading causes of death in humans.
Methods: This was a cross sectional analytical study. According to inclusion criteria of the
study total 259 participants were recruited from a rural area, Baidyerbazar union of
Narayanganj district. After taking history and clinical examination, relevant investigations
were done. Serum 25(OH)D was measured using chemiluminescent immunoassay (CLIA)
technology (DiaSorin Inc, Stillwater, MN). Renal functions of the study population were
assessed by e-GFR (calculated by CKD-EPI equation), urinary ACR and urine microscopy.
Results: In this study out of 259 study subjects on vitamin-D status 6.2%, 33.6% and
60.2% had vitamin-D sufficiency, insufficiency and deficiency respectively. Among participated
female (133) 78.2% had vitamin-D deficiency and among participated male (126) 41.3% had
vitamin-D deficiency. Among vitamin-D sufficiency, insufficiency and deficiency group the
mean eGFR was 102.94, 104.87 and 109.33 ml/min/1.73 m2 respectively. The mean uACR
level was 6.97, 22.89 and 37.29 mg/gm respectively.
Conclusion: The findings of the study suggest that 93.8% of study population had either
vitamin-D insufficiency or deficiency. Vitamin-D deficiency was more prevalent in females
than males. Serum 25- hydroxyvitamin D level was negatively associated with urinary ACR
level.
Keywords: 25-hydroxyvitamin D, eGFR, uACR
Mugda Med Coll J. 2022; 5(2): 82-87
INTRODUCTION nmol/L) and (iii) sufficiency when >30 ng/mL (>75

The American guideline for evaluation, prevention, nmol/L)1. Based on these cutoffs, it has been estimated
and treatment of vitamin D deficiency establishes that that about one billion people, worldwide, have
vitamin D should be determined by measurement of 25(OH)D deficiency or insufficiency. The prevalence
serum 25(OH)D with the following cutoff points: (i) of serum 25(OH)D deficiency and insufficiency
deficiency when <20 ng/mL (<50 nmol/L), (ii)
reportedly varies between 30% and 93%. The highest
insufficiency when between 20 to 30 ng/mL (50 to 75
prevalence of hypovitaminosis D has been reported
1. Dr. Satyajit Kumar Saha, Assistant Director, Mugda in temperate climate regions that receive limited
Medical College Hospital, Dhaka, Bangladesh. sunlight, especially during winter2. It is our general
2. Prof. M. Masud Iqbal, Professor of Nephrology, National
belief that vitamin D deficiency is prevalent only in
Institute of Kidney Diseases & Urology, Dhaka.
3. Dr. Palash Kumar Deb Nath, Assistant Professor of
western countries, but actual condition is reverse. It
Nephrology, Mugda Medical College, Dhaka. is surprising that in South Asia, 80% of the apparently
4. Dr. Md. Farhad Hasan Chowdhury, Assistant Professor of healthy population is deficient in vitamin D (<20 ng/
Nephrology, Mugda Medical College, Dhaka.
mL) and up to 40% of the population is severely
Address of correspondence: Dr. Satyajit Kumar Saha,
Assistant Director, Mugda Medical College Hospital, Dhaka, deficient (<5 ng/mL)3. In the adult population, 35%
Bangladesh. E-mail: [email protected] of adults in the United States are vitamin D deficient
82
whereas over 80% of adults in Pakistan, India, and shown that eGFR increased as vitamin-D level
Bangladesh are Vitamin D deficient4. increased, some have shown that eGFR increased as
vitamin-D level decreased and others found no
Some of the associated risk factors of vitamin D
association. The exact reason for these discrepancies
deficiency are age, sex, race, body mass index, use of
is not clear, however the findings differed depending
medications known to affect vitamin D metabolism,
on whether the subjects were patients with CKD or
inadequate amount of vitamin D in food, low sun
individuals with normal or mildly decreased eGFR9.
exposure, use of sunscreens, distance from the
Equator, black skin, smoking, poor food absorption, Vitamin-D is known to suppress the renin gene
and kidney and liver disease2. By cross-sectional transcription. In vitamin-D deficiency renin is
analysis of the NHANES III (1988–1994) and synthesized which activate RAAS. Angiotensin- II is
NHANES 2001–2004 databases that are a key mediator to raise efferent glomerular arteriole
representative of the US adult population, a number resistance which raises the glomerular filtration
of studies consistently demonstrated an association pressure and leads to increased GFR10. However in
of low serum 25(OH) D levels with increased CKD patients there is positive association between
prevalence of renal risk factors. It showed a correlation eGFR and vitamin-D level. It occurs as CKD patients
between low serum 25(OH) D and the risk of all-cause are lack of outdoor activities and dietary sources.
mortality in the general population5,6. Besides this, in the circulation 25(OH)D complexes
with vitamin D binding protein (DBP). Following
Vitamin D levels significantly decrease with
glomerular filtration the 25(OH)D-DBP complex is
increasing age. This is expected, because the skin
reabsorbed via megalin-mediated endocytosis in the
thickness decreases with age and thus, the production
proximal tubules, where 25(OH)D is converted to
of 7-dehydrocholesterol is also compromised. The
1,25(OH)2D3 by renal 1a- hydroxylase (CYP27B1).
decreased level could be due to the fact that, a more
In renal insufficiency, the decline in megalin-
sedentary and indoor lifestyle is easily adopted with
mediated endocytotic activity and renal 1a-
advancing age2.
hydroxylase activity and the loss of 25(OH)D-DBP
Vitamin D deficiency is more common in female than into the urine because of proteinuria contribute to the
male. This is due to many women stay at home and development of 25(OH)D and 1,25(OH)2D3
perform indoor activity. There are little exposure to deficiency5.
sunlight. The other conditions: Covering the entire
Albuminuria is a major risk factor for renal disease
body with clothing as customary in women in some
progression. A cross-sectional analysis of the
religions, use of sunscreen may significantly reduce
NHANES III data showed that the prevalence of
the production of vitamin D3 in the skin7.
albuminuria increased in a progressive fashion with
The color of skin of South Asian populations varies decreasing vitamin D level. It suggest that vitamin D
from light brown to almost dark. Dark color skin has has an intrinsic anti-proteinuric activity 5 .
been found to decrease skin synthesis of vitamin D Hypovitaminosis D causes albuminuria through a
because UV light cannot reach the appropriate layer number of mechanisms. First, lower circulating
of the skin due to presence of melanin3. Melanin acts vitamin D level causes activation of the renin-
as an effective natural sunscreen and, therefore, angiotensin- aldosterone system and lead to
increased skin pigment can greatly reduce the solar albuminuria through both hemodynamic and
UVB mediated cutaneous synthesis of vitamin D37. nonhemodynamic mechanisms. Second, vitamin D
Vitamin D binding protein (DBP) levels in blacks are deficiency reduces pancreatic beta cell function and
significantly lower compared to whites to compensate is associated with reduced peripheral insulin
for lower total serum 25(OH)D in blacks6. sensitivity. Diabetes and insulin resistance are
Impaired GFR is a cardinal manifestation of kidney established risk factors for albuminuria. Third,
disease. Lower GFR, even within its normal range, is vitamin D has direct effects on cell proliferation,
associated with markedly increased risk of differentiation, and apoptosis of podocytes.
cardiovascular death8. The relationship between Insufficient vitamin D may contribute to albuminuria
eGFR and vitamin-D is debated. Some studies have by podocyte loss and glomerulosclerosis through
83
direct cellular effects 8 . It is also possible that populations had vitamin-D deficiency (60.2%)
albuminuria leads to low levels of vitamin D. In the followed by vitamin-D insufficiency (33.6%),
kidney, vitamin D is filtered at the glomerulus and vitamin-D sufficiency (6.2%). The eGFR value ³90
actively reabsorbed in the proximal tubule by a ml/min/m2 was maximum in 87.3% and uACR
process facilitated by the luminal receptors megalin value <30 mg/gm was maximum in 91.9% of the
and cubulin. It is possible that increased filtration of study populations.
albumin into the urinary space interferes with vitamin
D reabsorption, leading to greater losses of vitamin D Table I: Distribution of the study population (N=259)
in urine11. Frequency(n) Percentage(%)
METHODS Age
This was a cross sectional analytical study. The study £30 65 25.1
was conducted for six months from July to December 31 – 40 81 31.3
of 2019. According to inclusion and exclusion criteria 41 – 50 49 18.9
of the study total 259 participants were recruited from 51 – 60 27 10.4
>60 37 14.3
a rural area, Baidyerbazar union of Narayanganj
Gender
district, where CKD screening program is going on.
Male 126 48.6
After taking history and clinical examination, relevant Female 133 51.4
investigations were done. Serum 25(OH)D was Vitamin-D status
measured using chemilumin-escent immunoassay Sufficiency 16 6.2
(CLIA) technology (DiaSorin Inc, Stillwater, MN). Insufficiency 87 33.6
Renal functions of the study population were Deficiency 156 60.2
assessed by e-GFR (calculated by CKD-EPI equation), eGFR (ml/min/m2)
urinary ACR and urine microscopy. ³90 226 87.3
60 – 89 31 11.9
Selection criteria: At first people with age ³18 years <60 2 0.8
living in rural area were included in this study. Then uACR (mg/gm)
pregnant women; patient with cognitive impairment; <30 237 91.9
patient who are on medication known to affect ³30 21 8.1
vitamin D absorption or metabolism such as
anticonvulsant, glucocorticoids, calcium, vitamin D Table II shows the association of vitamin-D status
with gender and renal risk factors. Females (78.2%)
supplements were excluded from this study.
were significantly more affected than males (41.3%)
RESULTS in case of vitamin-D deficiency group. High uACR
Table I. shows the distribution of the total 259 study value were found in vitamin- D deficiency group
(90.5%) and the results were statistically significant.
populations according to different catagories.
Table III shows the comparison of renal risk factors
Maximum study populations were in age group 31
in relation to vitamin-D status. Fasting blood glucose,
– 40 years (31.3%). Females (51.4%) were slightly
HbA1c, BMI levels were significantly increased in
predominant than males (48.6%). Maximum study case of vitamin-D deficiency group.
Table II: Association of vitamin-D status with gender and renal risk factors
Total Vitamin-D Vitamin-D Vitamin-D P
(n=259) Sufficiency Insufficiency Deficiency value
Gender 0.0001
Male 126 14 (11.1%) 60 (47.6%) 52 (41.3%)
Female 133 2 (1.5%) 27 (20.3%) 104 (78.2%)
uACR (mg/gm) 0.012
<30 238 16 (6.7%) 85 (35.7%) 137 (57.6%)
³30 21 0 (0.0%) 2 (9.5%) 19 (90.5%)
Chi square test was done.
84
Table III: Comparison of Renal factors in relation to vitamin-D status
Total Vitamin-D Vitamin-D Vitamin-D P

(n=259) Sufficiency Insufficiency Deficiency value
(n=16) (n=87) (n=156)
BP (mm of Hg)
SBP 129.85 ± 19.62 125.50 ± 18.87 130.17 ± 15.91 130.12 ± 21.53 0.648
DBP 79.43 ± 11.01 74.88 ± 6.32 78.48 ± 10.72 80.43 ± 11.43 0.149
FBG (mmol/l) 5.96 ± 2.27 5.18 ± 0.63 5.59 ± 1.27 6.24 ± 2.73 0.036
HbA1c (%) 6.06 ± 1.53 5.43 ± 0.24 5.87 ± 1.16 6.23 ± 1.75 0.049
BMI (kg/m2) 25.20 ± 4.34 21.51 ± 3.49 24.44 ± 4.13 25.99 ± 4.27 0.034
eGFR(ml/min/m2) 107.44 ± 17.44 102.94 ± 16.91 104.87 ± 16.51 109.33 ± 17.83 0.091
Creatinine (mg/dl) 0.76 ± 0.21 0.86 ± 0.16 0.80 ± 0.16 0.72 ± 0.23 0.003
uACR (mg/gm) 30.55 ± 79.18 6.97 ± 4.65 22.89 ± 50.25 37.29 ± 94.42 0.279
Calcium (mg/dl) 10.82 ± 1.73 10.07 ± 1.37 10.99 ± 1.57 10.80 ± 1.83 0.142
Phosphate (mg/dl) 4.17 ± 0.78 3.76 ± 0.54 4.22 ± 0.74 4.19 ± 0.82 0.092
ALP (u/l) 102.77 ± 36.12 84.63 ± 21.77 104.57 ± 34.26 103.62 ± 37.92 0.114
Data were expressed as mean ± SD. ANOVA test were done
DISCUSSION 14.6 ng/ml. 93.8% subjects was found either vitamin-

Growing scientific evidence has implicated vitamin D insufficiency or deficiency. According to Mayo Clin
D deficiency in a multitude of chronic conditions, Proc. July 2013 the vitamin-D deficiency scenario in
including diabetes mellitus, hypertension, South East Asia (78 – 98%), Middle East (90%) and
cardiovascular disease, renal disease and among Europe (57 – 64%). High prevalence of vitamin- D
others. With the growing prevalence of vitamin D deficiency of this study may be due to culture of people
deficiency and its association with these leading and seasonal variation. About half of the samples
causes of mortality, it has become more important were collected during winter season.
than ever to delineate vitamin D’s role in the
In this study vitamin-D deficiency is more common
pathogenesis of these diseases and use data to
in female (98.5%) than male (88.9%). It is due to less
pinpoint established risk factors for vitamin D
sun exposure of female as they perform more indoor
deficiency12.
activity and in outside their whole body is covered by
This study was conducted among 259 rural clothing like borkha. This finding is similar to Jeon et
population. Mean age of the study subjects was 41.62 al, 2011; Martins et al, 2007 study11,13.
± 14.74 years within a range of 18 to 88 years. Females
In this study, uACR showed negative correlation with
(51.4%) were slightly predominant than males
serum vitamin-D level. The uACR was 6.97 ± 4.65,
(48.6%).
22.89 ± 50.25, 37.29 ± 94.42 in vitamin- D sufficiency,
In this study, serum 25-OH-vitamin-D was assayed insufficiency and deficiency group respectively. This
by DiaSorin, Stillwater, MN. Kit which uses finding is similar to Boer et al, 2011; Kim et al, 2018
chemiluminescent immunoassay (CLIA) technology study8,10. Adjustment for hypertension and diabetes
The internal QC test value was 13.9 ng/ml with range resulted in some attenuation of this association,
9.73 to 18.1 ng/ml. In this study ivD QC result was suggesting that these factors may mediate or confound
85
a portion of the relationship of vitamin-D with 3. Ahasan HAMN, Das A. Vitamin D Deficiency in
albuminuria. South Asian Populations: A Serious Emerging
Problem. Journal of Enam Medical College. 2013;
In this study, when eGFR is ³60 ml/min/m2 it is 3(2): 63-66.
negatively associated with serum vitamin-D level and
4. Sizar O, Givler A. Vitamin D deficiency. Stat pearls.
when eGFR <60 ml/min/m2 it is positively 2019.
associated with serum vitamin-D level. Several studies
5. Li YC. Vitamin D: Roles in Renal and
have investigated the association between renal Cardiovascular Protection. Curr Opin Nephrol
function and vitamin D levels. However, the Hypertens. 2012; 21(1): 72–79.
relationship between eGFR and vitamin-D is debated. 6. Al-khalidi B, Kimball SM, Rotondi MA, Ardern CI.
Although some studies have shown that eGFR Standardized serum 25- hydroxyvitamin D
decreased as vitamin-D levels increased9,14 and some concentrations are inversely associated with
studies have shown that eGFR increased as vitamin- cardiometabolic disease in U.S. adults: a cross-
sectional analysis of NHANES, 2001–2010.
D levels increased15, others found no association
Nutrition Journal. 2017; 16: 1-12.
between vitamin D and GFR16,17. The exact reason
7. Ullah MI, Uwaifo GI, Nicholas WC, Koch CA. Does
for these discrepancies is not clear; however, it may
Vitamin D Deficiency Cause Hypertension?
be that most studies in patients with CKD have found Current Evidence from Clinical Studies and
a positive association between eGFR and vitamin D Potential Mechanisms. International Journal of
levels, whereas those conducted in the general Endocrinology. 2010; 1-10.
population typically found no association. 8. Boer IH, Katz R, Chonchol M et al. Serum 25-
Hydroxyvitamin D and Change in Estimated
CONCLUSION Glomerular Filtration Rate. Clin J Am Soc Nephrol.
The prevalence of serum 25(OH) D sufficiency, 2011; 6: 2141–2149.
insufficiency and deficiency in a rural population of 9. Park J, Ryu SY, Han MA, Choi SW. The association
Bangladesh is 6.2%, 33.6% and 60.2% respectively. of vitamin D with estimated glomerular filtration
Vitamin-D deficiency is more prevalent in females. rate and albuminuria: 5th Korean National Health
and Nutritional Examination Survey 2011–2012. J
Low serum level of 25(OH) D is associated with the
Ren Nutr 2016; 26: 360–366.
declining eGFR and increasing urinary albumin
10. Kim SG, Kim GS, Lee JH, Moon AE, Yoon H. The
excreation.
relationship between vitamin D and estimated
glomerular filtration rate and urine microalbumin/
LIMITATION OF THE STUDY
creatinine ratio in Korean adults. J. Clin. Biochem.
This study carried out at a short period of time, more Nutr. 2018; 62: 94–99.
time is needed for such study. As this was a cross-
11. Jeon Y, Shin J, Jhee JH, Cho Y, Park EC. Differential
sectional study, so it was impossible to infer causal Association of Vitamin D Deficiency With
or temporal relationship. The study did not evaluate Albuminuria by Sex in the Korean General
use of medications known to affect the blood pressure Population: A Cross-sectional Study of the Korea
and blood glucose level. National Health and Nutrition Examination Survey
2011-2012. J Prev Med Public Health. 2018; 51: 92-
REFERENCES 99.
1. Jorge AJL, Cordeiro JR, Rosa MLG, Bianchi DBC. 12. Parva NR, Tadepalli S, Singh P et al. Prevalence of
Vitamin D deficiency and cardiovascular disease. Vitamin D Deficiency and Associated Risk Factors
International Journal of Cardiovascular Sciences. in the US Population (2011-2012). Cureus. 2018;
2018; 31(4): 422-432. 10(6): 1-10.
2. Tangoh DA, Apinjoh TO, Mahmood Y et al. Vitamin 13. Martins D, Wolf M, Pan D et al. Prevalence of
D Status and Its Associated Risk Factors among Cardiovascular Risk Factors and the Serum Levels
Adults in the Southwest Region of Cameroon. of 25-Hydroxyvitamin D in the United States. Data
Hindawi Journal of nutrition and metabolism. 2018; from NHANES-lll. Arch Intern Med. 2007; 167: 1159-
1-9. 1165.
86
14. Rolim MC, Santos BM, Conceicao G, Rocha PN. 16. Damasiewicz MJ, Magliano DJ, Daly RM, Gagnon
Relationship between vitamin D status, glycemic C, Lu ZX, Sikaris KA, et al. Serum 25-
control and cardiovascular risk factors in Brazilians Hydroxyvitamin D Deficiency and the 5-Year
with type 2 diabetes mellitus. Diabetol Metab Incidence of CKD. Am J Kidney Dis. xx(x):xxx.2013
Syndr. 2016; 8: 77-83. 17. Melamed ML, Michos ED, Post W, Astor B. 25-
15. Polur H, Kedam D, Kumar R, Vinodh P. Study of hydroxyvitamin D levels and the risk of mortality
vitamin D: A risk factor of type-2 Diabetes Mellitus. in the general population. Arch Intern Med. 2008;
J Pharm. Sci. & Res. 2013; 5(1): 5-7. 168:1629–1637. [PubMed:18695076]
87
Original Article
Visceral Adiposity Index: An Effective Tool for
Predicting Metabolic Syndrome in Bangladeshi Adult
Population
Tabassum M1, Mozaffor M2, Muna FZ3, Rahman MM4, Khan MTI5, Naznen F6, Chowdhury MA7,
Sharmin S8
ABSTRACT
Background: Obesity induces adipocyte dysfunction with secretion of adipokines, which
results in a cascade of chemical reaction which triggers the atherogenic process and insulin
resistance leading to a set of metabolic abnormalities i.e., metabolic syndrome. The Visceral
Adiposity Index (VAI) is a simple, gender-based obesity index and has been proposed to be a
predictor of metabolic syndrome.
Objective: Our study aims to evaluate the effectiveness of the Visceral Adiposity Index
(VAI) in prediction metabolic syndrome in Bangladeshi adult population.
Methods: This cross-sectional study was carried out in Department of Biochemistry and
Molecular Biology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka,
Bangladesh, from January to June of 2017. A total of 200 apparently healthy subjects (108
men and 92 women) were selected for the study, who attended the out-patient-departments
of the same institution. Anthropometric measurements were recorded, e.g., height, weight,
waist circumference (WC). Body mass index (BMI) was calculated. Overnight fasting blood
samples were collected to estimate plasma glucose and serum lipid profile. Then VAI was
calculated for men and women separately and evaluated as a tool in diagnosis of metabolic
syndrome among the participants. Receiver operating characteristic (ROC) curves were
plotted to assess the performance of VAI in metabolic syndrome prediction by gender. The
power of metabolic syndrome prediction was quantified by the area under the curve (AUC)
with 95% confidence intervals.
Results: The mean age of the study participants was 42.4±5.2 years. Among 108 men, 63 had
metabolic syndrome, while among 92 women, 31 had metabolic syndrome. Sensitivity and
specificity of VAI in predicting metabolic syndrome in male study subjects were 83.2% and
70.3%, respectively, while in female study subjects 80.1% and 70.5% respectively. Receiver
operating characteristic (ROC) curve analysis showed that the optimal cutoff value of VAI in
male study subjects was 2.16 and area under the curve (AUC) value was 0.907, while in
female study subjects, the values were 2.25 and 0.918 respectively (P<0.001).
Conclusion: The Visceral Adiposity Index (VAI) was found simple, accessible, and effective
obesity index to predict metabolic syndrome in apparently healthy adults.
Keywords: Visceral Adiposity Index, Metabolic Obesity, Metabolic Syndrome, Bangladesh
Mugda Med Coll J. 2022; 5(2): 88-92
1. Dr. Mariya Tabassum, Associate Professor & Head, Department of Biochemistry, Abdul Malek Ukil Medical College,
Begumganj, Noakhali.
2. Dr. Miliva Mozaffor, Assistant Professor, Department of Biochemistry, Medical College for Women & Hospital, Uttara, Dhaka.
3. Dr. Farzana Zaman Muna, Assistant Professor, Department of Biochemistry, Abdul Malek Ukil Medical College, Begumganj, Noakhali.
4. Prof. Md. Matiur Rahman, Professor & Chairman, Department of Biochemistry and Molecular Biology, Bangabandhu Sheikh
Mujib Medical University (BSMMU), Dhaka.
5. Dr. Md. Tariqul Islam Khan, Registrar, Department of Cardiology, Mymensingh Medical College Hospital, Mymensingh.
6. Dr. Farhana Naznen, Lecturer, Department of Physiology, Community Based Medical College, Bangladesh (CBMC,B),
Winnerpar, Mymensingh.
7. Dr. Mehdi Ashik Chowdhury, Associate Professor & Head, Department of Pathology, Tairunnessa Memorial Medical College, Gazipur
8. Dr. Shegufta Sharmin, Associate Professor, Department of Pathology, Shaheed Monsur Ali Medical College, Uttara, Dhaka
Address of Correspondence: Dr. Mariya Tabassum, Associate Professor & Head, Department of Biochemistry, Abdul Malek
Ukil Medical College, Begumganj, Noakhali-3823. Email: [email protected]
88
INTRODUCTION There are several studies done in different regions of

Excess accumulation of intra-abdominal adipose the globe; however, to date, there is no published report
tissue, which is often termed as ‘visceral obesity’, is on VAI in our population. Hence, we proposed this
part of a phenotype including dysfunctional study to evaluate the effectiveness of the Visceral
subcutaneous adipose tissue expansion and lipid Adiposity Index (VAI) in prediction metabolic
storage closely related to clustering cardiometabolic syndrome in Bangladeshi adult population.
risk factors that results in some negative impacts on
health.1 Obesity induces adipocyte dysfunction with METHODS
secretion of adipokines. This results in a cascade of This cross-sectional study was carried out in
chemical reaction which triggers the atherogenic Department of Biochemistry and Molecular Biology,
process and insulin resistance leading to a set of Bangabandhu Sheikh Mujib Medical University
metabolic abnormalities.2 (BSMMU), Dhaka, Bangladesh, from January to June
of 2017. A total of 200 apparently healthy subjects
Body Mass Index (BMI) is the most commonly used (108 men and 92 women) were selected for the study,
tool to classify obesity. However, BMI-based who attended the out-patient-departments of the
classification is no longer reliable because it does not same institution. The study subjects were selected aged
take visceral fat distribution and adipocyte between 18 and 60 years through purposive and
dysfunction into account. Some normal-weight adults convenient sampling method (after exclusion of
are also found to have increased insulin resistance, subjects who were pregnant, diabetic, or having
atherogenic lipid profiles and hence are prone to history of kidney, liver, endocrine or malignant
suffer from Type 2 diabetes mellitus, cardiovascular disease or any type of infection). The purpose and
and cerebrovascular disease.3-5 Therefore, a newer procedures were explained to them in details and
term “metabolic obesity” has been coined to address written informed consent was taken. They were
this issue. Metabolic obesity can be defined as the evaluated by history, clinical examination, and
presence of metabolic syndrome in an individual, laboratory investigations as per data collection sheet.
irrespective of his/her BMI. This implies that a person Anthropometric measurements were recorded, e.g.,
could be metabolically obese, in spite of having a height, weight, waist circumference (WC). Then body
normal BMI or being normal-weight.6-9 mass index (BMI) was calculated i.e., weight in
In clinical practice, such metabolically obese but kilograms divided by the square of height in meters
normal-weight people seem to be the most challenging (Kg/m2), for each of them. In sitting position, systolic
one to deal with. People who are metabolically obese and diastolic blood pressure were recorded.
but have normal weights stay out of the focus of Overnight fasting blood samples were collected to
clinicians and researchers. They are often thought to estimate plasma glucose and serum lipid profile.
remain free from obesity-related complications due Fasting plasma glucose was estimated by using
to their normal BMIs. In contrast, being metabolically hexokinase method (in AU680 Clinical Chemistry
unhealthy, they are definitely prone to an increased Analyzer – Beckman Coulter, Inc., made in USA).
risk of Type 2 diabetes mellitus, cardiovascular Serum total cholesterol (TC), triglycerides (TG) and
diseases and stroke.6-9 Therefore, early and accurate High-Density Lipoprotein cholesterol (HDLC) were
detection of patients with this phenotype has estimated by using by enzymatic method (in
immense medical, social and economic significance. ARCHITECT c4000 Clinical Chemistry Analyzer –
Abbott Diagnostics Inc., made in USA). Low-Density
Very recently, a number of studies have validated the
Lipoprotein cholesterol (LDL-C) was calculated using
Visceral Adiposity Index (VAI) to be a reliable and
the ‘Friedewald formula’. Individuals were
valuable indicator of visceral fat distribution and
considered to have metabolic syndrome having at least
function. It also correlates well with the degree of
three or more of the criteria (as determined by the
insulin resistance.10 The Visceral Adiposity Index
American Heart Association/National Heart, Lung,
(VAI) is a simple, gender-based mathematical formula
and Blood Institute Scientific Statement)11, and were
comprising both anthropometric (body mass index,
categorized.
i.e., BMI and waist circumference) and biochemical
parameters (serum triglycerides and HDL cholesterol Visceral Adiposity Index (VAI) was calculated by the
levels). It does not require any complex investigation. following formula:10
89
For males: while among 92 women, 31 had metabolic syndrome

VAI = [WC/39.68 + (1.88 × BMI) × (TG/1.03) × (1.31/ (Table-I), as determined by the anthropometric and
HDL-C)] biochemical parameters, based on the criteria of the
For females: American Heart Association/National Heart, Lung,
VAI = [WC/36.58 + (1.89 × BMI) × (TG/0.81) × (1.52/ and Blood Institute Scientific Statement.11 Then study
HDL-C)] subjects were further evaluated by VAI. Sensitivity
and specificity of VAI in detection of metabolic
Here, WC or waist circumference is expressed in cm, syndrome in male study subjects were 83.2% and
BMI in kg/m2, serum TG and HDL-C in mg/dl. 70.3%, respectively, while in female study subjects
Then VAI was evaluated as a tool to predict metabolic 80.1% and 70.5% respectively (Table-II). Receiver
syndrome for each study subject. Receiver operating operating characteristic (ROC) curve analysis showed
characteristic (ROC) curves were plotted to assess the that the optimal cutoff value of VAI in male study
performance of (VAI) in prediction of metabolic subjects was 2.16, and area under the curve (AUC)
value was 0.907; those indicated that VAI is a good
syndrome by gender. The power of metabolic
predictor of metabolic syndrome in adult males.
syndrome prediction was quantified by the area under
(Table-II, Fig. 1). Similarly, in female study subjects,
the curve (AUC) with 95% confidence intervals, i.e., a
the optimal cutoff value was 2.25, and area under the
larger AUC reflecting better predictive accuracy.
curve (AUC) value was 0.918; those also indicated
All statistical analyses were conducted using SPSS that VAI is a good tool for prediction of metabolic
version 22.0. for Windows (SPSS, Chicago, IL, USA). syndrome in adult females (Table-II, Fig. 2).
The difference was considered statistically
significant at P value <0.05 based on a 2-sided Table-I: Presence of metabolic syndrome among the
probability. This study was approved by the study subjects (n=200)
Institutional Review Board (IRB) of Bangabandhu
Sheikh Mujib Medical University (BSMMU), Dhaka, Sex Metabolic Syndrome
Bangladesh. Yes (%) No (%) Total
Male 63 (31.5%) 45 (22.5%) 108
RESULTS
Female 31 (15.5%) 61 (30.5%) 92
The mean age of the study participants was 42.4±5.2
years. Among 108 men, 63 had metabolic syndrome, Total 94 (47%) 106 (53%) 200
Table-II: Performance of Visceral Adiposity Index (VAI) to predict metabolic syndrome
Cut-off Points Sensitivity (%) Specificity (%) AUC (95% CI) P value
Men Women Men Women Men Women Men Women Men Women
2.16 2.25 83.2 80.1 70.3 70.5 0.907 0.912 <0.001S <0.001S
S=significant
Fig. 1: Receiver Operating Characteristic (ROC) Curve Fig. 2: Receiver Operating Characteristic (ROC) Curve
for Visceral Adiposity Index (VAI) in men. for Visceral Adiposity Index (VAI) in women.
90
DISCUSSION study is expected to help clinicians diagnose

The present study demonstrated the utility of VAI as metabolic obesity even in normal-weight individuals
a simple but effective marker in detection of quickly and conveniently.
metabolically obese but normal-weight phenotype
It may be mentioned that similar studies were done
among Bangladeshi adults. To our knowledge, this
in the same hospital setting to predict metabolic
is the first report on VAI that it has a high rate of
syndrome using ‘lipid accumulation product’ and
accuracy for prediction of metabolic syndrome in
‘triglycerides and glucose index’, which showed that
Bangladeshi healthy men and women.
people having normal weights could be metabolically
Amato et al. studied on 1,764 Italian patients and obese and are at risk of diabetes mellitus or
reported optimal VAI cut-off points ranging from 1.92 cardiovascular diseases or other related
to 2.52 based on different age group,12 while Baveicy complications.19,20 Our present study reinforces that
et al. found the optimal cut-off points for VAI 4.11 individuals should be assessed early and periodically
(AUC: 0.82; 95% CI: 0.81–0.84) in men and 4.28 (AUC: and by using VAI, clinicians can detect metabolic
0.86; 95% CI: 0.85–0.87) in women to prediction of syndrome in a simple way, counsel their patients to
metabolic syndrome in 10,000 Iranian people.13
consider lifestyle interventions, and thereby prevent
Pekgor et al. reported a cut-off value of VAI in
a significant amount of morbidity and mortality.
predicting metabolic syndrome 2.2 as they studied
on 92 overweight and obese Turkish individuals.14 One of the limitations of the present study was its
Roriz et al. studied on 191 adults and elderly small sample size, due to time constraint and limited
Brazilians and found the cut-off value 1.24 to 1.45 budget; another one was being a single-centre study
(sensitivity e”76.9%, specificity e”61.1) in men and in an urban area. Besides, selection of the study
1.46 to 1.84 (sensitivity and specificity e”66.7) in subjects was purposive following convenient
women as well as a higher AUC i.e., 0.83 (CI: 0.705– sampling technique. Therefore, drawing conclusion
0.955) and 0.71 (CI: 0.566–0.856) in men and women for a general population from the study results would
respectively. 15 Joshi et al. investigated 3,329 be challenging. Moreover, the study design (cross-
asymptomatic and healthy Gujarati Indian adults and sectional) limits observation on the mechanism of
the results reported that VAI had the best AUC (0.856) visceral adiposity in metabolic syndrome or
for metabolic syndrome.16 According to Li et al., VAI assessment of the outcomes, which could be obtained
showed the best diagnostic value for metabolic from a prospective cohort study.
syndrome in men (ATPIII criterion: AUC 0.849, 95%
CI 0.812–0.886; IDF criterion: AUC 0.792, 95% CI CONCLUSION
0.739–0.844) in a Chinese population.17 Štìpánek et Our data suggest that there is a significant prevalence
al. reported a cut-off value of 2.37, with a sensitivity of metabolic syndrome in apparently healthy
of 0.86 and a specificity of 0.78, as they studied on Bangladeshi people and the Visceral Adiposity Index
783 Czech individuals and concluded that VAI may (VAI) is a simple, accessible, and effective tool to
provide a better estimation of subclinical predict metabolic syndrome in those apparently
atherosclerosis.18 healthy adults. However, a large-scale study involving
The result of our study was compared and found more multicentre both in rural and urban settings is
or less in agreement with that of above-mentioned recommended to reproduce the findings of this study
studies. However, we found only few studies to and make it generalizable to the reference population.
support our results as because very limited number REFERENCES
of studies have been conducted across the globe. Since 1. Tchernof A, Després JP. Pathophysiology of human
no previous studies were found in our country to visceral obesity: an update. Physiol Rev.
compare with our findings, it is still convincible with 2013;93(1):359-404.
our results that the study was an appropriate one
2. Freitas Lima LC, Braga VA, do Socorro de França
because of its simple mathematical calculations for
Silva M, Cruz JC, Sousa Santos SH, de Oliveira
clinical use, cost-effectiveness, and accessibility (with Monteiro MM, et al. Adipokines, diabetes and
minimum laboratory facilities of a resource-poor atherosclerosis: an inflammatory association. Front
country like Bangladesh). The result of the present Physiol. 2015;6:304.
91
3. Neeland IJ, Poirier P, Després JP. Cardiovascular 12. Amato MC, Giordano C, Pitrone M, Galluzzo A.
and metabolic heterogeneity of obesity: clinical Cut-off points of the visceral adiposity index (VAI)
challenges and implications for management. identifying a visceral adipose dysfunction
Circulation. 2018;137(13):1391-1406. associated with cardiometabolic risk in a Caucasian
Sicilian population. Lipids Health Dis. 2011;10:183.
4. Ruderman N, Chisholm D, Pi-Sunyer X, Schneider
S. The metabolically obese, normal-weight 13. Pekgor S, Duran C, Berberoglu U, Eryilmaz MA.
individual revisited. Diabetes. 1998;47(5):699-713. The role of visceral adiposity index levels in
predicting the presence of metabolic syndrome and
5. Pajunen P, Kotronen A, Korpi-Hyövälti E, Keinänen-
insulin resistance in overweight and obese patients.
Kiukaanniemi S, Oksa H, Niskanen L, et al.
Metab Syndr Relat Disord. 2019;17(5):296-302.
Metabolically healthy and unhealthy obesity
phenotypes in the general population: the FIN-D2D 14. Baveicy K, Mostafaei S, Darbandi M, Hamzeh B,
Survey. BMC Public Health. 2011;11:754. Najafi F, Pasdar Y. Predicting metabolic syndrome
by visceral adiposity index, body roundness index
6. Goossens GH. The metabolic phenotype in obesity:
and a body shape index in adults: a cross-sectional
fat mass, body fat distribution, and adipose tissue study from the Iranian RaNCD cohort data. Diabetes
function. Obes Facts. 2017;10(3):207-15. Metab Syndr Obes. 2020;13:879-87.
7. Lee SH, Ha HS, Park YJ, Lee JH, Yim HW, Yoon KH, 15. Roriz AK, Passos LC, de Oliveira CC, Eickemberg
et al. Identifying metabolically obese but normal- M, Moreira Pde A, Sampaio LR. Evaluation of the
weight (MONW) individuals in a nondiabetic accuracy of anthropometric clinical indicators of
Korean population: the Chungju Metabolic disease visceral fat in adults and elderly. PLoS One.
Cohort (CMC) study. Clin Endocrinol. 2014;9(7):e103499.
2011;75(4):475-81.
16. Joshi H, Shah K, Patel P, Prajapati J, Parmar M, Doshi
8. Hashemipour S, Esmailzadehha N, Hamid H, Oveisi D, et al. Novel indexes for diagnosing metabolic
S, Yakhchaliha P, Ziaee A. Association of metabolic syndrome in apparently healthy Gujarati Asian
syndrome components with insulin resistance in Indians: a cross-sectional study. QJM.
normal weight population: the Qazvin Metabolic 2016;109(11):717-22.
Diseases study. J Endocrinol Invest.
17. Li R, Li Q, Cui M, Yin Z, Li L, Zhong T, et al. Clinical
2015;38(10):1111-5.
surrogate markers for predicting metabolic
9. Ding C, Chan Z, Magkos F. Lean, but not healthy: syndrome in middle-aged and elderly Chinese. J
the ‘metabolically obese, normal-weight’ Diabetes Investig. 2018;9(2):411-8.
phenotype. Curr Opin Clin Nutr Metab Care. 18. Štìpánek L, Horáková D, Cibièková ¼, Vaverková
2016;19(6):408-17. H, Karásek D, Nakládalová M, et al. Can visceral
10. Amato MC, Giordano C, Galia M, Criscimanna A, adiposity index serve as a simple tool for
Vitabile S, Midiri M, Galluzzo A; AlkaMeSy Study identifying individuals with insulin resistance in
Group. Visceral adiposity index: a reliable indicator daily clinical practice? Medicina (Kaunas).
of visceral fat function associated with 2019;55(9):545.
cardiometabolic risk. Diabetes Care. 2010;33(4):920- 19. Tabassum M, Mozaffor M, Rahman MM, Huda RM.
2. Triglycerides and glucose index as potential marker
11. Grundy SM, Cleeman JI, Daniels SR, Donato KA, of metabolic syndrome. Int J Hum Health Sci
Eckel RH, Franklin BA, et al. Diagnosis and (IJHHS). 2021;5(1):85-9.
management of the metabolic syndrome: an 20. Tabassum M, Mozaffor M, Rahman MM, Huda RM.
American Heart Association/National Heart, Lung, Lipid accumulation product: an effective obesity
and Blood Institute Scientific Statement. index to predict metabolic syndrome. J Bangladesh
Circulation. 2005;112(17):2735-52. Coll Phys Surg. 2022;40(1):5-9.
92
Original Article
Risk Assessment of Coronavirus Disease (COVID-
19) Transmission among Physicians Working at a
COVID-dedicated Tertiary-care Hospital
Choudhury AY1, Sarkar NK2, Sobuj MR3, Biswas S4, Roy M5, Uddin JM6, Hamid MA7
ABSTRACT
Background and aims: In the earlier stage of pandemic, a sizeable number of physicians and
other healthcare workers were infected with SARS-CoV-2. The aim of this study was to
assess the factors associated with the risk of SARS-CoV-2 infection among physicians working
at a COVID-dedicated tertiary care hospital, within and outside the medical workplace.
Methods: This case control study was conducted among the physicians and surgeons working
at different departments of Mugda Medical College and Hospital and undergone different
pattern of exposure to COVID patients within the period of 20 April, 2020 and 20 July, 2020.
Respondents were queried regarding job description, workplace exposures, respiratory
protection, hospital policy of disease prevention, and extra-occupational activities during
duty period. Chi-square test was done and odds ratios for physicians’ infection were calculated.
A p-value <0.05 was considered as statistical significant.
Results: Increased risk of SARS-CoV-2 infection in physicians was associated with the use
of mobile phone during duty hour (OR, 15, 95% confidence interval 1.971 to 121.905,
p=0.001), and breech of PPE during doffing (OR, 2.52, 95% confidence interval 0.821 to
7.76, p=0.099). Extra-occupational risk factors included contact with known COVID patient
(OR, 5.735, 95% confidence interval 2.072 to 15.872, p=<0.001), and visit any gathering
(OR, 1.076, 95% confidence interval 0.412 to 2.81, p=0.881). Physicians worked in roster
group (50%) and round group (34.38%) were mostly infected than other facilities.
Conclusion: COVID-19 transmissions to physicians was associated with exposure at workplace,
breech in PPE during doffing, use of device during round/roster period, extra-occupational
exposure to known COVID patients outside the hospital, and visit any gathering. Close monitoring
of infection control measures in workplace and increase awareness of the risks of outdoor
activities in pandemic situation, may reduce the incidence of infection among physicians.
Keyword: COVID, Transmission Risk, Physicians, Tertiary-care Hospital.
Mugda Med Coll J. 2022; 5(2): 93-97
1. Dr. Adnan Yusuf Choudhury, Associate Professor, INTRODUCTION

Department of Respiratory Medicine, Mugda Medical While the COVID-19 pandemic continues unabated,
College, Dhaka
healthcare workers (HCW) at the forefront are in
2. Dr. Nirmal Kanti Sarkar, Assistant Professor, Department
of Respiratory Medicine, Mugda Medical College, Dhaka contact with and caring for COVID patients are
3. Dr. Mofizur Rahman Sobuj, Medical Officer, Department among the high risk groups in terms of disease
of Anesthesiology, Mugda Medical College Hospital, Dhaka transmission. 1-3 Nosocomial transmission remains
4. Dr. Sushanta Biswas, Medical Officer, Department of
to cause anxiety in healthcare professionals who are
Paediatrics, Mugda Medical College Hospital, Dhaka
5. Dr. Moumita Roy, Junior Consultant, Department of struggling with many factors as excessive working
Obstetrics & Gynaecology,Shaheed Suhrawardy Medical hour, psychological stress, extreme fatigue,
College Hospital, Dhaka occupational burnout and stigma.4 Direct contact and
6. Dr. Jalal Mohsin Uddin, Assistant Professor, Department
aerosol generating procedures constitute the highest
of Respiratory Medicine,National Institute of Diseases of
the Chest and Hospital, Dhaka risk in terms of contamination, especially in
7. Dr. Md. Abdul Hamid, Assistant Professor, Department departments with confirmed or suspected COVID-19
of Dermatology, Mugda Medical College, Dhaka patients. 5 The protection of HCW’s is one of the most
Address of correspondence: Dr. Adnan Yusuf Choudhury,
critical points in dealing with the pandemic.
Associate Professor, Department of Respiratory Medicine,
Mugda Medical College, Dhaka. E-mail: choudhury Therefore, determining the dynamics of nosocomial
[email protected] transmission within the group of HCW’s is of great
93
importance in preventing nosocomial outbreaks and calculated for all exposures. Statistical package of
protecting HCW’s from infection. social sciences (SPSS) version 23.0 was used for
statistical analysis of data.
The study aimed to investigate the incidence of
nosocomial transmission and the factors affecting the Ethical clearance was obtained from Institutional
transmission in physicians working in a COVID Review Board (IRB) of Mugda Medical College to
dedicated tertiary care hospital in Bangladesh. undertake the current study. According to Helsinki
Declaration for Medical Research involving Human
METHODS Subjects 1964, all the participants were informed
This case control study was conducted among the about the study design and the right of the
physicians and surgeons working at different participants to withdraw themselves from the research
departments of Mugda Medical College and Hospital at any time, for any reason.
and undergone exposure to COVID patients while
delivering treatment at the same hospital setting from RESULTS
20th April 2020 (date of operating as a COVID- This case-control study included total 92 physicians
dedicated hospital) to 20th July 2020. Data were worked at Mugda Medical College Hospital between
collected using a semi-structured questionnaire the period from 20 April, 2020 (date of operating as a
which was filled-up by the individual respondent. COVID-dedicated hospital) and 20 July, 2020. Among
them, 32 were case, and 60 control. Case and control
Respondents were categorized into three groups – (1)
were similar demographically. Overall, the mean age
diagnosed with laboratory confirmed COVID-19
of the case was 38.28 years and that of control was
(“cases”), (2) had experienced an illness suspicious
40.35 years. Sixty eight percent respondents were male
for COVID-19 that was not laboratory-confirmed
in case group and 63% in control group (Table-1).
(“possible cases”), and (3) had remained healthy
Most of them had no comorbidities (65.63% in case
while continuing to work (“controls”). Laboratory
group and 83.33% in control group). Half of the cases
confirmed COVID-19 was defined as report of a
were from roster group, followed by round group
polymerase chain reaction (PCR) test detecting severe
(34.38%). Those who were engaged in cabin round
acute respiratory coronavirus virus 2 (SARS-CoV-2).
and emergency department, were most commonly
Cases and possible cases were asked the date of
infected (31.25% and 28.13% respectively)
symptom onset and requested to report their exposures
during the 14 days prior to symptom onset. Controls
were asked to complete the questionnaire with respect Table-I: Demography
to the 14 days prior to survey completion. A 14-day
exposure window was chosen to correspond with Characteristics Cases (n=32) Control (n=60)
the incubation period of SARS-CoV-2.We collected Age, mean (±SD) 38.28 (±7.52) 40.35 (±7.76)
demographic data followed by questions about Sex
exposures to different healthcare settings (cabin/ Male 22 (68.75%) 38 (63.33%)
ward round, cabin/ward roster, ICU/HDU, Female 10 (31.25%) 22 (36.66%)
emergency department, triage room, laboratory, Type of job
radiology department, and medical college/hospital Round group 11 (34.38%) 24 (40.00%)
control room), activities outside the workplace, and Roster group 16 (50.00%) 28 (46.67%)
institutional policies regarding the use of PPE. Administrative 1 (3.13%) 6 (10.00%)
Respondents were asked about specific exposures Others 4 (12.50%) 2 (3.33%)
and respiratory protection used during the care of Place of work
such patients. Disposable surgical mask, KN95, N95, Cabin 10 (31.25%) 25 (41.67%)
N99, FFP2, and FFP3respirators (new or reused), Ward 4 (12.5%) 14 (23.33%)
powered air-purifying respirators (PAPRs), and Emergency 9 (28.13%) 12 (20.00%)
reusable elastomeric respirators were considered Triage room 1 (3.13%) 3 (5.00%)
respirator-level protection. ICU 3 (9.38%) 6 (10.00%)
Descriptive statistics included mean and standard Operation theatre 1 (3.13%) 0
deviation for age, and percentage and frequencies for Radiology 2(6.25%) 0
categorical variables. Pearson c2 test was done for Pathology/Microbiology 2(6.25%) 0
calculation of continuous and categorical variables. Comorbidities
Odds ratios with 95% confidence intervals with Yes 11 (34.38%) 10 (16.67%)
respect to respondents infected with COVID-19 were No 21 (65.63%) 50 (83.33%)
94
Most of the respondents used reused mask (75% in 2.072 to 15.872,p =<0.001). Visiting any gathering was
case group and 81.6% in control group). In case group, another factor of infection outside hospital (odds ratio
KN95 was the most commonly used respirator 1.076, 95% confidence interval 0.412 to 2.81,p= 0.881).
(46.88%), followed by N95 (40.63%). In control group,
N95 and N99 was mostly used (38.33%). In both
groups, respondents used double masks i.e. respirator Table-IV: Odds Ratios associated with occupational
plus surgical mask . factors and extra-occupational exposures
Variables OR all cases P
Table-II : Respiratory protection utilized (n=32) value
Cases Control Occupational factors
n=32 n=60 Occupational factors
Mask type Institutional training on 0.429 0.058*
(Respirators)
donning/doffing
KN95 15 (46.88%) 13 (21.67%)
N95 13 (40.63%) 23 (38.33%) (95% CI) (0.177-1.039)
N99 3 (9.38) 23 (38.33%) Use of full PPE on duty 0.925 0.907
Surgical mask+ 23 (71.87) 47 (78.33%) (95% CI) (0.249-3.430)
respirators
Any breech of PPE 2.524 0.099
Surgical mask only 0 1 (1.67%)
Pattern of mask used during doffing
Single time 8 (25.00%) 11 (18.33%) (95% CI) (0.821-7.760)
Reused 24 (75%) 49 (81.67%) Use of mobile phone on 15.00 0.001*
duty time
Most of the cases were symptomatic (73.3%), only 4
(95% CI) (1.971-121.9)
cases (12.5%) needed hospitalization .
Extra-occupational exposure
Contact with known 5.735 0.000*
Table-III: Clinical presentation and hospitalization status
COVID patient
Cases (n=32) (95% CI) (2.072-15.872)
Number Percent Visit any gathering 1.076 0.881
Clinical presentation (95% CI) (0.412-2.81)
Symptomatic 22 73.3 Use of public transport 0.714 0.596
Asymptomatic 8 26.7 (95% CI) (0.205-2.489)
Hospitalization status
Hospitalized 4 12.5 DISCUSSION
Not hospitalized 28 87.5 This case control study conducted at a COVID-
dedicated tertiary-care hospital may put some
Use of mobile phone during duty hour was associated valuable inputs for risk assessment of SARS-CoV-2
with increased rate of COVID infection (odds ratio
infection among physicians and other healthcare
15,95% confidence interval 1.971 to 121.905,p = 0.001).
workers at workplace and outside of hospital setting.
Those who notified any breech of PPE during doffing
This may also help policymakers to formulate
were mostly infected (odds ratio 2.524,95% confidence
guidelines to reduce infection in healthcare workers
interval 0.821 to 7.76,p=0.099). Institutional training
in different healthcare settings during COVID
on donning and doffing was protective against
pandemic.
acquiring disease (Table-IV).
Contact with known COVID patient was the most We observed that physician infection was more
common factor of infection outside the healthcare common among those who did their duty in cabin
setting (odds ratio 5.735, 95% confidence interval block and emergency department of our hospital.
95
Relatively lower incidence of infection was noted regarding individual patient’s condition. It is also
among those who worked in ICU, which is a potential used to follow health-related news, following updated
place of aerosol generating procedures (e.g. high flow guidelines, photography, sharing medical documents,
nasal cannula, CPAP, BiPAP, mechanical ventilators conducting telecommunications etc. In this study, it
etc.). This is probably due to more cautious practice was observed that the use of mobile phone in duty
of mask and PPE in this area. Round and roster group hour was associated with higher odds of infection
doctors were mostly infected, probably due to among physicians. They carry the device during ward
prolonged contact with COVID patients. Lentz R et or cabin round, make phone calls while close to
al. in their study also observed that nosocomial COVID positive patients, may often bring it to the
transmission to healthcare professionals were more duty room without proper disinfection. Mobile phone
common during routine contact with COVID-19 is a particular high risk object, which can directly
patients than during aerosol generating procedures.6 come in contact with the face and mouth, while talking
Use of medical mask is paramount in infection over phone, and a potential vehicle of transmission
prevention. 7-9 The World Health Organization of infection, even if hands are properly disinfected.
recommends medical masks for respiratory protection Breech in mobile phone hygiene is a potential source
during non-aerosol generating procedures, whereas of SARS-CoV-2 transmission.13-16
the US CDC advised for respirators.10,11 In our study, In our study, it was observed that some physicians
we observed that most of the respondents (both case contacted the disease outside the workplace. There
and control) used respirator and surgical mask for were higher odds of disease acquisition among those
better protection. KN95 and N95 was the most
who gave history of contact with known COVID
commonly used in case group, whereas N95 and N99
patients at home or elsewhere (e.g. sick relatives).
in control group. As we have institutional policy on
Visiting gathering i.e. grocery, market, mosque etc.
reusing masks, it was commonly practiced by all.
was another factor of extra-workplace infection. Same
We also observed that institutional training on observation was found in other study.6 Surprisingly
donning/doffing and use of full PPE during duty lower odds of infection were observed among those
hour was associated with lower odds of nosocomial who used public transport, although most of the
infection. At the outset of the pandemic, Directorate respondents used hospital arranged service or
General of Health Services (DGHS) arranged a training personal transportation.
program for the healthcare workers at Mugda Medical
Our study had several limitations. First, the sample
College Hospital on infection control and donning/
size was too small; hence the result may not depict
doffing. This had tremendous impact on infection
prevention among physicians at workplace. This type the real scenario. Second, the cohort included the
of training has a great impact in lowering physicians only. If sample design could include all
transmission of infection among healthcare the healthcare professionals (i.e. nurses, technicians,
workers.7Physicians, who noted any breech in PPE ward boy etc.) we could estimate the risk factors more
during doffing, got infected. Though the hospital precisely. Third, the study duration was only three
authority arranged training for all, a large bulk of months at the earlier period of pandemic. Extending
physicians, especially who were deputed on later the study period with prolonged vigilance might
period, could not be trained and they were infected clarify the risk factors. Fourth, we may have many
more. Many centers in different countries recruit PPE asymptomatic cases that were undiagnosed and may
observers, whonotify any breech during doffing. This underscore the total cases and risk factors.
can reduce the rate of contamination. Studies showed The strength of this study is that we recruited the
that appropriate PPE, familiarity with it’s use, and subjects in the earlier phase of disease in our country
dedicated PPE observers may reduce infection rate at to evaluate the risk factors of infection in hospital
workplace.6 setting and to alleviate the further risk by
Many physicians, especially junior doctors, use implementing the study result. Controls were matched
mobile phone during duty hour to communicate with as closely as possible to cases. Data on exposure and
others. They are often bound to do this as the senior respiratory protection were collected in detailed
colleagues and administrative persons ask them manner.
96
CONCLUSION 2. JAMA 2021;325(10):998–999. doi:10.1001/

This study enlightens our knowledge regarding jama.2021.1505.
various factors associated with physician infection 8. Bartoszko JJ, Farooqi MAM, Alhazzani W, Loeb M.
with SARS-CoV-2 in hospital as well as outside of Medical masks vs N95respirators for preventing
workplace settings. It was observed that physicians COVID-19 in healthcare workers: a systematic
not exposed to potential aerosol-generating review and meta-analysis of randomized trials.
procedures were equally or more infected and a big Influenza &Other Respir Viruses 2020;14:365–373.
portion of them acquired disease from outside of 9. Wang X, Pan Z, Cheng Z. Association between 2019-
hospital environment. Mobile phone using is an nCoV transmission and N95 respirator use. J Hosp
important risk factor. Proper uses of PPE, careful Infect 2020;105:104–105.
practice of hand hygiene, vigilance during outside 10. Rational use of personal protective equipment for
works are all coronavirus disease (COVID-19) and considerations
important measures to mitigate physician infection. during severe shortages. World Health Organization
website. http://www.who.int/publications-detail/
The results of this study have an impact on healthcare
rationaluse-of-personal-protective-equipment-for-
workers and public health policy makers to reduce
coronavirus-disease-(covid-19)-and-considerations-
infection now and in future. during-severe-shortages. Accessed August 21, 2021.
REFERENCES 11. Interim infection prevention and control
1. World Health Organization. Risk assessment and recommendations for patients with suspected or
management of exposure of health care workers in confirmed coronavirus disease 2019 (COVID-19) in
the context of COVID-19. Interim guidance, 2020. health care settings. Centers for Disease Control
and Prevention website. http://www.cdc.gov/
2. Wu Z, McGoogan JM. Characteristics and important
coronavirus/2019-ncov/hcp/infection-control-
lessons from the Coronavirus Disease 2019
recommendations.html.Published February 11,
(COVID-19) outbreak in China: Summary of a report
2020. Accessed August 21, 2021.
of 72314 cases from the Chinese Center for Disease
Control and Prevention. JAMA 2020;323. 12. Chu DK, Akl EA, Duda S, et al. Physical distancing,
face masks, andeye protection to prevent person-
3. Belingheri M, Paladino ME, Riva MA. COVID-19: to-person transmission of SARS-CoV-2and COVID-
health prevention and control in non-healthcare 19: a systematic review and meta-analysis.
settings. Occup Med 2020;70:82-83. Lancet2020;395:1973–1987.
4. Koh D. Occupational risks for COVID-19 infection. 13. Panigrahi SK, Pathak VK, Kumar MM, et al. Covid-
Occup Med 2020;70:3-5. 19 and mobile phone hygiene in healthcare settings.
5. CDC COVID-19 Response Team .Characteristics of BMJ Global Health 2020;5:e002505
Health Care Personnel with COVID-19 – United 14. Jayalakshmi J, Appalaraju B, Usha S. Cellphones as
States, February 12 – April 9, 2020. MMWR Morb reservoirs of nosocomial pathogens. J Assoc
Mortal Wkly Rep 2020;69:477-81. Physicians India 2008;56:388–9.
6. Lentz RJ, Colt H, Chen H, et al. Assessing 15. Chao Foong Y, Green M, Zargari A, et al. Mobile
coronavirus disease 2019 (COVID-19) transmission phones as a potential vehicle of infection in a
to healthcare personnel: The global ACT-HCP case- hospital setting. J Occup Environ Hyg 2015;12:
control study. Infection Control & Hospital Epidemiology D232–5.
2021;42:381-387.
16. Pal S, Juyal D, Adekhandi S, et al. Mobile phones:
7. Brooks JT, Butler JC. Effectiveness of mask wearing reservoirs for the transmission of nosocomial
to control community spread of SARS-CoV- pathogens. Adv Biomed Res 2015;4:144.
97
Review Article
Transforming Health Professions Education for

Universal Health Coverage: Challenges and
Recommendations for Low-Resource Countries
Mozaffor M1, Nurunnabi ASM2, Haseen F3, Sultan MT4, Saha S5
ABSTRACT
Health workforce challenge persists as a critical issue in achieving universal health coverage
(UHC) goals globally, especially in resource-poor countries. Evidence shows that health
professions education and training is primarily clinical and curricular; however, it is somewhat
deviated from the needs of the health system. In low-resource countries like Bangladesh, in the
context of limited financial realities, to achieve global health goals and maximize opportunities
for employment and economic development a paradigm shift is needed in health professions
education, workforce development and healthcare services of the country from its primary to
the tertiary level of health care respectively. There is a critical need to shift towards fair,
equitable, need-based employment policy that is compatible with the overall growth of the
health economy, and that acknowledges the role of both public and private sector in education
and training. This review paper tried to emphasize the importance and implications of a
paradigm shift in the sector. It argues the need for a 21st century framework for health
professions education. This framework should represent a more satisfactory interface between
supply and demand for health professionals, in line with the current need to meet the targets
of universal health coverage, rational employment in healthy sector and economic development.
Keywords: Health workforce, universal health coverage, health professions education
Mugda Med Coll J. 2022; 5(2): 98-103
INTRODUCTION However, around the world, health systems, and the

Universal health coverage (UHC) is included in the populations they serve are facing the same growing
Sustainable Development Goals (SDGs) as one of the challenge of lack of access to comprehensive,
targets and is being advanced by the World Health appropriate, timely, quality health services.2 Low-
Organization (WHO) as an important concept.1 income countries with larger populations are
especially experiencing serious shortages in meeting
1. Dr. Miliva Mozaffor, Assistant Professor, Department of
Biochemistry, Medical College for Women & Hospital,
health workforce requirements for universal health
Uttara, Dhaka-1230. coverage.2-5 The current demand shortage of millions
2. Dr. Abu Sadat Mohammad Nurunnabi, Assistant of health workers is expected to double by 2030, with
Professor, Department of Anatomy, OSD, Directorate
General of Health Services (DGHS), Dhaka-1212. the largest shortages predicted to occur in the regions
3. Dr. Fariha Haseen, Associate Professor, Department of of East Asia and the Pacific (8.3 million) and South
Public Health and Informatics, Bangabandhu Sheikh Mujib Asia (3.2 million), accentuating the global imbalances
Medical University (BSMMU), Dhaka-1000.
4. Dr. Mohammad Tipu Sultan, Medical Officer, Department in the distribution of health workers. In low-income
of Forensic Medicine & Toxicology, Dhaka Medical College, countries (LICs), for example, both the demand for
Dhaka-1000. and the supply of health workers are projected to
5. Dr. Shilpi Saha, Associate Professor, Department of
Obstetrics & Gynaecology, Medical College for Women & remain significantly below the needs-based threshold.
Hospital, Uttara, Dhaka-1230. As a result, these countries will likely face shortages
Address of correspondence: Dr. Miliva Mozaffor, Assistant
of health workers needed to provide basic health
Professor, Department of Biochemistry, Medical College for
Women & Hospital, Uttara, Dhaka-1230. Email: services and unemployment of health workers due to
[email protected] the limited capacity to employ the available supply
98
of workers (insufficient demand).5-7 Compared to the of the production of the health professionals every
health workers’ needs-based projections, the scenario year. However, several demerits were also observed
is even more troublesome for our country, relating to this mushroom growth. Such mushroom
Bangladesh.5,7 growth of medical, dental, nursing and other health
institutions in the country has undermined the quality
The Government of Bangladesh (GoB) aspires to
of health professions education to a great extent.8,12-
achieve Sustainable Development Goals (SDGs) by 14 Concerned authorities are taking steps to improve
2030. This means that the government is aiming to
the situation; however, the owners of these
reach the targets set for SDG 3 (Ensure healthy lives
institutions also need to put in their efforts to improve
and promote wellbeing for all at all ages) by 2030 that
qualities in terms of infrastructure development,
includes the attainment of universal health coverage
enhancement of teaching and training facilities.8,12
(UHC).5,7 To pave the way, GoB has approved the 4th
Health, Population and Nutrition Sector Support CHALLENGES IN HEALTH PROFESSIONS
Programme (HPNSP) (2017–2022) to ensure access EDUCATION
to quality and equitable health care in a healthy The education system is an indispensable component
environment for all that necessitates a competent and of the health system, and the provision of educational
committed health workforce, for which quality and services ensures the constant supply of an educated
standard health professional education and training and motivated workforce. Countries (including
is required.5,7,8 In this context, a new paradigm Bangladesh) that are aiming for universal health
around the idea of transformative health professions coverage (UHC) for all at an affordable cost need to
education is emerging and promotes the need for ensure adequate supply of the right categories of
transformation in health care systems, in the roles of workforce in the right places at the right time.9,15-17
health professionals and in the design of health However, low-resource countries encounter many
professions education. This review paper tried to problems in relation to health workforce development
emphasize the importance and implications of a through health professions education. Some of the
paradigm shift in the sector. issues are dynamic and interrelated. We tried to
categorize these problems under following headings:
HEALTH PROFESSIONS EDUCATION ON MOVE
The UHC agenda, with the underlying goal that 1. Balancing between shortage in health workforce and
everyone should have access to the quality health selecting appropriate candidates for health professions
services they need, without financial compromise, education: Like many other countries, Bangladesh
brings attention to three universal needs of all health is also experiencing a health workforce crisis. The
systems: financing; services; and populations. UHC recent COVID-19 pandemic is recognized as the
offers a compelling opportunity to better align the breaking point for many health workers who were
demand for health services and the demand for health already in short supply. Healthcare workers
workers with population health needs. However, the called for urgent mobilization to address
alignment of demand and need around UHC must find shortages, burnout, and backlog issues, which
a tangible link to the supply of health workers.5-7,9-11 became a focus of concern in the health sector.
There has been significant increase of the number of However, this is also important that healthcare
health professional education institutions along with workers must have the profile, skills, and
number of seats in 50 years (between 1971 and 2021). behaviour that are able to create trust and
Approximately 31 times increase of the total health confidence in the population and promotes
professional education institutions (of the seven demand for quality services.9,17 Hence, to meet
professional’s categories) under the MOHFW has the shortage in a short time frame, quality in
been observed.8 The increase has been rapid since education and training should not be
2010, especially in the number of the private health compromised. In most countries the selection of
professional education institutions, mainly in the students is done based on previous academic
capital city (e.g., about 67% increase in the number of grades and a selection test. Bangladesh is also
the private sector medical colleges and about 275% not an exception to this. This might be a good
increase in the number of private sector nursing predictor of future academic performance;
institutes).8 This has resulted in an increasing trend however, it does guarantee a future professional
99
performance in the sector.9,17-20 Many countries campaigns to attract students to occupations

have changed their admission process for the with unmet needs, for example, in the fields of
selection of medical, dental and nursing primary care nursing, radiography and medical
applicants to assess their mental attitude and laboratory technology focusing on supply chain
behavioural characteristics that might be to rural health services.25,26 In some contexts,
consistent with the demands of clinical practice increased remuneration and CPD training
in near future.9,10,17 facilities are important. For community-based
and mid-level health workers when adequately
2. Ensuring competency-based education in health
supported by the health system bring about
professions: Calls have been made from different
changes and effective results in expanding
stakeholders to transform current curriculum,
coverage and improving health service equity
teaching and learning strategies to ensure that
(e.g., in remote rural areas or for low-income or
future healthcare workers have the required
vulnerable groups).24-26 As we have already
competencies for the changing burden of
experienced in our country that upazila (sub-
diseases and technological environment.17 For
district) hospitals and community clinics have
educators and policy makers in the field, desirable
shown extraordinary performances in the health
competencies must be identified and aligned with
sector.7,8
population health priorities and any identified
skills gaps.9,17 In many countries, this means a 5. Regulating education and practice: The development
shift in focus towards education and training that and activation of a regulatory framework that
prepares the workforce to deliver effective upholds accepted standards of education and
primary care and meet the increasing challenge practice is crucial at the moment. Strengthening
of noncommunicable diseases, which is also true of Bangladesh Medical & Dental Council
for Bangladesh.18-20 (BM&DC), Bangladesh Nursing Council (BNC),
State Medical Faculty (for paramedics) is essential
3. Lack of proper investment in health professions
step towards this. National health policy and a
education: A primary constraint to the development
regulatory framework should cover the regulation
of health workforces in low- and middle-income
of work in both public and private sectors,
countries is that the prevailing investment model
including education institutions, mechanisms of
for educating healthcare workers is not aligned
surveillance of professional practice and the
with universal health coverage goals.17 In many
exercise of discipline in cases of malpractice or
of those countries, like Bangladesh, insufficient,
unethical behaviour by the healthcare
inefficient, and socially unaccountable
professionals.27
investment in health professions education is a
primary barrier to building a competent health 6. Discrimination in health professions: Literature on
workforce that meets population needs.17,21-23 gender and human resources for healthcare has
demonstrated that gender discrimination and
Moreover mushrooming growth of public and
inequality also remain as barriers to entry, reentry,
private institution without proper financial,
and retention in employment systems, especially
logistic and manpower support as well quality
for female health workers in health services.
education and training may only increase the
Moreover, families and communities resist some
number rather than achieving the real goals.12
of the changes required to address discrimination
4. Proper distribution of health graduates and based on caregiver responsibilities, because the
continuing professional development: There is a interventions challenge longstanding gender
notable gap in their rural retention. Most norms, expectations, and divisions of labour
graduates relocate to urban areas following their between men and women especially in our South
period of mandatory service24,25 to undertake Asian perspective.5,7,19,28
specialty training or move into more lucrative
private practice. Thus, doctors, nurses and other RECOMMENDATIONS
healthcare workers serving rural areas tend to be Evidence showed that health professions education
less experienced, and turnover rates are high. and training is primarily clinical and curricular;
Some countries have launched targeted however, it is somewhat deviated from the needs of
100
Fig. 1: Factors associated to improvement of health professions education aligned with heath workforce management to
ensure UHC (Source: Cometto, Buchan & Dussault, 2020)9
the health system.9,10 In low-resource countries like stages of a health care worker’s career. This includes
Bangladesh, in the context of limited financial strengthening of regional and national capacity in
realities, to achieve global health goals and maximize knowledge generation and management. Quality
opportunities for employment and economic improvement of pre-service training will be
development a paradigm shift is needed in health encouraged while ensuring adequate opportunities
professions education, workforce development and for systematic in-service training. The need to carry
healthcare services of the country from its primary to out research to bridge the knowledge gaps in areas
the tertiary level of health care respectively.9,17 There
related to health workforce will be given more
is a critical need to shift towards fair, equitable, need-
emphasis.18,21,28
based employment policy that is compatible with the
overall growth of the health economy, and that Moreover, we need to develop gender equality, equal
acknowledges the role of both public and private opportunity, or affirmative action policies to address
sector in education and training. 8,17,21 Now multiple forms of gender discrimination and
coinciding with falling public health investment,
inequality in healthcare sector – in recruitment,
emergence of non-communicable diseases, and a
education and training, employment, and
spiraling demand, there has been a steady growth in
the corporatization of healthcare in recent years.8,12 workplaces.8,28
We are not against it; however, we argue for proper Reforms and paradigm shift in health professions
monitoring and quality assurance by the health watch education is not all to solve the problems in health
authorities of the country. sector. The effective management of the health
In order to transform population health outcomes, workforce is also essential, as it includes the planning
the current efforts to scale up health professions and regulation of the supplying health workers and
education must increase not only the quantity, but maintenance its stock in the pipeline, as well as health
also the quality and the relevance of the providers of professions education, recruitment, employment,
the future. A transformative approach to medical performance optimization and retention.9,17,28 A
education is needed – one that is defined by a logical hierarchy and links among different action
commitment to social responsibility and insists on fields have been identified and described (Fig. 1) to
inter-sectoral engagement to determine how students show the pathways of health workforce development
are recruited, educated, and deployed as health to provide the universal health coverage in a specified
professionals.8,17,22 population as well as the role, status, and
The pursuit of knowledge, understanding and interdependence of health professions education with
personal development will be encouraged across all other factors.9
101
Finally, we would like to say mere availability of 5. Rahman MM, Karan A, Rahman MS, Parsons A, Abe
health workforce is not sufficient to provide UHC and SK, Bilano V, et al. Progress toward universal health
meeting SDGs by 2030. Only when this available coverage: a comparative analysis in 5 South Asian
healthcare workers are equitably distributed and countries. JAMA Intern Med. 2017;177(9):1297-1305.
accessible by the population, when they possess the 6. Sripathy A, Marti J, Patel H, Sheikh JI, Darzi AW.
required competency, and are motivated and Health professional education and universal health
empowered to deliver quality healthcare that is coverage: a summary of challenges and selected
case studies. Health Aff. 2017;36(11):1928-36.
appropriate and acceptable to the sociocultural
expectations of the population, and when they are 7. Joarder T, Chaudhury TZ, Mannan I. Universal
adequately supported by the health system, we may health coverage in Bangladesh: activities,
challenges, and suggestions. Psyche (Camb Mass).
succeed theoretical coverage translate into effective
2019;2019:4954095.
service coverage.15,17
8. Nuruzzaman M, Zapata T, Rahman MM. Informing
CONCLUSION the increasing production of the health workforce
Addressing population needs for the SDGs and UHC in Bangladesh: evidence from a mapping exercise
requires making the best possible use of limited of health professional education institutions.
Bangladesh J Med Educ. 2021;12(2):30-46.
resources, and ensuring they are employed
strategically through adoption and implementation 9. Cometto G, Buchan J, Dussault G. Developing the
of evidence-based health workforce policies tailored health workforce for universal health coverage. Bull
World Health Organ. 2020;98(2):109-116.
to the national health system context at all levels, as
to reach the targets of SDGs by 2030. However, further 10. World Health Organization (WHO). Transforming
research is needed to assess the impact of such and scaling up health professionals’ education and
training. WHO Guidelines 2013, Geneva: WHO;
initiatives on the long-term retention of workers –
2013. p.21.
particularly doctors – and the adequacy of the training
offered to lower-skilled workers to effectively plug 11. Horton R. A new epoch for health professionals’
education. Lancet. 2010;376(9756):1875-7.
medical personnel gaps. Last but not the least,
systematic monitoring of program affordability and 12. Shehnaz SI. Privatization of medical education in
cost-effectiveness over time must be prioritized, Asia. South East Asian J Med Educ. 2011;5(1):18-25.
alongside efforts to disseminate all the lessons 13. Diwate A. Growth of private medical colleges in
learned to inform better practice and policy in the Maharashtra and its implications for universal
health sector. healthcare. In: Qadeer I, Saxena KB, Arathi PM. eds.
Universalising healthcare in India. Singapore:
REFERENCES Springer; 2021. p.83-102.
1. Tangcharoensathien V, Mills A, Palu T. Accelerating 14. Reynolds J, Wisaijohn T, Pudpong N, Watthayu N,
health equity: the key role of universal health Dalliston A, Suphanchaimat R, et al. A literature
coverage in the Sustainable Development Goals. review: the role of the private sector in the
BMC Med. 2015;13:101. production of nurses in India, Kenya, South Africa
2. Reddock JR. Seven parameters for evaluating and Thailand. Hum Resour Health. 2013;11:14.
universal health coverage: including supply- and- 15. World Health Organization (WHO). Delivering
demand perspectives. Int J Healthcare Management. quality health services: a global imperative for
2017;10(3):207-18. universal health coverage. Geneva: WHO, OECD,
3. Liu JX, Goryakin Y, Maeda A, Bruckner T, Scheffler World Bank; 2018. p.11-20.
R. Global health workforce labor market 16. Jha A, Godlee F, Abbasi K. Delivering on the
projections for 2030. Hum Resour Health. promise of universal health coverage. BMJ. 2016;
2017;15(1):11. 353:i2216.
4. Celletti F, Reynolds TA, Wright A, Stoertz A, Dayrit 17. Evans TG, Araujo EC, Herbst C, Pannenborg O.
M. Educating a new generation of doctors to Transforming health workers’ education for
improve the health of populations in low- and universal health coverage: global challenges and
middle-income countries. PLoS Med. 2011;8(10): recommendations. World Health Popul. 2017;17(3):
e1001108. 70-80.
102
18. World Health Organization (WHO). Regional 24. Lehmann U, Dieleman M, Martineau T. Staffing
strategic plan for health workforce development remote rural areas in middle- and low-income
in the South-East Asia region. 2007. New Delhi, countries: a literature review of attraction and
India: WHO; p.4-6. retention. BMC Health Serv Res. 2008 Jan 23;8:19.
19. Wyss K. An Approach to classifying human 25. Buchan J, Couper ID, Tangcharoensathien V,
resources constraints to attaining health-related Thepannya K, Jaskiewicz W, Perfilieva G, et al.
millennium development goals. Hum Resour Early implementation of WHO recommendations
for the retention of health workers in remote and
Health. 2004;2:11.
rural areas. Bull World Health Organ. 2013;91(11):
20. Bhuiyan SMMS, Talukder MHK, Yasmin F, Bhuiyan 834-40.
FS. Aligning the contents of curriculum of
26. Russell D, Mathew S, Fitts M, Liddle Z, Murakami-
undergraduate medical education in Bangladesh
Gold L, Campbell N, et al. Interventions for health
with health related targets of Sustainable workforce retention in rural and remote areas: a
Development Goals (SDG). Bangladesh J Med Educ. systematic review. Hum Resour Health.
2020; 11(2):21-6. 2021;19(1):103.
21. World Health Organization (WHO). Global strategy 27. Frank JR, Taber S, van Zanten M, Scheele F, Blouin
on human resources for health: workforce 2030. D; International Health Professions Accreditation
Geneva: WHO; 2016. p.10. Outcomes Consortium. The role of accreditation in
21st century health professions education: report
22. Boelen C, Pearson D, Kaufman A, Rourke J,
of an International Consensus Group. BMC Med
Woollard R, Marsh DC, et al. Producing a socially
Educ. 2020;20(Suppl 1):305.
accountable medical school: AMEE Guide No. 109.
Med Teach. 2016;38(11):1078-91. 28. Campbell J, Dussault G, Buchan J, Pozo-Martin F,
Guerra Arias M, Leone C, et al. A universal truth:
23. Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans no health without a workforce. Forum report, Third
T, et al. Health professionals for a new century: Global Forum on Human Resources for Health,
transforming education to strengthen health Recife, Brazil. Geneva: Global Health Workforce
systems in an interdependent world. Lancet. Alliance and World Health Organization; 2013. p.9-
2010;376(9756):1923-58. 12.
103
Review Article
Quality Assurance Scheme of Undergraduate
Medical Education in Medical Colleges of
Bangladesh: Past, Present and Future
Nurunnabi ASM1, Parvin S2, Rahim R3, Begum M4, Ghosh S5, Sweety AA6, Sultana D7, Jahan N8,
Muqueet MA9, Islam MM10
ABSTRACT
Improving quality of medical education is a key contributing factor to improving the quality of
healthcare. The rapid increase in number of medical colleges in Bangladesh, especially in the
private sector, makes its vital to have effective quality assurance system in place. Quality
assurance resembles a state in which medical colleges take on challenges to address different
aspects of quality in undergraduate medical education through check and balance in a methodical
approach. In 1998, the World Health Organization (WHO) supported the Center for Medical
Education (CME) and the Directorate General of Health Service (DGHS) to develop and
publish the National Guidelines & Tools for the Quality Assurance Scheme (QAS) for medical
colleges in Bangladesh. Since then that guideline has been serving as resource material and
guide for institutionalization of the QAS based on the three principles of accountability, self-
evaluation, and external peer review, with the latest revision done in 2012. At the institutional
level, the scheme was proposed to be managed by the Academic Council, Academic Coordination
Committee, the four (previously three) Phase Coordination Groups, Subject Coordinators,
and Faculty Review & Development Committee. The operational framework is based on
course appraisal, faculty development and review scheme and external review. A model of
“pair of medical colleges” was also proposed as to oversee the QAS activities of each other and
report to the National Quality Assurance Body (NQAB). This review paper aims to highlight
the history of QAS in our medical colleges, their achievements to date and challenges as well
as scopes for future improvement to enhance the quality of medical education in Bangladesh.
Keywords: Quality assurance, medical education, MBBS programme, Bangladesh
Mugda Med Coll J. 2022; 5(2): 104-109
INTRODUCTION efficient, equitable and patient-centred” measures

Quality has been part of the healthcare and policy taken by a healthcare institution to its consumers.1
discourse for nearly half a century. Improving quality Improving quality of medical education is a key
in healthcare is a complex endeavour; in modern contributing factor to improving the quality of health
medicine quality care means “safe, timely, effective, care.2,3 Undergraduate medical education system in
1. Dr. Abu Sadat Mohammad Nurunnabi, Assistant Professor, Department of Anatomy, OSD, Directorate General of Health
Services (DGHS), Dhaka.
2. Prof. Shamima Parvin, Professor and Head, Department of Biochemistry & Vice-Principal, Mugda Medical College, Dhaka.
3. Dr. Riffat Rahim, Assistant Professor, Department of Obstetrics & Gynaecology, Mugda Medical College & Hospital, Dhaka.
4. Dr. Munira Begum, Assistant Professor, Department of Community Medicine, Rangpur Medical College, Rangpur.
5. Dr. Subrata Ghosh, Assistant Professor, Department of ENT and Head-Neck Surgery, Rajshahi Medical College & Hospital, Rajshahi.
6. Dr. Afroza Akbar Sweety, Assistant Professor, Department of Virology, Dhaka Medical College, Dhaka.
7. Dr. Dahlia Sultana, Assistant Professor, Department of Endocrinology, Sir Salimullah Medical College & Mitford Hospital, Dhaka.
8. Dr. Neelima Jahan, Assistant Professor, Department of Surgery, Shaheed Suhrawardy Medical College & Hospital, Dhaka.
9. Dr. Md. Abdul Muqueet, Assistant Professor and Head, Department of Nephrology, Pabna Medical College & Hospital, Pabna.
10. Dr. Md. Mozaharul Islam, Assistant Professor and Head, Department of Forensic Medicine & Toxicology, Shaheed Syed
Nazrul Islam Medical College, Kishoreganj.
Address of correspondence: Dr. Abu Sadat Mohammad Nurunnabi, Assistant Professor, Department of Anatomy, OSD,
Directorate General of Health Services (DGHS), Dhaka. Email: [email protected]
104
Bangladesh inherited the typical features of British the doctors of tomorrow which can be achieved by
colonial education, which is still in very much on demonstrating continuous review of the
that traditional pattern. The Bachelor of Medicine and curriculum.2,4,12-15 Thus, quality assurance has
Bachelor of Surgery (MBBS) degree is a 5-year become an integral part of medical education all over
programme followed by a 1-year compulsory logbook- the world and Bangladesh is also not an exception to
based internship training.4,5 At present, there are total it. This review paper aims to highlight the history of
113 recognized medical colleges in Bangladesh, 37 of QAS in our medical colleges, their achievements to
which are public and 70 private. 6 medical colleges date and challenges as well as scopes for future
are run by the Bangladesh Armed Forces and are improvement to enhance the quality of medical
under the Ministry of Defence.6 education in Bangladesh.
Quality assurance resembles a state in which medical HISTORY
colleges take on challenges to address different The World Health Organization (WHO) has been
aspects of quality through check and balance in a actively advocating reform and improved medical
methodical approach.7 Depending on the perspective education to meet the changing needs of healthcare
of a stakeholder, educational quality can be over decades.3 In response to the increasing health
understood as fitness for purpose (educating capable workforce needs of the country, the number of
future physicians), value for money (a return on government and private medical colleges have
investment in education), perfection (focusing on zero increased in recent years. The rapid increase in
defects), exceptional (standing out as the best number of medical colleges in Bangladesh, especially
program), or transformative (focusing on the in the private sector, makes its vital to have effective
educational learning effect).2,7-9 In the UK perspective, quality assurance system in place.5,16 Towards that
quality assurance is defined as “the totality of systems, end, the WHO Bangladesh office started to support
resources, and information devoted to maintaining the Center for Medical Education (CME) and the
and improving the quality and standards of teaching, Directorate General of Health Service (DGHS) to
scholarship, and research and of students’ learning develop and publish the National Guidelines & Tools
experience”.10 Moreover, it involves “the systematic for the Quality Assurance Scheme (QAS) for medical
monitoring and evaluation of learning and teaching, colleges in Bangladesh in 1998 looking at the future
and the processes that support them, to make sure of medical education in a low resource setting. Since
that the standards of academic awards meet the then, the above-mentioned published guideline has
Expectations set out in the Quality Code, and that the been serving as resource material and guide for
quality of the student learning experience is being
institutionalization of the QAS based on the three
safeguarded and improved.” 11 The Quality
principles of accountability, self-evaluation, and
Assurance Scheme (QAS) in medical education
external peer review.4,5,16,17 The scheme has both
review the way how a medical college implements its
national and institutional organizational framework.
MBBS programme ensuring its optimum quality and The National Quality Assurance Body (NQAB) is
standard. Several authors emphasized on the need to chaired by the Director General, DGHS and the
manage the ever increasing medical knowledge Director for Center for Medical Education (CME) is
domains and increased recognition of the importance the Member Secretary.5,17,18 At the institutional level,
of imparting students with independent learning the scheme was proposed to be managed by the
skills, and demonstrate the application of knowledge, Academic Council, Academic Coordination
skills, and attitudes in the ever changing local and Committee, the four (previously three) Phase
global scenarios,3,4,12-15 which are inherent in the Coordination Groups, Subject Coordinators, and
practice of medicine. Many of our short comings in Faculty Review & Development Committee. The
those aspects have been experienced since the academic coordinator is supposed to act as an
beginning of the COVID-19 pandemics, which signify honorary member of Faculty of Medicine of the
gaps in quality of medical education and training in respective universities as per approval and consent
the country. Besides, from an accreditation of the Dean of the Faculty of Medicine of the university
standpoint, many researchers have emphasized on governing the Professional MBBS Examinations.5,16,18
lifelong learning opportunities for the students, as Proposed model of “pair of medical colleges” will be
well as cultural and social competencies required for selected for each college to oversee the QAS activities
105
of each other and report to the NQAB. The operational colleges are in place though. A latest publication from
framework is based on course appraisal, faculty the World Health Organization (WHO) has
development and review scheme and external described an overview of the NQAS and the
review.5,16,18 Besides, the student evaluation will be assessment of its implementation in medical colleges
conducted phase wise rather than subject wise,5,16-18 in Bangladesh in 2017.22 Despite limited resources
as it was previously implemented through three and manpower and expertise in the field, all
phases (Phase I, II, III)19 and currently undergraduate government and most of the private medical colleges
medical education is of four phases (Phase I, II, III, have come out with the success of creating quality
IV).20,21 The curriculum, teaching and learning, assurance bodies in the respective institutions. The
assessment and evaluation as well as reporting QAS bodies have succeeded in functioning in the
procedure are following that guideline to date. following areas:5,15,16,22
Addressing the necessity of quality medical
1. Making academic calendar to run academic
education, a National Quality Assurance Scheme
activities and achieve phase wise target of
(NQAS) was established in 1998 in Bangladesh.
teaching and assessment to reach completion of
National guidelines and tools for quality assurance
syllabus much ahead of the Professional
were revised and published in 2012 with support
Examination conducted under the Faculty of
from the World Health Organization (WHO).22
Medicine of different Universities of the country;
Subsequently, the Government urged all medical
colleges in Bangladesh to follow and practice NQAS 2. Regular Meetings of the Subject Coordination
framework and guidelines in their respective Committee, Phase Coordination Committee,
institutions (Fig.1). Academic Coordination Committee, Academic
Council and Faculty Development & Review
Committee;
3. Arrangement of central seminars (fortnightly)
and conferences locally and if possible, by
inviting international faculties and experts in
different disciplines;
4. Provision of Phase wise evaluation and feedback
by the students to evaluate course works and
faculties involved to enhance overall teaching-
learning experience as well as the entire
environment of medical colleges;
5. Provision of evaluation and feedback by the
Fig. 1: Conceptual Framework of Quality Assurance and faculty members through the prescribed personal
Accreditation in Medical Education in Bangladesh review form to adopt policies on continuous
professional development (CPD) activities;
6. Arrangement of workshops and training on
ACHIEVEMENTS
teaching methodology, assessment and
Since 1998 different medical colleges have been
evaluation, research methodology, quality
practicing QAS for the improvement of medical
improvement, scientific writing etc. under faculty
education in Bangladesh; however, to date one time
development scheme;
pilot Quality Assessment & Audit Review (QAAR)
has been done in three government medical colleges 7. Meetings among pair medical colleges (or
(i.e., Dhaka Medical College, Chittagong Medical regional meeting), as per convenience [for an
College, Rangpur Medical College) under the example, meetings have been arranged
leadership of national quality assurance body (NQAB) participated by the representatives from Shaheed
in 2010.5 Therefore, we feel that there is a lack of Ziaur Rahman Medical College (SZMC), TMSS
annual formal auditing of QA activities, the informal Medical College and Army Medical College,
yearly reporting on QA activities by the medical Bogura];
106
8. Formation of Counseling Committee (academic and administrators from public and private sectors.24-
support) to counsels the irregular and low 26 Although this widespread participation allows for
performance students and address stress and a comprehensive review, it remains a difficult task
mental health issues among students; and for CME, BM&DC and other bodies to coordinate and
manage. Lack of willingness, shortage of logistics and
9. Formation of Examination Review Committee to
financial support have been in the list for decades.
evaluate both internal and external (Professional
Moreover, lack of expertise in the sector to coordinate
MBBS Examinations) examinations.
the curriculum design, evaluation, and integration
CHALLENGES process, and manage the quality assurance
Bangladesh Medical & Dental Council (BM&DC) is committees both at institutional and national level
the sole authority for accrediting undergraduate are also evident in Bangladesh, which is quite similar
medical and dental education in the country. It is a to other low-resource countries of South Asia.23,26-35
statutory body with the responsibility of establishing At medical college level, internal quality assurance
and maintaining high standards of medical education team in all medical colleges are not equally competent
and recognition of medical qualifications in and active. It is evident that politically influenced
Bangladesh. For an accreditation institution like committees are not always capable enough to perform
BM&DC, its responsibilities include to maintain the well. 5,23,26,27 Regular meetings of the Subject
quality of medical education is in line with the Coordination Committee, Phase Coordination
evolving needs of the healthcare delivery system and Committee, Academic Coordination Committee,
expectations of society as well as international Academic Council and Faculty Development &
standards. 5,22 However, medical educators are Review Committee as well as meetings among pair
showing increasing concerns about the nature of medical colleges (or regional meeting) are not held
current BM&DC accreditation standards, the years after years.5,16,26 There is also a scarcity of
accreditation processes, lingering operations of reports of medical curriculum research, policy
improvement/upgradation of MBBS curriculum and dialogue, public meeting, publication of the yearbook
the limited technical capacity to fulfill its and formal auditing of QA activities in the country.
administrative duties to ensure the quality of medical Besides, integrated teaching, problem based learning
education and medical practice in the country.5,22,23 (PBL), evidence-based medicine have been discussed
Evidence showed that an inherent bias exists in the
widely; however, in the practical field, those are
evaluation process between public- and private-sector
hardly practiced by the medical colleges.16,17,26
institutions. Many medical colleges adopted several
unethical and even illegal ad-hoc practices to get Individual institution committed to training future
through the process of accreditation and recognition. generations of physicians should recognize the
Once their target is achieved, they fall back to their importance of quality in undergraduate medical
original sub-standard practices in terms of required education and the need to regularly examine, reflect,
infrastructure, faculty-student ratio, regular academic and improve upon these efforts.15,16,36-39 Both faculty
activities and social responsibility.5,17,23 BM&DC and members and students should come up to run
DGHS have already suspended the academic academic activities smoothly and achieve phase wise
activities and admission process in some of the private target of teaching and assessment to reach completion
medical colleges due to lack of required infrastructure, of syllabus much ahead of the professional
poor management, and violation of regulatory examination, while administration should take the
rules.6,17 Surprisingly, recently founded government role to nurture free and fair educational environment
medical colleges have even worse conditions (in terms as well as monitor overall standards and strive for
of shortage of medical teachers, infrastructure, excellence in every aspect. 16,36-39 Besides,
teaching hospital and other essential facilities), as strengthening of the committees and monitoring of
most of them were established in line with the political their activities are time-demanding,22,25,38,39 which
sweet will of the government.16,17 should be done by the medical college authorities
Moreover, we observed several limitations to the internally as well as BM&DC, DGME and DGHS
curriculum review process. It relies on the externally.22,24 Last but not the least, it is worthy
participation of a large number of faculty, students, noticing that quality of medical education does not
107
solely depend on measurement instruments and tools, 3. World Health Organization (WHO). WHO
rather it revolves on how much quality awareness is guidelines for quality assurance of basic medical
present among medical faculty, students, and education in the Western Pacific Region. Manila,
regulatory authorities.38 Philippines: WHO; 2001. Available from: https://
apps.who.int/iris/bitstream/handle/10665/
CONCLUSION 207556/9290610204_eng.pdf (Accessed October 17,
Global changes are happening in medical education 2021).
in accordance and conformity with the advancement 4. Majumder MAA. Medical education in Bangladesh:
of science and technology. Besides, communities are past successes, future challenges. Bangladesh Med
increasingly demanding more accountability in J. 2003;32(1):37-9.
healthcare from their public institutions including 5. Talukder MHK. Quality control in medical
medical colleges and hospitals. We believe that a education: global and Bangladesh perspectives.
student centric, teacher guided, parent supported, Bangladesh J Med Biochem. 2010;3(1):3-5.
community oriented and values driven medical
6. Bangladesh Medical & Dental Council (BM&DC).
education programme can produce competence
Updated list of Recognized Medical & Dental
based medical graduates capable of ‘taking charge of Colleges and Dental Units (Govt. & Non-Govt.).
the future’. At this stage, every medical college in the 2022. Available from: https://www.bmdc.org.bd/
country (both public and private) must ensure its about-college-n (Accessed January 19, 2022).
quality assurance activities through respective
institutional QAS, which needs to be overviewed by 7. Joshi MA. Quality assurance in medical education.
the NQAB of the country. Besides, regulatory Indian J Pharmacol. 2012;44(3):285-7.
authorities like BM&DC, DGME, DGHS, Medical 8. Harvey L, Green D. Defining quality. Assess Eval
faculties of respective universities should strengthen High Educ. 1993;18(1):9-34.
their capacities to monitor and guide the medical 9. Vroeijenstijn AI. Quality assurance in medical
colleges to achieve an optimum standard to build a education. Acad Med. 1995;70(Suppl 7):S59-67.
better future in medical education, which will help
10. Agarwal, P. Indian higher education: envisioning
build a modern, efficient, and patient-centred
the future, New Delhi, India: Sage Publications;
healthcare in the country. 2009. p.361.
ABBREVIATIONS 11. Quality Assurance Agency for Higher Education,
BM&DC: Bangladesh Medical & Dental Council UK. Quality assurance. Available from: https://
www.qaa.ac.uk/glossary. (Accessed October 9,
CME: Centre for Medical Education
2021).
DGHS: Directorate General of Health Services
12. Gullo C, Dzwonek B, Miller B. A disease-based
DGME: Directorate General of Medical Education approach to the vertical and horizontal integration
MBBS: Bachelor of Medicine and Bachelor of Surgery of a medical curriculum. Med Sci Educ. 2016;26:93-
NQAB: National Quality Assurance Body 103.
NQAS: National Quality Assurance Scheme 13. Brauer DG, Ferguson KJ. The integrated curriculum
PBL: Problem Based Learning in medical education: AMEE Guide No. 96. Med
Teach. 2015;37(4):312-22.
QAAR: Quality Assessment & Audit Review
QAS: Quality Assurance Scheme 14. Weisberg DF. Science in the service of patients:
lessons from the past in the moral battle for the
WHO: World Health Organization future of medical education. Yale J Biol Med.
REFERENCES 2014;87:79-89.
1. Dhalla IA, Tepper J. Improving the quality of health 15. Masiæ I, Novo A, Deljkoviæ S, Omerhodziæ I,
care in Canada. CMAJ. 2018;190(39):E1162-7. Piraliæ A. How to assess and improve quality of
medical education: lessons learned from Faculty of
2. Bendermacher GWG, De Grave WS, Wolfhagen
Medicine in Sarajevo. Bosn J Basic Med Sci.
IHAP, Dolmans DHJM, Oude Egbrink MGA.
2007;7(1):74-8.
Shaping a culture for continuous quality
improvement in undergraduate medical education. 16. Talukder MHK, Nazneen R, Hossain MZ, Nargis T,
Acad Med. 2020;95(12):1913-20. Alam KK, Chowdhury IJ, et al. Quality assurance
108
scheme (QAS) in medical & dental colleges in 26. Amin Z, Hoon Eng K, Gwee M, Dow Rhoon K,
Bangladesh – Teacher’s knowledge. Bangladesh J Chay Hoon T. Medical education in Southeast Asia:
Med Biochem. 2010;3(1):6-10. emerging issues, challenges and opportunities. Med
Educ. 2005;39(8):829-32.
17. Halder BB, Khan MI. Current practice of quality
assurance scheme (QAS) in different medical 27. Batool S, Raza MA, Khan RA. Roles of medical
colleges of Bangladesh. Bangladesh J Med Educ. education department: what are expectations of the
2015;6(1):2-7. faculty? Pak J Med Sci. 2018;34(4):864-8.
18. World Health Organization (WHO) & Centre for 28. Ahluwalia G, Grewal GS. Medical education in
Medical Education (CME). National guidelines and India: critical challenges and solutions. Indian J
tools for quality assurance scheme (QAS) for medical Chest Dis Allied Sci. 2015;57(4):215-7.
colleges in Bangladesh. Dhaka, Bangladesh; WHO:
29. Chacko TV. Quality assurance of medical education
2012. Available from: (Accessed November 1, 2021).
in India: the concerns, available guiding
19. Bangladesh Medical & Dental Council (BM&DC). frameworks, and the way forward to improve
Curriculum for Under-graduate Medical Education quality and patient safety. Arch Med Health Sci.
in Bangladesh –2002. Dhaka, Bangladesh: BM&DC; 2021;9(2):320-7.
2012. Available from: https://www.bmdc.org.bd/
30. Ansari M. Quality of medical education in Nepal.
docs/CurriculumMBBS_2002 (Accessed January 19,
Educ Health (Abingdon). 2012;25(2):130.
2022).
31. Adhikari B, Mishra SR. Urgent need for reform in
20. Bangladesh Medical & Dental Council (BM&DC).
Nepal’s medical education. Lancet. 2016;388(10061):
Curriculum for Under-graduate Medical Education
2739-2740.
in Bangladesh – Updated 2012. Dhaka, Bangladesh:
BM&DC; 2012. Available from: https:// 32. Kommalage M, Ponnamperuma G. The Flexner
www.bmdc.org.bd/curriculum-2012 (Accessed Report and contemporary medical education in
January 19, 2022). South Asia: an exception. Acad Med. 2011;86(6):662.
21. Bangladesh Medical & Dental Council (BM&DC). 33. de Silva NR, Samarasinghe HH. Quality in medical
Bachelor of Medicine & Bachelor of Surgery (MBBS) education. Ceylon Med J. 2000;45(2):55-7.
Curriculum in Bangladesh. Dhaka, Bangladesh:
34. Tariq M, Ali SA. Quality assurance and its
BM&DC; 2021. Available from: https://
application in medical education. J Coll Phys Surg
www.bmdc.org.bd/curriculum-2021 (Accessed
Pak. 2014;24(3):151-2.
January 19, 2022).
35. Tenzin K, Dorji T, Choeda T, Pongpirul K. Impact
22. World Health Organization (WHO). Quality
of faculty development programme on self-efficacy,
assurance scheme (QAS): final technical brief. 2019.
competency and attitude towards medical education
Retrieved from: http://origin.searo.who.int/
in Bhutan: a mixed-methods study. BMC Med Educ.
entity/bangladesh/finaltechnicalbriefnqas
2019;19(1):468.
070118.pdf (Accessed January 19, 2020).
36. Wong BM, Levinson W, Shojania KG. Quality
23. Khan AW, Sethi A, Wajid G, Yasmeen R. Challenges
improvement in medical education: current state
towards quality assurance of basic medical
and future directions. Med Educ. 2012;46(1):107-19.
education in Pakistan. Pak J Med Sci. 2020;36(2):4-9.
37. Stratton TD. Legitimizing continuous quality
24. World Health Organization (WHO). Quality
improvement (CQI): navigating rationality in
assurance hand book 1998, Further Improvement
undergraduate medical education. J Gen Intern Med.
of the Medical Colleges (FIMC) in Bangladesh.
2019;34(5):758-61.
Dhaka, Bangladesh: WHO; 1998.
38. MacCarrick G. Quality assurance in medical
25. World Federation for Medical Education (WFME).
education: a practical guide. London, UK: Springer;
Basic medical education: WFME global standards
2013.
for quality improvement. 2020 revised edition.
Available from: https://wfme.org/wp-content/ 39. Dent J, Harden RA. A practical guide for medical
uploads/2020/12/WFME-BME-Standards-2020.pdf educators. 4th ed. London, UK: Churchill
(Accessed November 1, 2021). Livingstone; 2013.
109
CASE REPORT
Pycnodysostosis: Report of A Rare Case
Sultana F1, Ahmed L2, Chatterjee S3, Farzana MN4, Ahmed R5, Deepa ZS6
ABSTRACT
A 20-year old male patient reported in the outpatient department of Shaheed Suhrawardy
Medical College Hospital, Dhaka, Bangladesh, with the complaints of body aches along with
pain in the upper and lower limbs for several years. He also gave history of previous
hospitalization for the same reason. He also had complaints of failure to thrive in his adolescence.
However, he was treated as a case of polyarthritis in his previous admission in the district
hospital. On clinical examination, he was found to have short stature, low-weight, peculiar
face, prominent forehead, receding jaw and partial dysplasia of the terminal phalanges. He was
sent for radiological investigations in the Department of Radiology & Imaging of the same
hospital. Plain radiograph of his skull showed brachycephaly with wide sutures and persistent
fontanelles with sclerotic changes in the base of skull and orbital rims. The angle of the
mandible was obtuse, and the maxilla was found hypoplastic. Lumbar region showed ‘spool-
shaped’ vertebral bodies with quite prominent anterior defects; bones had sclerotic changes.
Both hands had acro-osteolysis of distal phalanges of thumb, index, middle and ring fingers
(both right and left sides) along with irregular distal fragments; bones were sclerotic, too.
Those features were consistent with pycnodysostosis. The patient was kept admitted into the
hospital and treated accordingly. After obtaining a written informed consent, he was presented
as a special case in clinical seminar.
Keywords: Pycnodysostosis, osteosclerosis, bone fragility, radiological investigation
Mugda Med Coll J. 2022; 5(2): 110-113
INTRODUCTION osteosclerosis and short stature.1,2 The patients are

Pycnodysostosis (also spelled as ‘pyknodysostosis’), usually short (below 150 cm) and the skeleton is
or osteopetrosis acro-osteolytica (often termed as susceptible to fracture.2 The disease is found in all
Toulouse-Lautrec syndrome), is a rare autosomal races, incidence is rare though. The incidence of
recessive bone dysplasia, characterized by pycnodysostosis has been estimated to be 1.0 to 1.7
per million live births, with an equal sex distribution.3
1. Dr. Farhana Sultana, Assistant Professor, Department of 30% of the cases are offsprings of consanguineous
Radiology & Imaging, Shaheed Suhrawardy Medical
College & Hospital, Dhaka-1207. unions.4 The principal characteristics of this
2. Dr. Luna Ahmed, Medical Officer, Department of syndrome are short stature, cranial dysplasia, obtuse
Radiology & Imaging, Shaheed Suhrawardy Medical
angle of mandible, clavicular dysplasia, total or
3. Dr. Sutapa Chatterjee, Assistant Professor, Department partial dysplasia of the terminal phalanges and
of Radiology & Imaging, Satkhira Medical College & generally increased bone density.5,6 The exfoliation
Hospital, Satkhira-9400.
4. Dr. Mst. Nilufar Farzana, Assistant Professor, Department of deciduous teeth is usually altered, as well as the
of Radiology & Imaging, Shaheed Suhrawardy Medical eruption of the permanent dentition.6 Here we have
5. Dr. Rokshana Ahmed, Assistant Professor, Department of
presented a case of pycnodysostosis (in a young male
Radiology & Imaging, National Institute of Neurosciences patient reported with complaints of body aches and
& Hospital, Dhaka-1207. pain in the limbs for several years) for academic and
6. Dr. Zereen Sultana Deepa, Medical Officer, Department of
Radiology & Imaging, Bangabandhu Sheikh Mujib Medical clinical interest.
University (BSMMU), Dhaka-1000.
Address of correspondence: Dr. Farhana Sultana, Assistant CASE SUMMARY
Professor, Department of Radiology & Imaging, Shaheed
Suhrawardy Medical College & Hospital, Dhaka-1207. Email:
A 20-year old male patient reported in the
[email protected] outpatient department of Shaheed Suhrawardy
110
Medical College Hospital, Dhaka, Bangladesh, with

the complaints of bodyache along with pain in the
upper and lower limbs for several years. He also
gave history of previous hospitalization for the same
reason. He was born to unrelated parents. He gave
a history of failure to thrive in his adolescence.
However, he denied any history of intellectual
disability and currently is attending a vocational
college. He remains a mouth and nasal breather.
However, he was treated as a case of polyarthritis
in his previous admission in the district hospital.
He was on NSAIDs drugs. On clinical examination,
he was found to have short stature, low-weight,
peculiar face, prominent forehead, receding jaw and
partial dysplasia of the terminal phalanges. He was
sent for radiological investigations in the
Department of Radiology & Imaging of the same
hospital. X-ray of his skull showed brachycephaly
with wide open cranial sutures and persistent
fontanelles with sclerotic changes in the base of
skull and orbital rims. The angle of the mandible
was obtuse, and the maxilla was found hypoplastic
(Fig. 1), while lumbar region showed ‘spool- Fig. 2: X-ray of lumbar region (anteroposterior and lateral
views) showing spool shaped vertebral bodies with quite
shaped’ vertebral bodies with quite prominent
prominent anterior defects; bones have sclerotic changes.
anterior defects; bones had sclerotic changes (Fig.
2). X-ray of both hands revealed acro-osteolysis of
distal phalanges of thumb, index, middle and ring
fingers (both right and left sides) along with
irregular distal fragments; bones were sclerotic, too
(Fig. 3). Those features were consistent with
pycnodysostosis. The patient was then admitted
under the Department of Orthopaedic Surgery and
treated accordingly.
Fig. 3: X-ray of both hands (anteroposterior view) showing

acro-osteolysis of distal phalanges of thumb, index, middle
and ring fingers (both right and left sides) along with
irregular distal fragments; bones are sclerotic, too.
Fig. 1: X-ray of skull (anteroposterior and lateral views) DISCUSSION

showing brachycephaly with wide open cranial sutures Our patient had typical imaging findings which
and persistence of open fontanelles, sclerosis of the base of include “spool shaped” vertebrae, acro-osteolysis of
skull and the orbital rims. The angle of the mandible is distal phalanges of hands, obtuse mandibular angles,
obtuse, and the maxilla is hypoplastic. wide open cranial sutures and persistent fontanelles.
111
However, pycnodysostosis can be confused with other REFERENCES

similar diseases, such as osteopetrosis and 1. Capan E, Turan S, Kilicoglu H. Clinical and
cleidocranial dysostosis, because they present some cephalometric analysis of three cases with
clinical and radiographic similar signs. 7,8 pycnodysostosis: case reports. J Istanb Univ Fac
Differentiation from osteopetrosis solely on the basis Dent. 2015;49(1):51-5.
of plain radiograph is not often possible.7 Hence, it is 2. Schmidt GS, Schacht JP, Knee TS, Shakir MKM,
important that the physician knows how to make the Hoang TD. Pyknodysostosis (osteopetrosis acro-
differential diagnosis in order to indicate the best osteolytica). AACE Clin Case Rep. 2020;6(5):
e257-61.
treatment for each patient. Several studies supported
that the most common finding in patients with 3. Soliman AT, Ramadan MA, Sherif A, Aziz Bedair
ES, Rizk MM. Pycnodysostosis: clinical, radiologic,
pycnodysostosis is obtuse mandibular angle.2-6,8-11
and endocrine evaluation and linear growth after
The presence of diffuse sclerosis, cortical thickening growth hormone therapy. Metabolism. 2001;50(8):
of bones, and acro-osteolysis on plain radiographs 905-11.
in the setting of other common clinical features is often
4. Bathi RJ, Masur VN. Pyknodysostosis—a report of
sufficient to make the diagnosis.2,3,8-10 If the disease two cases with a brief review of the literature. Int J
is not diagnosed in infancy, fractures resulting from Oral Maxillofac Surg. 2000 Dec;29(6):439-42.
trauma due to fragility of bones usually lead to the
5. Rajan AR, Singh V, Bhave AA, Joshi CS.
diagnosis of this disease.11 However, in our case it
Pycnodysostosis: A rare cause of short stature. Med
was an incidental diagnosis. J Armed Forces India. 2015;71(4):393-5.
Several evidence suggest surgical management of 6. Alves N, Cantín M. Clinical and radiographic
these patients with bone grafting, fixation screws and maxillofacial features of pycnodysostosis. Int J Clin
bone plates.12 Dental, maxillofacial and orthopaedic Exp Med. 2014;7(3):492-6.
surgeons have managed such patients based on 7. Gabra P, Jana M, Naranje P, Gupta N, Kabra M,
suitability of surgery and stability of reconstruction Gupta AK, et al. Spine radiograph in dysplasias: A
procedures.12 Besides, looking at relevant biomarkers pictorial essay. Indian J Radiol Imaging. 2020;
and evaluation of hormonal status have roles in such 30(4):436-47.
cases.3 Thus, a team of specialists is often involved in 8. Aynaou H, Skiker I, Latrech H. Short stature
treatment that include a paediatrician, an internist, revealing a pycnodysostosis: a case report. J Orthop
an orthopaedic or dental surgeon, and perhaps an Case Rep. 2016;6(2):43-5.
endocrinologist. 9. Muto T, Michiya H, Taira H, Murase H, Kanazawa
M. Pycnodysostosis. Report of a case and review of
CONCLUSION the Japanese literature, with emphasis on oral and
Patients with pyknodysostosis come to medical maxillofacial findings. Oral Surg Oral Med Oral
attention for a variety of reasons but often go Pathol. 1991;72(4):449-55.
undiagnosed even when presenting with classic 10. Fleming KW, Barest G, Sakai O. Dental and facial
features due to the rarity of the condition and the bone abnormalities in pyknodysostosis: CT
overlap with other skeletal dysplasias. Diagnosis of findings. Am J Neuroradiol. 2007;28(1):132-4.
this condition is strongly implied by clinical and 11. Alves Pereira D, Berini Aytés L, Gay Escoda C.
radiographic findings, but genetic testing can confirm Pycnodysostosis. A report of 3 clinical cases. Med
the diagnosis. However, treatment should consist of Oral Patol Oral Cir Bucal. 2008;13(10):E633-5.
a multidisciplinary approach to address concerning 12. Taka TM, Lung B, Stepanyan H, So D, Yang S.
Orthopedic treatment of pycnodysostosis: a
symptoms to improve the patient’s quality of life.
systematic review. Cureus. 2022;14(4):e24275.
112
CASE REPORT
Diabetic Myonecrosis Involving Both Lower Limbs
in Hemodialysis Patient: A Rare Complication of
Diabetes
Chowdhury MFH1, Anwar MMR2, Hossain M3, Nath PKD4, Nargis T5
Abstract:
Diabetic myonecrosis (DMN) is the term used for spontaneous ischemic necrosis of skeletal
muscle, unrelated to atheroembolism or occlusion of major arteries. DMN is a rare
microangiopathic disorder that can present as an acutely painful and swollen limb in patients
with established diabetes mellitus. Muscles of the thighs are commonly affected in DMN. The
condition can be diagnosed noninvasively with magnetic resonance imaging and resolves
with analgesia, bed rest, and glycemic control. The majority of patients with DMN have
diabetic nephropathy, yet this condition is not widely recognized. Due to uncommon
presentation, lack of specific marker of investigation, diagnosis is often missed, resulting in
unnecessary and deleterious interventions such as antibiotics, muscle biopsies, and surgery;
the latter two of which can prolong recovery. Here, we report a patient on hemodialysis who
is ultimately diagnosed as DMN affecting both lower limb and treated successfully.
Mugda Med Coll J. 2022; 5(2): 113-116
INTRODUCTION: affects the lower limbs. It was first described in 1965

Diabetes mellitus is associated with microvascular by Angervall and Sterner as “tumoriform focal
and macrovascular complications like diabetic muscular degeneration”. 1 Concomitant diabetic
nephropathy, retinopathy and neuropathy. Less well- nephropathy is present in 75% (95/126) of cases.2
known complications are equally important, for The pathophysiology is currently unclear, although
diagnosis and treatment to decrease morbidity.
thought to relate to microvascular dysfunction, with
Diabetic myonecrosis (DMN), also known as diabetic
hypotheses including atheromatous occlusion,
muscle infarction (DMI), causes spontaneous
thrombus formation, endothelial damage, and
ischemic necrosis of skeletal muscle most commonly
in the thigh or calf. DMN is usually unilateral and dysfunction of local coagulation mechanisms.3 It
presents clinically as sudden pain, swelling and
1. Dr. Md. Farhad Hasan Chowdhury, Assistant Professor, tenderness of the involved muscle.4 Painful swelling
Department of Nephrology, Mugda Medical College, may be acute or evolve over days to weeks. There is
Dhaka, Bangladesh.
2. Dr. Mohammed Rashed Anwar, Associate Professor,
no specific marker for the disease. Diagnosis is based
Department of Nephrology, Mugda Medical College, on clinical presentation, laboratory investigations
Dhaka, Bangladesh. and imaging, for which MRI is the modality of choice.
3. Dr. Momtaz Hossain, Assistant Professor, Department of
Nephrology, Mugda Medical College, Dhaka, Bangladesh. Muscle biopsy should be reserved for atypical
4. Dr. Palash Kumar Deb Nath, Assistant Professor, presentation, uncertain diagnosis, or when treatment
Department of Nephrology, Mugda Medical College, fails to improve symptoms.
Dhaka, Bangladesh.
5. Dr. Tania Nargis, Medical Officer, Department of Bed rest, analgesia, and intense glycemic control are
Nephrology, Mugda Medical College Hospital, Dhaka,
Bangladesh.
the cornerstones of diabetic myonecrosis therapy. It
Address of correspondence: Dr. Md. Farhad Hasan is important to note that a large majority have
Chowdhury, Assistant Professor, Department of Nephrology, concomitant kidney disease with renal replacement
Mugda Medical College, Dhaka, Bangladesh. email.
[email protected] therapy. With accurate and timely diagnosis and
113
initiation of treatment, diabetic myonecrosis resolves in lt. thigh. The pt. discharged on 23.08.2022 and pt.
spontaneously over a few weeks to months. Average returned to Bangladesh and admitted in Mugda
recovery times were 5.5 weeks with aspirin and/or medical college hospital.
NSAID use, 8 weeks with bed rest and analgesics,
On admission, he was afebrile with a pulse rate of 90
and 13 weeks with surgical resection.10 Even with
beats/min and blood pressure of 130/90 mm Hg. He
treatment, diabetic myonecrosis carries a high
had a swollen left thigh, tender to palpation. The
recurrence rate of 34.9 to 47.8% usually involving a
overlying skin was palpably indurated with erythema
contralateral limb within 6 months.4,11 Differential
and warmth with no evidence of discharge. Active
diagnoses include infection (pyomyositis, soft tissue
and passive movements at the left hip and knee were
abscess, osteomyelitis, cellulitis), tumors (lymphoma,
limited due to pain. Lower extremity pulses were
sarcoma),and vascular pathologies (thromboses,
palpable bilaterally. Laboratory studies were
compartment syndrome, calciphylaxis). Due to a
remarkable for leukocytosis 20200/cumm, Hb 6.8 gm/
relative lack of awareness regarding the condition,
dl, elevated creatinine kinase (CK) 436 U/L (42–196
avoidable interventions such as muscle biopsies and
U/L), C-reactive protein (CRP) 18 mg/dL (N<6 mg/
even surgery are sometimes pursued, which have been
dL), and erythrocyte sedimentation rate (ESR) 110
associated with prolonged recovery times.4,12 A
mm/hr (N 0–10 mm/hr). Additionally, poor glycemic
higher index of suspicion should be reserved for
control was confirmed with random blood glucose of
poorly controlled, longstanding diabetes patients
11 mmol/L and hemoglobin A1c 10.8%. Serology was
with coexisting complications. Here we report a rare
negative for HIV and hepatitis B and C. Altogether,
case of DMN affecting both thighs in patients on
with these findings, previous MRI report and
hemodialysis.
treatment history, a diagnosis of diabetic myonecrosis
CASE SUMMURY: of lt. thigh was made. Patient condition improved
A 45-year-old male presented to the emergency with analgesics, with optimization of glycemia,
department (ED) with painful Rt. thigh swelling for 3 regular thrice weekly hemodialysis via JVC.
weeks. He has type 2 Diabetes Mellitus for more than
10 years, Hypertension for 1 year, End-stage renal
disease (ESRD) on hemodialysis for 1 month. He
complained redness and swelling of his rt. thigh and
described his thigh pain as constant, aching, stabbing
pain in the rt. posteriolateral mid-thigh with radiation
distally to the calf. He denied any trauma or falls and
reported worsening pain with weight-bearing and
ambulation. With these complains, he admitted in
King Fahad Specialist Hospital, Saudi Arabia on
30.07.22 and initially diagnosed as Cellulitis of Rt.
thigh and treated with IV antibiotics and analgesics.
X-ray of the right thigh, knee and lumbar spine,
venous Doppler of the right lower extremity were
normal. As improvement of his condition was not
satisfactory, MRI of both thighs done. MRI of rt. thigh
showed diffuse intra and inter muscular fluid
collection seen extending from the upper third of the
right thigh down to the knee region replacing
quadriceps muscle group mainly with diffuse
interstitial edema in the periosseous, inter and intra
muscular plane and comment about possibilities of
diabetes myonecrosis. MRI of lt. thigh showed similar
yet much less appreciated changes. After 15 days with
some improvement of rt. thigh, pt. complained of pain
114
DMN is usually unilateral and affects the lower limb.

The most commonly affected muscles are quadriceps,
hip adductors, and hamstrings.6 Yong and Khow in
their study showed the muscle groups affected in
diabetic ESRD patients on hemodialysis were thighs
in 82% (22 cases), calves in 11% (3 cases), and upper
limbs in 7% (2 cases) respectively.5 In our pt. both
thigh muscles were affected. Bilateral limb
involvement is uncommon.7 Bilateral involvement has
been reported in 8.4% cases.9
Regarding diagnosis of diabetic myonecrosis routine
laboratory investigations are relatively nonspecific.
There may be leukocytosis and serum creatine kinase
levels may remain normal or slightly elevated. MRI is
the most sensitive diagnostic modality, and in the
appropriate clinical setting muscle biopsy is not
DISCUSSION: required. The characteristic MRI feature is an
Diabetic myonecrosis is one of rare complication of increased signal from the affected muscle area
diabetes. The first case of diabetic myonecrosis was (intramuscular and perimuscular tissues), isointense
described as ‘tumoriform focal muscular or hypointense areas on T1-weighted images
degeneration’ in 1965 by Angervall and Stener. They secondary to increased water content from edema and
reported two patients, both underwent excision of a inflammatory changes that accompany the
painful swelling in the proximal part of lower limbs, infarction.13 In our pt. there was leukocytosis, raised
which showed ischaemic muscular necrosis.1 Since CK, ESR and CRP with characteristic MRI changes
then, around 200 cases have been described. It has like diffuse intra and inter muscular fluid collection
been reported in both type 1 and type 2 diabetes. A extending from the upper third of the right thigh down
systematic analysis of the available literature showed to the knee region replacing quadriceps muscle group
DMN was found in 54% in women, 50% had type 2 mainly with diffuse interstitial edema in the
DM, mean age of presentation was 44.6 years, mean periosseous, inter and intra muscular planewhich
duration of diabetes at the time of DMN diagnosis supports the diagnosis of DMN.
was 18.9 years for T1DM and 11.0 years for T2DM.
The most accurate diagnostic modality is by tissue
There was a preponderance of patients with other
biopsy. On biopsy it grossly appears as
microvascular complications (65.8% had other
nonhemorrhagic pale muscle tissue. Histologically,
microvascular complications) commonly renal failure
there are large areas of muscle necrosis and edema,
(75% had nephropathy) reflecting poor glycaemic
phagocytosis of necrotic muscle fibres, granular
control, evident by mean HbA1c of 9.3%.4 Another
tissue, and collagen.14 As muscle biopsies are more
study by Yong and Khow analysed 24 publications
hazardous in HD patients as they got regular heparin
with 41 patients having DMI.5 Of these, 53.7% were
during dialysis procedure, muscle biopsy was not
women, 41.5% had type 1 diabetes, 53.7% had type 2
done in our case. Muscle biopsy usually not done
diabetes, mean duration of DM at the time of DMI
regularly in DMN as it is associated with poor wound
diagnosis was 17.3 years for type 1 diabetes and 15.7
healing and a higher risk of infection, seroma and
years for type 2 diabetes, 29 patients were receiving
haematoma. Therefore, currently it is recommended
renal replacement therapy in the form of
to make the diagnosis of DMN on the basis of clinical
haemodialysis (60.1%), peritoneal dialysis (21%) and
presentation and radiological findings; open muscle
renal transplant (12.2%) and the average HbA1c value
biopsy should be limited to atypical cases only.15
was 7.2%, which is high considering the effect of
renal failure on insulin metabolism. Our pt. was 45 Treatment is conservative with supportive measures
years old male, suffered from Type 2 DM for 10 years, aimed at pain control with analgesics along with
had ESRD on hemodialysis with uncontrolled DM maintaining target glycemic control. Non-weight-
(HbA1c 10.8%) which supports these data. bearing activity and physical rehabilitation may be
115
useful after the acute phase. Those who underwent 5. Yong TY, Khow KSF. Diabetic muscle infarction in
surgery had an average recovery period of 13 weeks end-stage renal disease: A scoping review on
compared to 5.5 weeks for those only received epidemiology, diagnosis and treatment. World J
conservative treatment11. Our pt. was treated with Nephrol. 2018; 7: 58-64.
regular thrice weekly hemodialysis with adequate 6. P. V. Rocca, J. A. Alloway, and D. J. Nashel,”Diabetic
control of DM (HbA1c 6.5% after a week of treatment), muscular infarction. Seminars in Arthritis and
bed rest and paracetamol. 6 weeks after initial Rheumatism. 1993;22,(4):280–287.
presentation, pt. condition improved markedly. 7. T. Joshi, E. D’Almeida, J. Luu. Diabetes myonecrosis
Although diabetic myonecrosis has a good prognosis, – A rare complication. Diabetes Research and
it is an indicator of poor long-term outcome. However, Clinical Practice. 2015;109 (3):18–20.
recurrence rate are reported to be high (40%) with a 2
8. B. K. Choudhury, U. K. Saikia, D. Sarma, M. Saikia,
year mortality rate of 10%.16 S. D. Choudhury, and D. Bhuyan, “Diabetic
CONCLUSION: myonecrosis: an underreported complication of
diabetes mellitus,” Indian Journal of Endocrinology
Diabetic myonecrosis is a rare and underreported
and Metabolism. 2011; 15(5):58–61.
complication of longstanding, poorly controlled
diabetes mellitus. It can occur in diabetic renal 9. J. Trujillo-Santos. Diabetic muscle infarction: an
patients with or without hemodialysis. Diagnosis underdiagnosed complication of long-standing
requires clinically a higher index of suspicion for diabetes. Diabetes Care.2003;26(1):211–215.
poorly controlled, longstanding diabetes patients 10. S. Kapur, J. Brunet, and R. McKendry. Diabetic
with coexisting complications supported by MRI muscle infarction: case report and review. The
findings. Muscle biopsy is not routinely indicated Journal of Rheumatology.2004;31:190–194.
and treatment is mainly conservative with analgesia 11. T. Yong, K. Khow. Diabetic muscle infarction in
and rest. However, the recurrence rate remains high, end-stage renal disease: A scoping review on
and long-term prognosis is poor. Awareness and epidemiology, diagnosis and treatment. World
early diagnosis of this condition will help to improve Journal of Nephrology.2018; 7(2):58–64.
treatment, patient care, and prevent unnecessary
12. S. Kapur,R. J. McKendry. Treatment and outcomes
invasive interventions or antibiotics. of diabetic muscle infarction. Journal of Clinical
REFERENCES: Rheumatology.2005;11(1): 8–12.
rence: 13. J. S.Jelinek, M.D. Murphey, A. J. Aboulafia, R. G.
Dussault, P. A. Kaplan,W. N. Snearly. Muscle
1. L. Angervall, B. Stener. Tumoriform focal muscular
degeneration in two diabetic patients. infarction in patients with diabetes mellitus: MR
Diabetologia. 1965;1(1):39–42. imaging findings.Radiology.1999; 211(1).241–247.
2. NCD Risk Factor Collaboration (NCD-RisC). 14. E. Grigoriadis, A. G. Fam, M. Starok, L. C. Ang.
Worldwide trends in diabetes since 1980: a pooled Skeletal muscle infarction in diabetes mellitus. Journal
analysis of 751 population-based studies with 4.4 of Rheumatology.2000; 27(4): 1063–1068.
million participants. Lancet. 2016; 387: 1513-1530. 15. Bhasin R, Ghobrial I. Diabetic myonecrosis: a
3. Habib GS, Nashashibi M, Saliba W, Haj S. Diabetic diagnostic challenge in patients with longstanding
muscular infarction: emphasis on pathogenesis. diabetes. Journal of Community Hospital Internal
Clin Rheumatol. 2003; 22: 450-451. Medicine Perspectives. 2013; 31(4): 103-4.
4. W. Horton, J. Taylor, T. Ragland, et al. Diabetic 16. Kapur S, McKendry RJ. Treatment and outcomes of
muscle infarction: a systematic review. BMJ Open diabetic muscle infarction. Journal of Clinical
Diabetes Research & Care. 1965; 3,(1): 2015. Rheumatology: 2005; 11: 8–12.
116
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MuMC Mugda Medical College Journal

ISSN (Print): 2958-1281

Chairperson : Prof. Dr. Abul Bashar Md. Jamal, Principal, MuMC.

Histopathological Diagnosis and its Pitfall:

Histopathological diagnosis and knowledge of histopathological reports in extremely low costing. As

Adolescent Pregnancy Outcome in a District

INTRODUCTION Majority of these births (95.0%) occur in low and

not accessible. The effect of time on adolescent RESULTS

Table IV: Use of contraceptives

Table V: Antenatal checkup

Table VI: Clinical state on admission

Table VII: Antepartum and Intrapartum complications

Table VIII: Mode of delivery

Mode Adolescent Adult Test of significance

Table IX: Perinatal outcome

Condition Adolescent Adult Test of significance

Better perinatal outcome found in adult group.

DISCUSSION women. For instance, in 2014 the prevalence of

INTRODUCTION: of mechanical, pharmacological and organ allocation

rate (ml/min) 84.03±17.61 Pretransplant serum

Fig.1 shows recipients graft status at 7 th

aUnpaired Student’s ‘t’ test

ns = Not significant ** = Significant at P<0.01

(Mean±SD) 108.11±123.45 51.57±11.68 0.043*

(Mean±SD) 13.68±3.13 13.76±2.41 0.930ns

(Mean±SD) 83.84±112.62 354.52±215.84 0.0001***

* = Significant at P<0.05 cFisher’sexact test ** = Significant at P<0.01

50 RGF IGF Figure 2 shows adverse events at day 7. In RGF group,

DISCUSSION: Regarding sex of donor and recipient, among the

INTRODUCTION purpose of. brevity, the guideline developers use the.

and the overall incidence is estimated to be 30-50% of RESULTS

7. Schmidt L, Munster K. Infertility, involuntary (assertatin), Dhaka Bangladesh College of Physicians

INTRODUCTION from the initiation of resuscitation continue to have

Table I: Demographic characteristics of the study population (n=147)

Table II: Baseline characteristics of the study population (n=147)

Table III: Status of the patients among lactate variability groups

Lactate variability group Survivor Non-survivor X2 P value

Group I (mild) 37(84.09%) 7(15.91%) 14.56 0.001

1. Dr. Md. Iqbal Ahmed, Assistant Professor, Department of INTRODUCTION

RESULTS Table II: Distribution of the participants by various

Observation Period Palmoplantar surface area involvement

Table IV : Distribution of participants by erythema at different follow-up periods (n=30)

Table V : Distribution of participants by hyperkeratosis at different follow-up periods (n=30)

Observation Period Hyperkeratosis

Prognosis Histopathological types

Histopathological diagnosis revealed that 52% DISCUSSION

the remaining 6 (20.0%) had 75 to 100.0% CONCLUSION

9. Palmoplantar Keratoderma [Internet]. Palmo- Journal of Bangladesh College of Physicians and

INTRODUCTION nmol/L) and (iii) sufficiency when >30 ng/mL (>75

Table III: Comparison of Renal factors in relation to vitamin-D status

Total Vitamin-D Vitamin-D Vitamin-D P

Data were expressed as mean ± SD. ANOVA test were done

DISCUSSION 14.6 ng/ml. 93.8% subjects was found either vitamin-

INTRODUCTION There are several studies done in different regions of

For males: while among 92 women, 31 had metabolic syndrome

Table-II: Performance of Visceral Adiposity Index (VAI) to predict metabolic syndrome

DISCUSSION study is expected to help clinicians diagnose

1. Dr. Adnan Yusuf Choudhury, Associate Professor, INTRODUCTION

CONCLUSION 2. JAMA 2021;325(10):998–999. doi:10.1001/

Transforming Health Professions Education for

INTRODUCTION However, around the world, health systems, and the

performance in the sector.9,17-20 Many countries campaigns to attract students to occupations

INTRODUCTION efficient, equitable and patient-centred” measures

Signature (1) Printed Name Date

Signature (2) Printed Name Date

Signature (3) Printed Name Date