Professional Documents
Culture Documents
2022 12 13 06 59
2022 12 13 06 59
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
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
54
Original Article
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
55
MuMC Journal Volume 5, No. 2 July 2022
56
MuMC Journal Volume 5, No. 2 July 2022
Complication rate were more in adolescent group, like preeclampsia (12%), eclampsia (14%), preterm labor
(12%), prolonged labor (14%), obstructed labor (8%).
57
MuMC Journal Volume 5, No. 2 July 2022
58
MuMC Journal Volume 5, No. 2 July 2022
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]
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MuMC Journal Volume 5, No. 2 July 2022
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MuMC Journal Volume 5, No. 2 July 2022
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
47.5
Anti CMV (IgG)
52.5
Positive 36 90.0
Negative 4 10.0
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***
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MuMC Journal Volume 5, No. 2 July 2022
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)
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
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MuMC Journal Volume 5, No. 2 July 2022
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MuMC Journal Volume 5, No. 2 July 2022
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
MuMC Journal Volume 5, No. 2 July 2022
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
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MuMC Journal Volume 5, No. 2 July 2022
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
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MuMC Journal Volume 5, No. 2 July 2022
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.
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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,
Dhaka Medical College Hospital, Dhaka-1000.
3. Dr. Md. Siddiqur Rahman, Assistant Professor, Department of Anaesthesia, Analgesia, Palliative and Intensive Care Medicine,
Dhaka Medical College Hospital, Dhaka-1000.
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]
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MuMC Journal Volume 5, No. 2 July 2022
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MuMC Journal Volume 5, No. 2 July 2022
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).
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MuMC Journal Volume 5, No. 2 July 2022
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
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MuMC Journal Volume 5, No. 2 July 2022
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
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MuMC Journal Volume 5, No. 2 July 2022
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.
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MuMC Journal Volume 5, No. 2 July 2022
Table III: Distribution of participants by palmoplantar surface area involvement at different follow-up periods (n=30)
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.
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
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MuMC Journal Volume 5, No. 2 July 2022
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)
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MuMC Journal Volume 5, No. 2 July 2022
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MuMC Journal Volume 5, No. 2 July 2022
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
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MuMC Journal Volume 5, No. 2 July 2022
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
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MuMC Journal Volume 5, No. 2 July 2022
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.
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MuMC Journal Volume 5, No. 2 July 2022
85
MuMC Journal Volume 5, No. 2 July 2022
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
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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]
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MuMC Journal Volume 5, No. 2 July 2022
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.
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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
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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%)
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MuMC Journal Volume 5, No. 2 July 2022
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.
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MuMC Journal Volume 5, No. 2 July 2022
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.
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MuMC Journal Volume 5, No. 2 July 2022
97
Review Article
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
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MuMC Journal Volume 5, No. 2 July 2022
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
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MuMC Journal Volume 5, No. 2 July 2022
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
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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
MuMC Journal Volume 5, No. 2 July 2022
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
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]
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MuMC Journal Volume 5, No. 2 July 2022
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
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MuMC Journal Volume 5, No. 2 July 2022
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];
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MuMC Journal Volume 5, No. 2 July 2022
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
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MuMC Journal Volume 5, No. 2 July 2022
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
MuMC Journal Volume 5, No. 2 July 2022
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
110
MuMC Journal Volume 5, No. 2 July 2022
111
MuMC Journal Volume 5, No. 2 July 2022
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
113
MuMC Journal Volume 5, No. 2 July 2022
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
MuMC Journal Volume 5, No. 2 July 2022
115
MuMC Journal Volume 5, No. 2 July 2022
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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