Management of Hepatitis C Virus Infection - New Era Has Been Started.

Hepatitis C virus is a major cause of chronic hepatitis and is responsible for majority of liver transplantation worldwide. It has got no vaccine for prevention. Interferon containing regimen was the only management options for treatment of Hepatitis C virus till last year. Due to side effect profile and treatment cost this treatment options was not reachable for general population. Besides, response rate was not so satisfactory (Genotype 1, 40-50%, Genotype 2 & 3, 70-80%). New oral antivirals were introduced in 2014 which has got little side effect profile as well as good treatment response rate (80-95%). These new drugs with their different combination regimens along with indications, contraindications and treatment monitoring of Hepatitis C virus are discussed briefly in this review.

A Study of Snake Bite Cases in Faridpur Medical College Hospital, Faridpur.

Snakebite is one of the important cause of mortality in our country. This study was carried out to see the common type of snakes in local area with clinical presentations, complications and outcome of snake bite patients inFaridpur. Fifty cases of snakebite patients in medicine wards of Faridpur Medical College Hospital from 1st January 2012 to 31th April 2013 were studied. Among 50 snake bite patients 35 (70%) were male and 15 (30%) were female. Among them 30 (60%) were venomous and 20 (40%) snake bite cases were non-venomous.The common victims were farmers (53%) and housewives (13%). The bites were commonly encountered during rural foot walking (32%) followed by sleeping (15%). 55% were bitten during outdoor and agriculture related activities. 65% had sustained bite in lower limbs. The majority (82%) of the snakebites were observed during the month. Total 98% patients applied multiple tight tourniquets in the affected limb. A common local practice (seen in 85%) was to receive pre hospital treatment from 'Ohzas'. Among 30 poisonous cases, drooping of the upper eyelid, external ophthalmoplegia and brocken neck were the common features of poisoning. Among the 30 venomous snake bite cases 21 (70%) recovered completely after getting polyvalent antivenom serum and 9 (30%) died after admission. Total 80% cases recovered with 10 vials of polyvalent antivenom serum but others required upto 30 vials depending on severity of symptoms and its duration. No reaction to anti-snake venom was noticed.

Treating Asthma in Pregnancy - An Update.

Asthma is one of the most common chronic medical conditions affecting the lungs during pregnancy. At any given time, up to 8% pregnant women have asthma. During pregnancy, asthma not only affects the woman, but it can also cut back on the oxygen to fetus. But this does not mean that having asthma will make pregnancy more difficult or dangerous to fetus. Pregnant women who have asthma that is properly controlled generally have normal pregnancies with little or no increased risk to pregnant women or their developing babies. Currently available national guidelines for the treatment of asthma during pregnancy emphasize the objective measurement of control, patient education, motivation, caution and medication adherence. The article reviews the available literature highlighting the appropriate selection of medications in the treatment of asthma during pregnancy, and to identify those factors which may influence the asthma care provider's ability to successfully manage this condition, and also illustrate that maintaining asthma control with long term medications in pregnancy is safer than the risk of uncontrolled asthma or untreated exacerbations for both the mother and the fetus. Women's drug treatment during pregnancy should be regularly assessed in the light of asthma control criteria.

Antimicrobial Sensitivity Pattern of Helicobacter pylori Isolates among Subgroup of Bangladeshi Patients.

This cross sectional study was carried out at Bangabandhu Sheikh Mujib Medical University (BSMMU) and International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) from July 2008 to September 2009. Aim of the study was to find out the antimicrobial susceptibility profile of Helicobacter pylori isolates from dyspeptic patients. Total 224 dyspeptic patients from Out Patient Department (OPD) of BSMMU were initially enrolled after informed written consent. After upper GI endoscopy 157 patients were finally included who had erosions, ulcers or atrophic changes in the stomach or duodenum. Two biopsy samples were taken from each of them. Samples were incubated at 370C in a double gas incubator with 5%O2, 10%CO2 and 85%N2. Total 82 (52.23%) samples were found positive for H. pylori. Isolated organisms were then tested for sensitivity to Amoxicillin, Clarithromycin, Tetracycline, Levofloxacin and Metronidazole by Agar dilution method. Among 82 patients 51(62.2%) were male and 31(37.8) were female with a male:female ratio 1.6:1. Patients were categorized into two groups one having gastric or duodenal ulcer (30.5%) and other having no ulcer (69.5%). Among these isolates 92.7% were sensitive to Amoxicillin, 89% to Clarithromycin, 81.7% to Tetracycline, 80.5% to Levofloxacin and only 26.8% to Metronidazole. Beside these, 81.7% isolates were sensitive to both Amoxicillin and Clarithromycin, 74.4% to Amoxicillin and Tetracycline, 73.2% to Amoxicillin and Levofloxacin, 72% to Clarithromycin and Tetracycline, 59% to Clarithromycin and Levofloxacin and 51% to Tetracycline and Levofloxacin.

Management of Inflammation in Chronic Obstructive Pulmonary Disease-Update.

Chronic obstructive pulmonary disease (COPD) is a systemic inflammatory condition, the earliest manifestation of which is airway obstruction which is only partially reversible and the treatment rationales are provided accordingly. Research has shown that COPD-inflammation involves multiple inflammatory cells and mediators and the underlying pathology differs from asthma inflammation.For these reasons, therapeutic agents that are effective in asthma patients may not be optimal in COPD patients. COPD exacerbations are intensified inflammatory events compared with stable COPD. The clinical and systemic consequences believed to result from the chronic inflammation observed in COPD, suggest that inflammation intensity is a key factor in COPD and exacerbation severity and frequency. Although inhaled corticosteroids are commonly used and are essential in asthma management, their efficacy in COPD is limited, with only a modest effect at reducing exacerbations. The importance of inflammation in COPD needs to be better understood by clinicians, and the differences in inflammation in COPD versus asthma should be considered carefully to optimize the use of anti-inflammatory agents. Current COPD management focuses predominantly on symptom relief by optimizing bronchodilatation. The role of phosphodiesterase type 4 inhibitors (PDE4), statins, angiotensin converting enzyme inhibitors, theophylline and tumor necrosis factor inhibitors in COPD management will be reviewed. Targeting COPD inflammation with the goal of reducing exacerbations is a major focus of current clinical practice & outcome research.

Outcome of Upper Gastro Intestinal Haemorrhage - a Hospital Based Prospective Study.

Upper GI bleeding is a common medical emergency with a significant mortality, outcome of which depends upon the cause, appropriate and early intervention in a specialized center. This study was carried out to see the outcome of patient with Upper GI haemorrhage. Fifty cases with episode of upper gastrointestinal haemorrhage, admitted into medicine units of Faridpur Medical College Hospital from January 2011 to December 2011, were studied. Duodenal ulcer was the commonest cause of haematemesis and melaena followed by oesophageal varices, gastric ulcer and erosive gastritis. The peak incidence was among 35 to 45 years of age. Over all male female ratio was 4.55:1 but in case of duodenal ulcer it was 9:1. During hospital stay recurrent bleeding was noted in 10% of patients and during subsequent follow up it was 10% of the total and 50% in case of variceal bleeding group. Over all hospital mortality was 4% .

Efficacy of Different Laboratory Tests to Diagnose Helicobacter pylori Infection.

Helicobacter pylori is a Gram negative bacteria which causes chronic gastritis, peptic ulcer disease, primary B-cell gastric lymphoma, and adenocarcinoma of the stomach. There are a set of laboratory tests to diagnose H. pylori infection with a variable accuracy, they are divided into non-invasive tests and invasive tests. Non-invasive tests include serology, urea breath test (UBT) and stool antigen test (SAT). Invasive tests include rapid urease test (RUT), histology and culture. This cross sectional study was carried out in the Department of Gastroenterology, Bangabandhu Sheikh Mujib Medical University (BSMMU) and H. pylori laboratory of International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) from July 2008 to September 2009 to evaluate the efficacy of RUT, SAT and Culture as a diagnostic tool for H. pylori. Dyspeptic patients were collected from outpatient department of BSMMU. Out of 224 dyspeptic patients 149 patients had ulcers or erosions in the stomach or duodenum. Stool sample could be collected from 139 patients. RUT has sensitivity of 100%, specificity 80.28%, positive predictive value 85% and negative predictive value 100%. Regarding culture, sensitivity is 100%, specificity 94.37%, positive predictive value 95% and negative predictive value 100%. Stool antigen test has sensitivity 95.94%, specificity 92.31%,positive predictive value 93% and negative predictive value 95%.

Hyperinfection with Strongyloides stercoralis in an Immunosuppressed Patient.

Strongyloides stercoralis is a common intestinal parasite in tropics and subtropics. In Bangladesh, prevalence is likely to be high due to poor sanitation. Clinical presentations are frequently nonspecific. However, in immunosuppressed individuals, infection becomes overwhelming and may disseminate and results in high rates of mortality. Unless a high index of suspicion, this readily treatable disease may be missed. Here we report a case of hyperinfection with Strongyloides stercoralis in a patient who was on corticosteroid treatment. A 45 years old male was admitted in Gastroenterology department of Bangabandhu Sheikh Mujib Medical University (BSMMU) with the complaints of abdominal pain, vomiting and diarrhea for 2 weeks. He was on prednisolone 60 mg with omeprazole 40 mg daily for 4 weeks for his eyelid drooping prior to the development of abdominal symptoms. Physical examination revealed a severely malnourished, moderately anemic patient with muscle wasting, angular stomatitis, desquamated skins of feet and hands. Abdominal examination revealed generalized tenderness with moderate ascites. Investigations revealed Hb-7.4 gm/dl with normal WBC count (eosinophil-11% before steroid therapy), S.albumin-19gm/l with prolonged prothrombin time and hypokalemia. USG of abdomen revealed moderate ascites. Endoscopy of upper GIT showed congestion and multiple erosions in the stomach and also in the duodenum. Biopsy from the duodenum revealed adult Strongyloides stercoralis on the surface, larva and ova in the duodenal crypts. The patient was treated with 10 days of oral ivermectin along with blood transfusion, correction of nutritional status and electrolyte imbalance. Patient was discharged home after a total of 20 days of hospitalization.

A Case Report on Recurrent Lepra Reaction-Type 2.

Lepra Reactions (LR) comprises immunologically mediated inflammatory states that cause considerable morbidity. Type-2 LR occurs exclusively in patients with the lepromatous end of the leprosy spectrum (BL-LL). In 90% of the cases it follows during or after completion of chemotherapy, generally within 2 years. Here we report a case of type-2 LR. He is a twenty years old fisherman with history of hypopigmented skin lesion 3 years back and was treated as a case of lepromatous Leprosy (LL). After six months of completion of treatment he developed type-2 LR presenting with recurrent bouts of fever, polyarthritis, erythema nodusum, orchitis, mononeuritis multiplex and was treated in Faridpur Medical College Hospital (FMCH) on three occasions within last one and half years.

EPI Coverage among Under 5 Children Attending Pediatric Department of Dhaka Medical College Hospital.

This cross-sectional study was carried out among 1000 children between 10 months to 5 years of age during November 2004 to February 2005 attended in the department of pediatrics, Dhaka Medical College Hospital (DMCH) with different childhood illness. Aim of study was to know the Immunization (EPI) coverage, dropout rate and factors influencing dropout. According to parent's statement, 82.5% of the children were fully, 16.1% were partially and 1.4% were non-immunized. Specific immunization coverage revealed that, 97.3% were immunized with BCG, 96.7% with DPT1/OPV1, 92.9% with DPT2/OPV2, 91% with DPT3/OPV3 & 84% with measles vaccine. Among the BCG vaccinated children 91.77% had BCG scar. Drop out of DPT1-DPT3 was 5.78% & DPT1- measles was 12.88%. The main reason found for non-immunization were lack of faith in programme (57.1%), lack of awareness (21.4%), and fear of side effects (21.4%), whereas lack of awareness (41.6%) and illness of child (32.9%) played role behind drop out. Drop out cases were found to be associated with female sex, parent's illiteracy, higher number of children in the family and father's occupation (p<0.001), whereas mothers occupation had no independent effect on coverage (p>0.05). The study findings suggested that despite the effort taken by Government and NGOs to expand coverage, dropout rates are unacceptably high. To combat this challenge counseling and motivation on EPI, improvement of information system, health education and training of health workers are required.

Evaluation of Prescribing Pattern of the Private Practitioners in Bangladesh.

A prescription order is a written instruction of doctors to pharmacist to supply drugs in particular form to a patient and the directions to the patients regarding the use of medicines. This study was undertaken to observe the prescribing patterns of the private practitioners in Bangladesh, 430 prescriptions were collected randomly from Dhaka city and analyzed using WHO/INRUD indicators. There were average 3.40 drugs per prescription. Drugs were prescribed in generic name only in 0.20%. About 46.31% drugs were prescribed from the Essential Drug List, only 19% of prescriptions were complete in respect to patient medication information. Antibiotics were prescribed in 70.33% of the prescriptions; injections were prescribed in about 8.35% of the prescriptions.

Cutaneous Manifestations of Chronic Kidney Disease-An Observational Study in 100 Cases.

Chronic Kidney Disease (CKD) presents with an array of cutaneous manifestations. Newer changes are being described since the advent of haemodialysis, which prolongs the life expectancy, giving time for these changes to manifest. This cross sectional study was performed in 100 cases of CKD admitted in nephrology department of Dhaka Medical College Hospital (DMCH) and Bangabandhu Sheikh Mujib Medical University (BSMMU) from April 2008 to August 2008 to evaluate the prevalence of dermatologic problems. Among them most belong to 2nd to 5th decade, 68 are male and rests are female. Glomerulonephritis (44%), Diabetes mellitus (22%), Obstructive uropathy (13%) and Hypertensive nephropathy (12%) are found common causes of CKD. Among these patients 38% patients were treated with conservative treatment, 31% with intermittent peritoneal dialysis (IPD), 19% with haemodialysis and 12% with some form of immunosuppressive therapy. Total 88% of study population had some form of skin disorder; pallor was the most common (82%), while xerosis (61%), pruritus (53%), pigmentation (37%) and bacterial infection (37%) were other common problems. Purpura and fungal infection was 29% and 27% respectively. Viral infection (9%), dermatitis (4%), gynaecomastia (1%), kyrle's disease (3%) are relatively less common findings. Lindsay's nail was seen in 23% of patients and was more prevalent in glomerulonephritis and diabetic patients with prevalence of 13% and 9% respectively. Other nail changes included koilonychia (4%), subungual hyperkeratosis (1%), splinter hemorrhages (3%) onychomycosis (8%) and Beau's lines (1%). So, CKD is associated with a complex array of cutaneous manifestations caused either by the disease or by treatment.

Risk Factor for Relapse in Childhood Nephrotic Syndrome - A Hospital Based Retrospective Study.

Nephrotic Syndrome (NS) is a common childhood illness characterized by massive proteinuria, hyperlipidemia, hypoalbuminemia & edema. NS is a disease of relapse and it is a major problem to manage the cases with frequent relapse. So it is very important to find out such children who are prone to develop frequent relapse. This retrospective study was conducted in the paediatric department of Dhaka Medical College Hospital (DMCH) from January to December 2005.Total 100 children with relapsed NS of them 50 had Frequent Relapse NS (FRNS) and 50 had Infrequent Relapse NS (IFRNS) were included in the study with a view to find out the risk factors for relapse. Data were collected from previous medical and hospital records. Data were analyzed by using SPSS program. Chi-squared test and Student's t-Test were used as statistical test and p value < 0.05 was taken as significant. NS was more common among 2-6 years of age (67%) with male to female ratio roughly 2:1. Most of patient with frequent relapse had age <5 years, came from rural area and belongs to poor social class compared to that of infrequent relapse. The mean age at first onset was significantly less in frequent relapse group than that of infrequent relapse group. Majority of atopic child belongs to frequent relapse cases. Low serum albumin level, low serum total protein level, culture positive Urinary Tract Infection (UTI) at initial attack were observed to be statistically significant in case of frequent relapse group.

Familial Hypoparathyroidism with Pregnancy- Challenging Issue for Patient as well as for Physician.

Familial hypoparathyroidism is a rare cause of hypoparathyroidism. It may be x-linked recessive, autosomal dominant or autosomal recessive. In autosomal dominant hypoparathyroidism there is activating mutation of the calcium sensing receptor leading to inhibition of Parathormone (PTH) secretion at inappropriately low serum ionized calcium level. The disease often manifests in the first decade but may appear later. Clinical signs primarily involving neuromuscular disturbances including generalized seizure. Management of pregnancy in hypoparathyroidism is challenging as both under treatment and over treatment is dangerous for fetus. Treatment of hypoparathyroidism in pregnancy includes combination of oral calcium supplementation with calcitriol with an aim to keep serum calcium within normal range. Here we discussed a case of 21 year pregnant lady with familial hypoparathyroidism with successful delivery of a healthy baby.

Improper Inhalation Technique-A Barrier to Good Asthma Control.

Bronchial Asthma (BA) is a chronic airway disorder with significant morbidity and mortality but due to recent advances in the field of medicine most patients with BA can have complete symptom control and live a normal life. There are various routs of drug delivery for asthma control but among them aerosol inhalation is considered the optimal route. A number of pressured Metered Dose Inhalers (MDI) & Dry Powder Inhalers (DPI) are available for this purpose. However inhalation of therapeutic aerosols is not without difficulty, it requires precise instructions on the inhaler maneuvers, which is different from spontaneous normal breathing. Also, the characteristics of the inhaler device have to be suitable for the user. Available data indicate that, lack of knowledge demonstrated by health professionals & patients on the inhalation maneuvers & handling of inhalers resulting in a reduction of therapeutic benefit. The paper reviews the literature concerning the fundamental aspects of inhaler devices, inhalation maneuvers & device selection, in an attempt to increase the knowledge of and to optimize the clinical use of therapeutic inhalers. As a result of which Asthmatics can be kept under good control.

Prospective Study of Bronchial Asthma.

Bronchial asthma is an atopic disease characterized by chronic airway inflammation and hyper-responsiveness. Severe acute asthma is a medical emergency and sometimes difficult to treat. This prospective study was done at Dhaka Medical College Hospital from January 1997 to January 1998. Total 30 patients of bronchial asthma were included in this study. Diagnosis was established on the basis of symptoms, evidence of airflow obstruction and its reversibility by bronchodilator therapy. The age range was 18 to 80 years with a mean 36.64±4.91. Of them, 63% were male and 37% were female. It revealed that all patients had classical triad of dyspnoea, wheeze and cough. Almost all patients (80%) had some precipitating agents for their attack. Regarding treatment of severe acute asthma - Nebulized salbutamol is superior to conventional intravenous aminophylline, as p value of nebulized salbutamol group is <0.001 which is significant. So, severe acute asthma should be managed with nebulized salbutamol instead of intravenous aminophylline.

Clinical Presentation, Histological Findings and Prevalence of Helicobacter pylori in Patients of Gastric Carcinoma.

Carcinoma stomach is the second leading cause of cancer death worldwide. This study was undertaken to determine the clinical and pathological profile of carcinoma stomach in Bangladesh and to find out the prevalence of H. pylori infection in carcinoma stomach subjects. Patients with carcinoma stomach confirmed on histopathology were included in the study. Data were recorded regarding demography, clinical features, blood group of the patients, location and macroscopic type of the cancer at endoscopy. Three to five biopsies from non-necrosed region and two paired biopsies from non-cancerous part of stomach were taken. One piece of each paired specimen was placed in the urea-agar media for CLO test and the other piece was used for histological examination. Out of 50 patients, 64% were male and 36% were female. The mean age was 51.05±14.98 years. Common presenting complains were dyspepsia/ abdominal pain, vomiting and dysphagia; abdominal mass, metastatic lymph node and ascites were predominant signs. About one third (34%) patients had blood group A. About 50% cancer was located in antrum followed by antrum and body (24%), then body (18%), fundus and body (4%) and fundus (4%). In 56% cases the lesion was ulcerative followed by polypoid (34%) and ulceroinfiltrative (10%). Histopathologically 52% was intestinal type, 28 % was diffuse type 20% was poorly differentiated adenocarcinoma. The prevalence of H. pylori in overall carcinoma stomach cases was 60% but individually in intestinal type 88%, in diffuse type 57% and in poorly differentiated type 50%.

" Lutembacher's Syndrome " - A Case Report.

Lutembacher's Syndrome is a rare heart disease comprises ASD (congenital) secundum with Mitral stenosis (Rheumatic origin). The patient Md. Mosharraf Hossain, 72 years old man, non diabetic, non hypertensive, smoker admitted in FMCH on 10.10.2010 with the complaints of respiratory distress and chest pain for 10 days. He had a previous history of Rheumatic fever in early childhood. There was history of recurrent attack of Rheumatic fever. Subsequently he developed MS from Rheumatic carditis. ASD was congenital in origin. If diagnosis could be done earlier, surgical closure of ASD with replacement of mitral valve bears a good prognostic value. Our patient is in elderly age and already developed pulmonary hypertension, operative procedure is not suitable. So the patient should be kept in conservative treatment.

A Case Report of Adrenal Pheochromocytoma.

Pheochromocytoma is a rare catecholamine secreting tumour originating usually from adrenal medulla and produces signs and symptoms due excessive catecholamine secretion from tumour. A young female patient of 21 year age presented with paroxysmal attacks of hypertension causing palpitation, dizziness, blurring of vision and headache for last 06 months. Clinical suspicion of pheochromocytoma was confirmed by 24 hour urinary catecholamine level, transabdominal USG and CT scan of abdomen. After having two weeks of preoperative preparation with phenoxybenzamine and propanolol, open surgical removal of pheochromocytoma was done. Peroperative fluctuation of BP was well managed by IV fluid overload, intravenous phentolamine, intravenous esmolol and intravenous ephedrine. Postoperative recovery was uneventful and BP regains to normal range from 1st postoperative day. Pheochromocytoma is a rare cause of hypertension. If the diagnosis of pheochromocytoma is overlooked, the consequences could be disastrous, even fatal; however, if a pheochromocytoma is identified, it is potentially curable, as being one of the cause of surgically correctable hypertension.