Bacteriological Spectrum of Different Infections and their Antibiogram at NICVD, Dhaka.

Background: One of the major causes of death in the current era is the infectious diseases. Aerobic bacteria are one of the most commonly isolated organisms from hospitalised patients. Objectives: The aim of the present study was to observe the infections caused by aerobic bacteria and their antibiotics susceptibility pattern. Methods: This retrospective study was carried out in the National Institute of Cardiovascular Diseases (NICVD) from January 2012 to December 2012 for a period of one year. Patients who were admitted in medical wards and medical ICU suffering from different infections were undertaken for this study. Proper thoroughly clinical examination, routine and specific investigations were done in each case. Microbiological samplings were tried on day 1, after completion of antibiotic therapy or in between as required. Aerobic bacterial culture and sensitivity tests were done according to clinical laboratory standard institute (CLSI) standard. Result: A total of 660 samples were studied of which male (70.0%) were predominant than female (30.0%). The highest number of patients was in the age group of 30-60 years (54.0%) followed by 15-30 years (21.5%) and less than 15 years (13.0%). The mean age with standard deviation was 38.61±19.236 years. The most common isolated bacteria was Escherichia coli (40.1%) followed by Pseudomonas species (30.4%), coagulase negative Staphylococcus (19.0%) and coagulase positive Staphylococcus (5.9%); however, beta-haemolytic Streptococcus (4.2%) was detected. Urine culture has yielded Pseudomonas species (13.3%), E. coli (71.1%) and CNS (15.0%). From pus Pseudomonas species (37.3%) was isolated mostly which was 62 cases followed by E. coli (31.3%), CNS (19.3%) and CPS (7.2%). Pseudomonas species was resistant to penicillin, amoxycillin and vancomycin and ~50% resistant to cotrimoxazole, cefuroxim, ceftriaxone, piperacillin, azythromycin, cephalexin, netelmycin and pfloxacillin. Conclusion: In the conclusion, majority bacteria are resistant to commonly used antibiotics.

Early Outcome of Laparoscopic Abdominoperineal Resection, Our Experience in Bangabandhu Sheikh Mujib Medical University.

Anorectal malignancies that require abdominoperineal resection (APR) is very common. Laparoscopic APR can be a better option. Laparoscopic APR has been seldom studied. This study aims to evaluate perioperative and early postoperative outcomes of laparoscopic APRs performed for the treatment of ano-rectal carcinomas. Patients operated for ano-rectal carcinoma between June 2011 to June 2013 in Bangabandhu Sheikh Mujib Medical University (BSMMU) were observed. Demographics, tumor and procedure-related parameters, perioperative results, early postoperative outcomes and survival were observed. Total 22 patients were under went laparoscopic APR. Male: Female ratio was 15:7 (68.18%: 31.82%). Age range was from 30-65 years with a mean age of 36.55 years. Mean operation time was 165 minutes and mean post-operative hospital stay was 6.8 days. Overall complication rate was 45.45%. Laparoscopic APR is a safe, effective and technically feasible procedure. It can be a better operative procedure than open APR.

A Case Report of Middle Aortic Syndrome: A Rare Vascular Disorder.

The middle aortic syndrome (MAS) is rare (about 0.5-2% of all the cases of aortic coarctation) vascular disorder characterized by severe narrowing in the descending thoracic aorta, abdominal aorta, or both. It can be congenital or acquired due to several conditions.MAS may present clinically as uncontrolled hypertension, abdominal angina or lower limb claudication. Surgical treatment is effective in controlling symptom and improves life expectancy.

Inequity of diagnosis of diabetes by plasma glucose and HbA1c.

Objective: Both plasma glucose and glycosylated hemoglobin are the recommended tools to diagnose diabetes by the International Expert Committee and World Health Organization (WHO). The aim of this study was to compare these two parameters in the diagnosis of diabetes in a selected group of Bangladeshi subjects. Materials and Methods: This cross-sectional study included 800 subjects attending the outdoor in a tertiary healthcare center during the period of September 2009 to September 2010. Fasting, postprandial (2 hours after glucose load) plasma glucose and HbA1c were measured. Diabetes is defined according to HbA1c and plasma glucose. Subjects were classified into three groups according to HbA1c values (HbA1c: =6.5%, HbA1c: 6.0-6.4% and HbA1c: < 6.0%) and also in the diabetics, prediabetics (IGT+IFG) and nondiabetics by plasma glucose. Results of the HbA1c classified subjects were compared with the plasma glucose classified subjects to see the inequity of classification. Results: Inequity of classification occurred for 11.87% of the total subjects with HbA1c =6.5% but impaired (8.25%) and nondiabetic (3.62%) by plasma glucose; for 10.13% of the subjects with HbA1c: 6.0-6.4% but diabetic (3.25%) and nondiabetic (6.88%) by plasma glucose, and for 8.5% of the total subjects with HbA1c <6.0% but diabetic (1.88%) and impaired (6.62%) by plasma glucose. Concordant classification occurred for 69.5% and inequity of classification occurred for 30.5% of the total study subjects. Conclusion: Inequity of classification of diabetes by HbA1c and plasma glucose is remarkable in the study population.

Comparison of C-reactive protein among controlled, moderately controlled and uncontrolled diabetic subjects in a Bangladeshi population.

Poor glycemic control is significantly associated with the development of macrovascular complications of diabetes. C-reactive protein (CRP) is considered as a sensitive and independent risk factor for cardiovascular events. The aim of this study was to compare elevated CRP among controlled, moderately controlled and uncontrolled diabetic subjects in a Bangladeshi population. CRP and glycosylated hemoglobin A1c (HbA1c) were measured in 226 confirmed diabetic subjects purposively and randomly. Elevation of CRP in the moderately controlled (relative risk 1.64, P<0.01) and uncontrolled diabetic subjects (relative risk 1.8, P<0.001) were significantly higher than controlled diabetic subjects. HbA1c was significantly associated with the likelihood of elevated CRP in the moderately controlled diabetic subjects (OR:2.87, 95% CI: 1.41 to 5.87, P<0.01) and in the uncontrolled diabetic subjects (OR:3.83, 95% CI: 1.94 to 7.58, P<0.001). This study revealed that the likelihood of elevated CRP is associated with the increase of HbA1c in diabetic subjects.

Evaluation of alternative diagnostic techniques for diagnosis of cerebral malaria in a tertiary referral hospital in Bangladesh.

Five alternative techniques for diagnosis of malaria were evaluated in 124 clinically diagnosed cerebral malaria cases admitted in a tertiary hospital in Bangladesh. Clinical diagnosis of cerebral malaria was done by WHO criteria. The tests were conventional routine malaria microscopy; prolonged microscopy; dipstick antigen capture assay (Para Sight TM-F test); pigments in peripheral leucocytes and routine microscopy repeated at 12 hours interval. First four tests were done at 0 hours of hospital admission and repeat routine microscopy was added at 12 hours interval. Diagnostic capability of the test was 64%, 65%, 69%, 27% and 63% respectively. None of the tests except pigments in peripheral leucocytes was superior at initial evaluation. Only the dipstick test added 5% more diagnostic possibility compared with routine microscopy as standard. Stratification of diagnostic capability in different ways improved diagnosis 15% and 11% in smear negative cases by dipstick and prolonged microscopy respectively. It was increased by 50% (5/10 patients) with dipstick test in the smear negative patients with history of anti-malarials prior to hospital admission.

Anti-snake venom: use and adverse reaction in a snake bite study clinic in Bangladesh

Snakebites can present local or systemic envenomation, while neurotoxicity and respiratory paralysis are the main cause of death. The mainstay of management is anti-snake venom (ASV), which is highly effective, but liable to cause severe adverse reactions including anaphylaxis. The types of adverse reaction to polyvalent anti-snake venom have not been previously studied in Bangladesh. In this prospective observational study carried out between 1999 and 2001, in the Snake Bite Study Clinic of Chittagong Medical College Hospital, 35 neurotoxic-snake-bite patients who had received polyvalent anti-snake venom were included while the ones sensitized to different antitoxins and suffering from atopy were excluded. The common neurotoxic features were ptosis (100%), external ophthalmoplegia (94.2%), dysphagia (77.1%), dysphonia (68.5%) and broken neck sign (80%). The percentage of anti-snake venom reaction cases was 88.57%; pyrogenic reaction was 80.64%; and anaphylaxis was 64.51%. The common features of anaphylaxis were urticaria (80%); vomiting and wheezing (40%); and angioedema (10%). The anti-snake venom reaction was treated mainly with adrenaline for anaphylaxis and paracetamol suppository in pyrogenic reactions. The average recovery time was 4.5 hours. Due to the danger of reactions the anti-snake venom should not be withheld from a snakebite victim when indicated and appropriate guidelines should be followed for its administration.(AU)

Arthrographic distension of the shoulder joint in the management of frozen shoulder.

The study was an open randomized controlled trial to compare the outcome at 8 weeks with two different modalities in the treatment of 'Frozen shoulder'. Clinical cases with painful limitation of movement of shoulder were randomized to receive physical therapies alone versus physical therapies and shoulder arthrography with intra-articular steroid in a sequential randomization process. Cases suspected of having a concomitant illness and has potential to cause secondary frozen shoulder were excluded, such as, history of trauma to shoulder over the last 6 months, symptomatic clinical cervical degenerative diseases, and causes in and around the shoulder (infective and non-infective). Physical Therapies provided to all patients were therapeutic exercises, transcutaneous electrical nerve stimulation (TENS) and infra-red radiation (IRR). Outcome measures were improvement of pain on a Visual Analogue Scale (VAS) score and range of motion measured by Goniometer at 8 weeks. Patients were followed weekly for 8 weeks and outcome parameters were recorded on every evaluation. The baseline range of motion in the two groups was comparable. At 8 weeks a statistically significant difference in outcome were observed in the two groups. The chi-square means difference of improvement in range of motion for abduction was p <0.00 and for external rotation was p <0. 00. The pain reduction on VAS score was not significant in the two groups (p <0. 40). In the present small series, the distension arthrography with intra-articular (IA) steroid plus physical therapy was superior over physical therapy alone in the functional improvement of the frozen shoulder. Further studies with larger sample size are required to confirm the observations.

Prognostic factors relating to outcome of severe malaria among children in Bangladesh.

This study was done in the Paediatric in-patient department of Chittagong Medical College Hospital (CMCH), Chittagong, Bangladesh to identify and quantify the prognostic factors associated with increased mortality in severe malaria (SM) cases. All the patients with parasitologically confirmed clinical syndromes of SM, admitted between June 1997 and May 1998, were included. A total of 53 consecutive cases were studied. Cerebral malaria (CM) was the commonest type of SM, observed in 36(68%) cases, second commonest type was severe anaemia 13(25%). More than one type of severe manifestations were present in 23(44%) cases. Overall case fatality rate (CFR) was 17% and it was 30% among those who had multi-organ manifestations. Important poor prognostic clinical variables were Blantrye coma score (BCS) score of 0 and 1 on day 1 (OR = 7.78) and day 2(OR = 40.0), multi-organ manifestations (OR = 6.8) and in-hospital complications (OR = 5.18). Important poor prognostic laboratory variables were day 2 parasite count > 50,000/cmm (OR = 5.5), blood glucose < 2.2 mmol/l (OR = 21.5) and raised CSF protein > 50 mg/dl (OR = 7.0). It can be concluded that certain clinical variables e.g. low BCS on day 1 & 2, multi-organ manifestations, in-hospital complications; and laboratory variables e.g. high parasite count, low blood glucose level, raised CSF protein levels are associated with increased mortality rate in SM cases.

Monitoring efficacy of commonly used antimalarials by a 14-day in-vivo test in a new settler's camp in endemic zone at Cox's Bazar.

The study was done in a new settler's camp "Barachara" under Sadar thana of Cox's Bazar district. It has a total population of 784 of all age groups, registered in the middle of the study period. A prospective evaluation of all cases of fever were done over 12 months, to see the pattern of febrile illness among the population and to compare the therapeutic efficacy of two alternative drug regimens for uncomplicated falciparum malaria (UM). Blood for malarial parasite (MP) was done in all cases of fever and was treated in line with the new clinical case definitions and treatment guidelines for malaria in Bangladesh. Slide positive UM cases were subjected to a "14-day in-vivo test" for therapeutic efficacy testing of antimalarial agents. The two drug regimens were randomised by lottery--a) 3 days oral chloroquine plus single dose sulphadoxin/pyrimethamine (CQ + SP) and, b) 3 days oral quinine plus single dose sulphadoxin/pyrimethamine (Q3 + SP). Drug administration was supervised by the field assistant and was followed up on days 3, 7 and 14 for blood slide examinations and clinical assessment. Sensitive response was observed in 79% of the cases in the CQ + SP group and 84% in the Q3 + SP group. Early treatment failure (persistently febrile and parasitaemic on days 3 or 7) was observed in 16% in the CQ + SP group and 9% in the Q3 + SP group. Both the evaluated drug regimens had less than 20% failures and can be used as alternative first line agents and Q3 + SP regimens can also be used as the second line agents for treatment failure (to chloroquine and/or SP) UM cases in the study area.

Cerebral malaria--a study of 104 cases.

One hundred and four adult cases of cerebral malaria (73 male, 31 female) were studied between July 1995 to June 1996 in Chittagong Medical College Hospital. Diagnosis of cerebral malaria was based on unrousable coma or any neurological manifestation in a febrile patient with asexual Plasmodium falciparum in blood film. Intermittent fever (83%), vomiting (80%), headache (75%), convulsion (60%) and history of travel or residence in malaria endemic area were important features noted in patients with cerebral malaria. Most of the patients (69%) were admitted within 25 to 48 hours following unconsciousness. The factors are more common in cases with high mortality with diastolic blood pressure (DBP) below 60 mm of Hg, anaemia, persistence of Glasgow Coma Score below 5 on day 2, high parasite count at presentation, proteinuria and high level of serum urea. Out of 104 cases of cerebral malaria 66 patients (63.5%) recovered without sequelae, 34 patients (32.7%) died and 4 patients (3.8%) recovered with some residual sequelae. Establishment of intensive care unit in tertiary level hospitals is necessary to take appropriate measure for severe cerebral malaria cases for reduction of mortality.