Aorto-bi-Femoral Bypass for Juxtarenal Aortic Occlusion in a Patient with Multiple Co- Morbidities: Report of a Challenging Case.

Aorto-bi-femoral bypass for aorto-iliac occlusive disease is a fairly common procedure in vascular surgical practice. The procedure, despite its extensive nature, is generally well tolerated particularly by those having an infrarenal type of aortic occlusion. Patients having a juxtarenal aortic occlusion require a considerably more expeditious surgery necessitating maneuvers to protect the renal arteries. Surgical risk increases significantly in those having multiple co-morbid conditions. We report here a successful case of aorto-bi-femoral bypass for juxtarenal aortic occlusion in a patient having multiple co-morbid conditions like ischemic heart disease, occluded right renal artery with chronic kidney disease, severe malnutrition, hypertension and chronic obstructive pulmonary disease

Recent Advancement in Non-surgical Interventional Treatment in Congenital Heart Disease at National Institute of Cardiovascular Disease (NICVD)-a Tertiary Care Hospital of Bangladesh.

Background: Treatment of Congenital Heart Disease (CHD) is either Surgical or Interventional. Medical management is mainly symptomatic / palliative. Although surgery is the main mode of treatment but in the recent past non-surgical Interventional method is replacing it because of its multiple advantages over surgical procedures. Since 2005, we started our journey in National Institute of Cardiovascular Diseases with a PDA device closure. In this article we tried to review the success rate of the interventional procedures in this hospital. Methods: The aim of this retrospective study is to review the short term & Intermediate outcome of the non surgical interventional treatment of congenital heart diseases. We included all the interventional rocedures done in this Institute since 2005 upto December 2013. Results: During this period, we performed total 150 cases of patent ductus arteriosus (PDA) device, 20 cases of PDA Coil closure, 60 cases of atrial septal defect (ASD) device, 90 cases of Balloon Pulmonary Valvuloplasty (BPV), 20 cases of Balloon Aortic Valvuloplasty (BAV), 22 cases of Coarctation Balloon Angioplasty, 35 cases of Mitral Valvuloplasty (PTMC), 15 cases of Balloon Atrial Septostomy. Almost all of our intervention procedures were successful except one case of mortality related to procedure of PDA device closure, 4 device embolization (2 ASD & 2 PDA) and one case of PDA coil with persistent Intravascular hemolysis. All the embolized devices were subsequently retrieved surgically with repair. All other patients of interventional treatment are enjoying new life without any morbidity. Conclusion: Thus, we concluded that interventional methods of suitably selected case of congenital heart disease may be an alternative lucrative safe & effective option of remedy for many of the congenital heart diseases.

effects of sevoflurane and propofol anesthesia on renal sodium-potassium adenosine triphosphatase activity during pneumoperitoneum in rats

To evaluate the renal sodium-potassium adenosine triphosphatase [Na+/K+ATPase] activity, kidney morphology, and the probable protective effects of 2 different anesthetic agents used during pneumoperitoneum [PP]. The study was performed at Gazi University Experimental Research Center, Ankara, Turkey between January and July 2009. Twenty-four Wistar albino male rats weighing 320-380 g were randomly allocated to 4 groups after receiving ethics committee approval. All rats were cannulated, intubated, and ventilated under ketamine anesthesia. No further surgical intervention was performed for group I. An intraabdominal pressure [IAP] of 10 mm Hg was created by CO[2] insufflation in 18 animals for one hour. The animals in group II received no further anesthetic agents, while the animals in groups III and IV received propofol and sevoflurane. At the end of the protocol, all animals underwent left nephrectomy without sacrificing. Urine was collected from each animal for the following 24 hour for the evaluation of urine creatinine and protein. The activity of renal Na+/K+ATPase was significantly lower in groups II [p=0.014], III [p=0.019], and IV [p=0.032] compared to group I. The pathological score was significantly higher in groups II [p=0.017], III [p=0.028], and IV [p=0.039] compared to group I. No statistically significant difference was found among groups II, III, and IV in terms of Na+/K+ATPase activity and pathological scores. Elevated IAP is related with impaired kidney functions and morphology, and the so-called renoprotective agents neither improved, nor worsened PP-related renal impairment

Health insurance and the ethical issue of equity

Health insurance planned and implemented according to the shari'at is considered a form of mutual self-help, takafulijtimae. The purpose of protecting life, maqsadhifdh al nafs, makes equitable access to the basic and necessary health services a basic right of every citizen to be fulfilled by the family, the community and the state in that order of increasing responsibility. Health services beyond the basic necessary ones are considered a privilege; they fall under the categories of needs, haajiyaat; complements, mukammilaat, and embellishments, tahsinaat, that can be provided to each according to economic ability. Health insurance helps reduce disparities in health care among various socio-economic groups but does also introduce new ones. This paper reviews empirical experiences of various aspects of health insurance from the perspectives of purposes of theshari'at and as they relate to the major ethical issue of equity. The issues reviewed are: access, coverage, type of care, quality of care, utilization of services and type of insurance. The paper reaches two conclusions: [a] health insurance improves access to health care but does not always assure equity, [b] private insurance is generally more effective but has objectionable aspects from the Islamic Law perspective. The paper recommends adopting some of the free market tools of private insurance to increase quality and efficiency of government or cooperative community insurance but making sure that the objections of jurists to commercial insurance are eliminated.

Residual Ventricular Septal Defect after Surgical Repair of TOF—A Case Report.

Residual Ventricular septal defect after surgical repair for Tetralogy of fallot(TOF) can occasionally be heamodynamically important requiring re-intervention.Closed observation and followup make this defect heamodynamically insignificant, required no medication and no endocarditis.We describe one patient having residual defect after surgical repair of TOF.

Double Chamber of Right Ventricle (DCRV) - A Case Report.

Primarily double chamber of Right ventricle (DCRV) is an uncommon congenital anomaly consists of one or more anomalous muscle bundles(AMB) that divide Right ventricle into proximal high and distal low pressure chamber .Outcome of surgical treatment is excellent if diagnosed properly. A 5years old girl presented with breathlessness on exertion and repeated attack of cough, fever for last 4 years .patient ultimately diagnosed as DCRVand underwent intracardiac repair by open heart surgery. Her postoperative outcome was uneventful. Patient is discharged on 8th postoperative day after follow up postoperative chest X Ray and Echocardiography .

Ventricular Septal Defect in Children with Down Syndrome-Two Case Reports.

The association of Down syndrome (DS) with congenital cardiovascular malformation is well established. Complete atrioventricular septal defects have been associated most commonly with DS. There are also reports of VSD, ASD, TOF and PDA with DS. We here reported two patients of Down syndrome with ventricular septal defect (VSD), underwent repair of VSD, diagnosis was suggested by echocardiography and confirmed by surgery and chromosomal study. Both the patient discharged from hospital with good result. Survival and quality of life have been improving in patient with Down syndrome after repairing VSD.

Total Anomalous Pulmonary Venous Connection (TAPVC) (Supra cardiac type)- A Case Study.

Repair of Total Pulmonary venous connection (TAPVC) continues to be associated to significant mortality and morbidity.We here reported a female patient of two and half years, underwent rechanneling of supracardiac TAPVC, diagnosis was suggested by Echocardiography and confirmed by catheter-angiography which allowed definition of the anatomy. The patient has got fluent pulmonary venous drainage and her heart function resumed to NYHA I. TAPVC should be operated on immediately at definite diagnosis, the fluency of common pulmonary vein-left atrium anastomosis and proper post operative care can ensure a satisfactory outcome.

Effect of Tranexamic Acid after Cardiac Surgery in Children.

Background: The antifibrinolytic drug tranexamic acid (TA) decreases blood loss in Pediatric patients under going cardiac Surgery. However its efficacy has not been extensively studied in children. Method: We examined 750 children under going cardiac surgery form 2004 to 2007 in National Institute of Cardiovascular Diseases (NICVD), 379 children in the Tranexamic Acid group (TA) and 371 included in placebo (P) group. After induction of anesthesia and prior to skin incision, patients received either tranexamic acid (10mg/kg followed by 1mg/kg/hr) and saline placebo. After admission to intensive care unit total blood loss and transfusion requirements during the first12 hours were recorded. Result: Children who were treated with tranexamic acid had 24% less total blood loss (26±7 vs 34±17 ml/kg) compared with children who received placebo (p<0.05). Additionally, the total transfusion requirements, total donor unit exposure and financial cost of blood components were less in the tranexamic acid group. Conclusion: Tranexamic acid can reduce perioperative blood loss in children undergoing cardiac surgery.

Evaluation of stentangioplasty in university cardiac center.

In this ongoing prospective study conducted in University Cardiac Center, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, from July 2004 to January 2006. Fifty (50) patients (mean age 56+/-7.2 years) underwent stentangioplasty were evaluated. The study group of 50 patients consisted of 42 (84%) men and 08 (16%) women. The aim of this study was to evaluate in-hospital success, failure and complications during the procedures. About risk factors 19(38%) had hypertension, 13(26%) were smoker, 11(22%) suffered from diabetes mellitus, 05(10%) had family history of ischaemic heart disease. Average left ventricular ejection fraction was 54+/-7. Target vessel percutaneous coronary angioplasty (PTCA) were done in 61 vessel, intracoronary stent implanted in 58 vessels, direct stenting were done in 35 cases, failed PTCA were in 03(6%) cases and two had dissection. The native vessels had a mean reference diameter of 2.91 mm and their luminal diameter increased significantly after percutaneous coronary intervention (PCI). All the patients were discharged by one to three days of the procedure with improvement of their clinical condition. In conclusion, intracoronary stent deployment in coronary artery stenosis following balloon angioplasty is a valid and beneficial strategy with good in-hospital results.

Gastrointestinal tuberculosis: retrospective review of 86 cases

The aim of this study is to present our experience in the management of gastrointestinal tuberculosis in Iraq. 86 cases with intestinal tuberculosis were histologically proven by endoscopy or surgery, during the period 1965-2004 at the Medical City Teaching Hospital, and two private hospitals [Alousi and Mustansiria], Baghdad. 54[62.8%] were female and 32[37.2%] were male. Age ranged from 6-82 years [mean 33yrs], peak 30-39 years. Clinical presentation were; intestinal obstruction 44[51.2%], abdominal mass 20[23.3%], malabsorption 13[13%], massive gastrointestinal bleeding 3[3.5%], peritonitis 3[3.5%], pyloric obstruction 2[2.3%] and dysphagia 1[1.2%] patients. Chest X-ray reported; normal in 62[72.1%], active pulmonary tuberculosis in 3[3.5%], and healed lesion in 21[24.4%] patients. Barium study revealed dilated bowel loops in 31[45.6%]; other less frequent findings were strictures, filling defect, shortening and bowel irregularity. OGD showed a significant pathology in 7 out of 11 patients examined. Ultrasound showed helpful imaging modality in 15/21 patients; ascitis, masses, enlarged lymph nodes, and thick bowel loops in some cases. Site of lesions were; ileocecal 42[48.8%], small bowel 33[38.4%], colorectal 8[9.3%] and stomach 3[3.5%] patients. Gross appearance were hyperplastic 33[38.4%], ulcerative 20[13.9%], strictures 21[24.4], and mixed 12 [13.9%] patients. Surgical procedures were; right hemicolectomy 38[44.2%], resection of small bowel 23[26.7%], colectomy 4[4.7%], by-pass 4[4.7%], stricturoplasty 2[2.3%], and subtotal gastrectomy 1[1.2%] and biopsy only 14[16.3%] patients. One patient died post-operatively from pulmonary embolism, 6 lost to follow, 4 had relapse after stopped treatment within 3-5 months [one of them died from intestinal obstruction] while the result in those followed 74 [including 3 who relapsed and re-treated] patients whom received chemotherapy for over one year were very satisfactory. Gastrointestinal tuberculosis affects females more than males. No age is immune, peak in 3rd decade. Symptomatology is non-specific, it should be suspected in patients having abdominal pain, weight loss, anorexia, fever, ascites and abdominal mass. Sub-acute or acute intestinal obstruction is the most common presentation followed by abdominal mass or malabsorption in our study. Normal chest radiograph does not exclude the presence of abdominal tuberculosis, but it should be suspected in high ESR patients. Surgical interventions is not alternative to standard anti-tuberculous therapy

Comparison between IS6110 and MPB64 primers for the diagnosis of Mycobacterium tuberculosis in Bangladesh by polymerase chain reaction (PCR).

The study was carried out to evaluate the efficacy of two different primers in PCR based diagnosis of tuberculosis on the basis of the time involvement, steps of PCR, cost and accuracy of results. Among 17 clinically suspected pulmonary tuberculosis patient's (M:F 65:35) sputum samples, 12 were found positive by both primers. Among 81 routine samples (sputum = 12; blood = 27; cerebrospinal fluid = 16; ascitic fluid = 12 and urine = 14), 12 were found to be positive by IS6110 primer while 13 were found positive by MPB64. The result of M. tuberculosis DNA PCR in sputum, ascitic fluid, CSF and urine samples were found to be similar in both the primers used. It is suggested that, M. tuberculosis DNA PCR in blood samples using MPB64 primers sometime gives false positive result and therefore, may not be recommended for blood samples. As in other samples both the primers gave almost the same result and therefore, both the primers can be used for MTB DNA PCR vice versa in order to cross check if one gives dubious result.

Urinary iodine status and thyroid dysfunction: a Bangladesh perspective.

Iodine deficiency is endemic in Bangladesh. Compulsory iodization of table salt was introduced since 1993 to prevent and improve thyroid disorders in the country. Urinary iodine status, thyroid function and antithyroid antibodies were studied in 397 newly diagnosed thyroid patients and 94 age-sex matched controls. Among thyroid patients, 96 were hyperthyroid, 185 euthyroid and 116 hypothyroid. Mean and median urinary iodine were higher (p=0.075) in thyroid patients (26.13+/-0.91 and 23.03) than controls (22.65+/-1.47 and 18.59); in hyperthyroid and euthyroid than hypothyroid (p=0.020); in multinodular (28.08+/-2.80 and 26.94) and diffuse (27.35+/-1.19 and 26.71) goitre than uninodular (23.91+/-2.37 and 19.14) and nongoitrous (NG, 21.5+/-2.05 and 18.27) (p=0.098) patients but no sex difference (p=0.466). Antimicrosomal (26.7%) and antithyroglobulin (34%) antibodies were more frequently positive among thyroid patients than controls (6.4% and 12.8% respectively) (p=0.00002 and p=0.00005 respectively). Antibody positivity was higher in diffuse (82/228) and multinodular (20/47) goitre than nongoitrous (20/56) and uninodular (13/66) goitre (p=0.046) as well as in hypothyroid (55.2%) and hyperthyroid (36.5%) than euthyroid (19.5%) patients (P<0.001). Urinary iodine correlated neither with antimicrosomal (thyroid patients: p=0.597 and control: p=0.112) nor with antithyroglobulin (thyroid patients: p=0.388 and control: p=0.195) antibody. Thyroid autoimmunity and dysfunction seems common; and interaction of salt iodization with iodine status and thyroid disorders may be important in Bangladesh.

Parental magnesium sulfate [MgSO4] in the treatment of atrial fibrilation [AF]

The antiarrhythmic effects of magnesium sulfate were known long ago particularly in ventricular tachycardia and in torsade de points. This study reported the results of IV MgS04 in 30 patients with chronic AF. A prospective study conducted on 30 patients [12 males and 18 females with a mean age of 54 +/- 8.12] was carried out. Underlying heart disease comprised RHD in 9 patients, CAD in 5 patients and cardiomyopathy in 2 patients. The remaining patients had no structural heart disease. Following clinical evaluation, all patients had an infusion of MgS04 at a rate of 25mg/Kg following a bolus of 35-mg/Kg-body weight. The results revealed that of the 30 patients subjected to IV MgS04 infusion, 8 were successfully cardioverted to sinus rhythm over a mean period of 2 hours [ranging from 6-12 hours], while 10 patients had achieved rate control from a mean of 140/min to 100/min. over a period of 3 hours and twelve patients failed to respond. The study concluded that IV MgSO4 can be used successfully in the therapeutic cardioversion and/or rate control of AF particularly in patients with small left atrium

Chronic carriers of hepatitis B virus in Bangladesh: a comparative analysis of HBV-DNA, HBeAg/anti-HBe, and liver function tests.

Serological markers of hepatitis B virus (HBV), liver function tests and quantitative estimation of HBV-DNA are important in the assessment of the state of infection and prognosis following treatment for hepatitis B. This study aimed to determine whether low-cost assays, eg hepatitis B e antigen (HBeAg) and liver function tests, could be used for the assessment of infectivity as an alternative to HBV-DNA estimation. We tested 125 hepatitis B carriers for HBeAg, antibody to HBeAg (anti-HBe), and serum HBV-DNA; we also carried out a range of standard liver function tests. Seventy-three subjects were positive and 52 were negative for HBeAg. Of the HBeAg positive cases, 3 were also positive for anti-HBe; of the HBeAg negative cases, 5 were also negative for anti-HBe. Of these 8 cases, 7 had no detectable HBV-DNA. Most of the HBeAg positive but anti-HBe negative subjects were positive for HBV-DNA (74.3%; 52/ 70) whereas most of the HBeAg negative and anti-HBe positive subjects (93.6%; 44/47) were also negative for HBV-DNA. Of 56 HBV-DNA positive individuals, alanine transaminase (ALT) was found to be raised in 69.6% (p=0.066) and aspartate transaminase (AST) was raised in 66.1% (p=0.011), while 67.9% had normal alkaline phosphatase (ALP) (p=0.054). HBeAg (p=0.018) and raised ALT (p=0.008) were found to be independent predictors for HBV-DNA positivity among HBV carriers. This study suggests that HBeAg positive and anti-HBe negative hepatitis B carriers with raised ALT and AST are likely to be positive for HBV-DNA; the combination of routine serology and biochemical tests may be considered as an alternative to HBV-DNA in evaluating the state of chronic HBV infection. However, HBV-DNA should be specifically assessed if discordance is observed between seromarkers and transaminases.

Predominance of the DEN-3 genotype during the recent dengue outbreak in Bangladesh.

A recent outbreak of dengue in Bangladesh was marked by many fatal complications. As clinical virulence varies among the genotypes of dengue virus, a study was conducted to investigate the molecular genotypes of dengue in Bangladesh. Reverse transcription polymerase chain reaction was used to determine viral genotypes using oligonucleotide generic primers that produce a 511 bp product. The resulting product was typed by nested PCR with strain-specific primers, yielding 482 (DEN-1), 119 (DEN-2), 290 (DEN-3) and 392 (DEN-4), visualized on UV transilluminator after electrophoresis on 2% agarose gel stained with ethidium bromide. Of 45 clinically diagnosed dengue patients (mean age 28 years; male/female 30/15), 19 (42.2%) had detectable viral RNA in their blood. However, during the first 5 days of fever in 30 patients, the frequency was 60% (18/30), implying that the sooner serum is drawn after the fever, the greater the chances of detecting viral RNA. DEN-3 was detected in all except 2 patients who were infected with DEN-2. DEN-2 (two cases) and DEN-4 (one case) were present as co-infections with DEN-3. All of the patients presented with fever, anorexia and vomiting; many had headache and general body ache; a few had a rash. About a quarter had suffered episodes of bleeding, while ascites, pleural effusion and CNS symptoms were found in a few patients Patients positive for viral RNA were also positive for anti-dengue IgM (p=0.007) in subsequent sampling. The study suggests the predominance of DEN-3 infection with occasional co-infection with other types, during the recent outbreak of dengue in Bangladesh.

Genetic background of diabetic and nondiabetic sibs in young Bangladeshis.

The prevalence of diabetes mellitus in the young is higher in Bangladesh like other Asian developing nations. Albeit, undernutrition has been shown to be associated with diabetes in the young, not all such individuals are diabetic. Diabetes Mellitus is a multigenic disease. In IDDM, DR3/4 heterozygotes were shown to have a greatly increased risk of developing the disease, suggesting the concept of genetic factor(s) being involved in the development of diabetes. Therefore, this study was undertaken to determine the distribution of HLA class II alleles (DRB) and to identify the HLA associated risk for developing diabetes mellitus in the young Bangladeshis. A total of fifty individuals were investigated. Half of them (n=25) were diabetic patients, registered in BIRDEM and half the participants were their non-diabetic sibs. A genomic DNA PCR and Enzyme Linked Probe Hybridization Assay (ELPHA, Bio-test, Germany) was used to determine HLA class II alleles (DRB1, DRB 3, 4, 5) by in vitro amplification of DRB gene. Among all the sero-equivalent antigens found in the study subjects, the prevalence of DR15 (DR2) was overrepresented, both in the diabetic subjects and in their non-diabetic sibs. Moreover, compared with the non-diabetic group the diabetic patients showed higher frequency of DR15 alleles (39 and 25%) though the difference was not significant (chisq. 1.7, p>0.05). Next to DR15, DR4 was the most prevalent HLA-DRB gene found in the study population. Interestingly, the frequency of DR4 was higher in the diabetic than in the non-diabetic group (20 vs. 14%). The study showed that the DR15 and DR4 were the most prevalent in the study population. Moreover, DR7 though not very significant, was higher in non-diabetic compared to their diabetic sibs. Comparison between the diabetic and non-diabetic sibs could have been interesting and significant but we could not confirm our findings, possibly, due to small sample size. A study in a larger paired sample of unrelated population is also needed to substantiate our findings, and also to prove the susceptibility or resistant haplotype in the young diabetic subjects.

Prevalence of infectious diseases and drug abuse among Bangladeshi workers.

Individuals seeking jobs abroad need health fitness certificates before entering into those countries. Medical screening of 43,213 Bangladeshi job seekers (M/F: 42,290/923) was carried out in our reference center during the period August, 1994 to May, 1996. Albeit male predominance, they represented middle and lower middle socio-economic class of the population from all over the country. All were young adults (age: 27.05+/-3.56 years; mean+/-SD) applying for job visas to different Asian countries. Physical examination and laboratory investigations including markers for several infectious diseases and drugs of abuse were carried out as required by countries recruiting the workers. Serological tests revealed that 1,884 (4.4%) of individuals were positive for hepatitis B surface antigen (HBsAg), 737 (1.7%) for Treponema pallidum hemagglutination (TPHA) and only 83 (0.2%) for antibody to human immunodeficiency virus (anti-HIV). However, we could not confirm any case of infection with HIV. Chest X-ray suggestive of pulmonary tuberculosis was found in 162 (0.4%) and on blood film, malarial parasites could be observed only in 4 cases. Their urine analysis revealed the presence of opiates or cannabinoids in 471 (1.1%) individuals. HBsAg-positive cases (p = 0.003) and abuse of opiates (p = 0.024) or cannabinoids (p = 0.002) were significantly higher among males. TPHA reactivity and chest X-ray suggestive of tuberculosis were found to be higher among opiates (p = 0.002 and 0.027) and cannabinoids (p = 0.000 for both) abused as well as with increasing age (p = 0.000). These results may represent a cross-sectional view of the prevalence of different infectious diseases and abuse of drugs among the young adult population of Bangladesh.

Women's involvement in a rural Bangladesh water and sanitation project.

Rural women were involved in a water and sanitation project (WSS) in which health impacts were compared between children in two areas: intervention and comparison areas. In intervention area people were provided with handpumps, latrines and hygiene education, whereas, in the comparison area, people did not receive these project inputs. In the intervention area women were directly involved in the site selection of handpumps and latrines, their installation, construction, and maintenance. Observations on women's involvement and their performances in the intervention area are presented. About 89% of the pumps maintained by women (n = 30), and 86% of those maintained by project workers (n = 49) were found to be in good working condition. Women supervised the construction of all 754 latrines, fenced 58% of the projects-supported latrines (n = 268) and emptied the pits of 65% of the 276 filled-up latrines. Socio-cultural factors were not barriers to women's involvement and performance. The findings have policy implications for effective involvement of rural women towards the development of sustainable WSS programs.