Predictors of In-hospital Mortality in Patients Presenting with Acute Coronary Syndromes in a Tertiary Cardiac Center in Dhaka, Bangladesh.

The outcomes of acute coronary syndromes (ACS) vary internationally, given regional differences in patient co-morbidities, access to health care, interventional procedures and adherence to guideline-based management practices. This study aimed to identify the predictors of mortality from a large ACS registry of patients admitted to a tertiary care cardiac centre in Dhaka, Bangladesh. This was a hospital record based retrospective cross sectional observational study that included all patients presenting with ACS to Ibrahim Cardiac Hospital and Research Institute, Dhaka, Bangladesh from January 2013 to December 2013. Data were collected from cardiac catheterization laboratory database and hospital discharge records. Statistical analysis was done using Statistical Package for Social Sciences (SPSS) version 16.0. A p value <0.05 was considered statistically significant. Ethical approval was obtained by Institutional Review Board of the hospital. A total of 1914 ACS patients were studied: 39.8% presented with ST-elevation myocardial infarction (STEMI), 39.7% with non-ST-elevation myocardial infarction (NSTEMI) and 20.5% with unstable angina (UA). There were 146 in-hospital deaths (7.6%). Mortality was highest among STEMI patients (10.5%), followed by NSTEMI (8.1%) and UA (1.03%). The mean age of expired patients was significantly higher than that of those who survived (64.82±12.14 years vs. 57.32±11.99 years; p<0.001). Male patients were 71.4%, with no significant gender differences observed between expired and surviving groups. Age >50 years {odds ratio (OR) 2.56, p=0.005}, chronic kidney disease (CKD) (OR 2.1, p<0.001), shock (OR 16.82, p<0.001), left ventricular failure (LVF) (OR 2.43, p<0.001) and STEMI (OR 1.92, p=0.002) were independent predictors of mortality among ACS patients. Although diabetes per se was not associated with mortality (OR 1.3; 95% CI=0.89-1.91; p=0.169), uncontrolled diabetes defined as HbA1c levels ≥7.5% had significant risk of mortality (OR 51.4, p<0.001). ACS patients who did not undergo angiography (OR 16.4; p<0.001) or PCI (OR 18.9; p<0.001) had greater risk of mortality. ACS patients complicated with shock, LVF, uncontrolled diabetes and CKD had increased risk of in-hospital mortality. Improved outcomes may be likely with prompt angiography and PCI during index admission. This study is a preliminary initiative, and prospective multi-centre registries with nation-wide involvement are warranted.

Risk factors of multi-drug-resistant tuberculosis in Bangladeshi population: a case control study.

Despite success in tuberculosis control, multi-drug resistant tuberculosis in Bangladesh is increasing and currently multi-drug-resistant tuberculosis rate is 3.6% in new cases and 19% in re-treatment cases. This study focused on determination of multi-drug-resistant tuberculosis which is warranted for effective prevention strategy. An unmatched case control study was conducted in 2010. Purposively recruited 136 culture-proved multi-drug-resistant- tuberculosis cases and 152 cured tuberculosis patients were interviewed. Associations between exposure and outcome variables were initially tested by chi2-test, t-test. A result was considered significant at p value < 0.05. Effects of exposure variables were also assessed after adjusting for other variables by binary logistic regression models. Crude and adjusted Odds Ratio with 95% Confidence Interval was computed. Younger age (p = 0.008) and, peri-urban locality (p = 0.002) were associated with multi-drug-resistant tuberculosis. History of contact (p < 0.001) and tuberculosis in the past (p < 0.001) were four and eight times, respectively, more likely to influence multi-drug-resistant tuberculosis. Regularity [Odds Ratio 0.05; 95% Confidence Interval (0.01 to 0.39)] and always observation of treatment [Odds Ratio 0.25; 95% Confidence Interval (0.10 to 0.61)], sputum conversion [Odds Ratio 0.02; 95% Confidence Interval (0.01 to 0.08)] negatively associated with multi-drug-resistant tuberculosis. Gender and socio-economic status did not show any influence. Treatment course and sputum conversion was the best predictors. Like other developing countries adequacy of treatment is the most important exposure variable. Strengthening of control activities might contribute in preventing development of resistance in tuberculosis patients.

Comparison of P2Y12 receptor inhibition by clopidogrel and prasugrel in patients undergoing percutaneous coronary intervention.

Dual antiplatelet treatment (DAPT) with aspirin and clopidogrel is vital after percutaneous coronary intervention (PCI). Clopidogrel and prasugrel act on P2Y12 platelet surface receptors. Both these P2Y12 inhibitors are pro-drugs and depend on cytochrome system of the liver for their conversion to active metabolite. There is growing concern regarding suboptimal response in platelet inhibition by clopidogrel. Verify Now system got approval by Federal Drug Administration, USA, for assessing platelet function as its result is almost comparable to gold standard Light Transmission Aggregometry (LTA). There are no data on the prevalence of clopidogrel resistance in Bangladeshi population. Prasugrel, as an antiplatelet drug, is a newer introduction in this country. This study will show light on the efficacy of these drugs on our population especially in patients who undergo PCI where DAPT is mandatory. A total 120 (60 diabetics) patients with Acute Coronary Syndrome (ACS), were alternatively given 600 mg clopidogrel loading dose (LD) followed by 75 mg maintenance dose (MD) daily or 60 mg LD of prasugrel followed by 10 mg MD daily. Five samples of blood were taken at different time intervals over a period of 2 weeks. Measurement of percent inhibition of P2Y12 was done by VerifyNow. Patients who showed less than 20% inhibition (clopidogrel resistant) at any stage were switched to prasugrel. The outcomes of clopidogrel, prasugrel and clopidogrel switched to prasugrel groups were then compared. Nearly half (46.7%) of the patients in the clopidogrel group was found resistant to the drug as opposed to none in the prasugrel group. No difference was found between diabetic and non-diabetic subjects with respect to drug resistance. Intracoronary blood samples showed high degree of platelet inhibition with prasugrel. There was a gradual decline of platelet inhibition over two weeks with prasugrel. Almost fifty percent of the population is clopidogrel resistant in our study. Prasugrel is a much more potent antiplatelet drug and should be preferred in patients undergoing PCI. Prasugrel may also show resistance over time.

Effects of catchment, first-flush, storage conditions, and time on microbial quality in rainwater harvesting systems.

Rainwater collected from a rooftop rainwater harvesting (RWH) system is typically not considered suitable for potable uses, primarily because of poor microbial quality. The quality of stored rainwater, however, can be improved through basic design and maintenance practices during the construction and operation of an RWH system. This paper presents the microbial analysis of rainwater in two RWH systems installed at the Seoul National University Campus in South Korea. Rainwater samples were collected at different locations within each system and analyzed for total and fecal coliforms, Escherichia coli, and heterotrophic plate count bacteria. Within their storage tanks, water quality improved horizontally from inlet to outlet points, and higher quality was observed at the supply point (located about 0.5 m from the base of the tank) than at the surface or bottom of the tank. First-flush rainwater was found to be highly contaminated but rainwater quality improved following about 1 mm of precipitation. The catchment surface also had a significant effect on the quality of rainwater; samples collected from a rooftop exhibited better microbial quality than from a terrace catchment. Better water quality in underground tanks (dark storage conditions) compared to open weirs/ filters (exposed to natural light) demonstrated the importance of storage conditions. Water quality also improved with longer storage, and a decrease of 70% to 90% in microbial concentrations was observed after about 1 week of storage time. The findings of this study demonstrate that the microbial quality of harvested rainwater can be improved significantly by the adoption of proper design and maintenance guidelines such as those discussed in this paper.

Noise level in different places of Dhaka Metropolitan City (DMC) and noise-induced hearing loss (NIHL) in Dhaka City dwellers.

A cross sectional, exploratory study was designed at "National Center for Hearing and Speech for Children" (NCHSC), Dhaka, Bangladesh, from May 2001 to June 2002, with a view to determine the average noise level in different places of Dhaka Metropolitan City (DMC), and also aiming at evaluating the extent of Noise-induced Hearing Loss (NIHL) in different groups of city dwellers and finally a base line information. A total of 32 places in DMC were selected randomly. The highest noise level recorded 104 dB at Sayedabad bus terminal and the lowest 68 dB in Banani and Baridhara residential area. In silent zone of DMC, average noise level was 79 dB, in residential zone 72 dB, in commercial zone 90 dB, and in mixed zone average noise level was recorded at 91 dB. Measured noise levels were more than acceptable and permissible levels in all places of DMC. A total of 312 persons aged between 15-45 years (mean age- 24.64 years) were enrolled for the study as per inclusion criteria. Gender-wise male were 211(67.62%) and female were 101(32.57%). Profession-wise Automobile drivers were 57(18.26 %), Garment workers 58(18.55 %), City dwellers 72(23.07%), Students 72(23.07%), Traffic polices 12(3.85%), Hawkers and Road side shopkeepers were 41(13.1%). Definite noise notch (>25dB) at 4KHz observed in 33(10.58%) audiogram of persons under study. Automobile drivers, Traffic polices, Road side hawkers and Shop keepers, Garment workers are mostly affected were 17.54%, 16.4%, 12.09% and 12.06% respectively. A total of 201 persons (64.42%) were not aware of their hearing impairment, 244(78%) of the person had poor level of knowledge regarding bad effects of noise on health and about protective means available. Amongst persons (33) found to have NIHL did not use any protective device.

A comparison of polyacrylamide gels and radiochromic film for source measurements in intravascular brachytherapy.

For intravascular brachytherapy with catheter-based systems, AAPM Task Group 60 has recommended measurements that should be made to characterize the sources. Beta emitters, including (90)Sr/(90)Y are ideal for intravascular brachytherapy, but problems arise in measuring dose distributions in the high dose gradient region at short distances from the source. In this paper, measurements of radial and orthogonal dose distributions and dose profiles for a (90)Sr/(90)Y source train using polyacrylamide gel (PAG) dosimetry and a high-field 4.7 Tesla MRI scanner are presented and compared with measurements made with two types of radiochromic film, MD-55 and HD-810. For the PAG system, the dose distributions were determined with in-plane resolutions of 0.4 mm and 0.2 mm. The measurements of absorbed dose distributions both orthogonal and parallel to the source axis show good agreement between the PAG and radiochromic film. The absolute dose at a radial distance of 2 mm in the central 32 mm of a line parallel to the axis was measured. For the PAG the measured absorbed dose was 1.25% lower, for MD-55 4% higher and for the HD-810 1.6% higher when compared with the value given by the source calibration. These results confirm that both absorbed dose and dose distributions for high gradient vascular brachytherapy sources can be measured using PAG but the disadvantages of gel manufacture and the need for access to a high resolution scanner suggests that the use of radiochromic film is the method of choice.

Determination of chromium in river waters by electrothermal atomic absorption spectrometry with preconcentration on a tantalum wire.

The preconcentration of chromium on tantalum wire followed by electrothermal atomic absorption spectrometry with a tungsten tube atomizer is described. The preconcentration is accomplished by adsorbing chromium on a tantalum wire. The optimal immersion time was 3 mm. The best pH for chromium adsorption was 3. Under optimal conditions, the detection limit was 15 pg mU1 (3 x SIN). The effects on the preconcentration of chromium by large amounts of contaminants were evaluated. Even though matrix elements existed in 10(3)-10(4)-fold excess in water, the chromium absorption signal was not affected by the matrix elements. The method with preconcentration on tantalum wire was applied to the determination of chromium in river water.

Recurrent respiratory papillomatosis: a study of 24 cases.

24 cases of recurrent respiratory papillomatosis (RRP) in children were treated by surgical removal with cup forceps and followed up for variable periods between 1990-95. Most of the patients required multiple operations due to recurrence. No anaesthetic death or complication was recorded. Voice changes of different degrees were noted. Four patients has glottic web formation. The findings suggest that recurrence of RRP is very common & needs multiple session of surgery. For children with persistent and progressive voice change/cry, the necessity of precise & comprehensive endoscopic examination of the upper aerodigestive tract under general anesthesia (GA) is emphasized.

Follow up study of thyroidectomy.

One hundred thyroidectomized patients were followed up. The male:female ratio was 1:4. Majority (62%) of the patients were in the 4th and 5th decades. Multinodular goiter was the commonest lesion found in 74, diffuse colloid goiter in 12 and carcinoma in 14 cases. After operation, sixty-five patients were relieved of all preoperative symptoms of thyroid disease. Thirteen patients had some persistent symptoms. Rest 22 had developed different types of complication in addition to some preoperative symptoms. Three patients developed hoarseness of voice due to recurrent laryngeal nerve injury. Hypoparathyroidism occurred in 1, hypothyroidism in 4 and recurrent neck swelling in 14 patients. One patient died. It seems that a thorough knowledge of the surgical anatomy and meticulousness during the procedure would reduce the rates of such complications in future.

Screening--a unique way of better health care delivery for ENT patients.

A few Ear Camps were carried out amongst 25 schools and madrashas of Dhaka City having 10,102 pupils, to see the prevalence of ENT diseases and hearing impairment. A primary screening was done by the Bangladesh Council for Child Welfare (BCCW) with the possibilities of suffering from ear, nose & throat diseases with the help of questionnaire and clinical examination by qualified doctor. The word "Screening" is used in this paper not in the epidemiological sense but to imply primary selection. 1,403 (13.89%) were issued registration card for ENT consultation. Five otolaryngologist, one audiometrician, two ancillary staffs, BCCW workers, local volunteers and school teachers conducted the 3 days long camp. Secondary screening by the otolaryngologists revealed pathology in 1,101 students (10.89%). 26 children (0.26%) were attending schools with severe hearing loss. ENT diseases appeared to be common in urban school children and screened proved to be an efficient method for health care delivery.

Ewing's sarcoma of maxilla--a case report.

This paper reports the case of an adolescent girl who was admitted in the ENT ward, IPGMR in February '88 with the complaints of nasal obstruction, nasal discharge associated with progressive swelling of the right side of her face for 1 year. She had an operation at Chittagong Medical College Hospital 1 year back for some problem in the right side of the nose. No history of pain, nasal bleeding or visual disturbance were present. The nasal mass was mobile, insensitive and did not bleed on touch, but the facial swelling was red, soft and cystic. Clinically diagnosed as an Antral growth with Ethmoidal involvement. Radiologically revealed soft tissue swelling, obliteration of nasal fossa and opacification of sinuses. After surgical resection the facial mass was diagnosed as Ewing's sarcoma histopathologically. The patient needed radiotherapy but did not follow it.