2023 Management Recommendations of Bangladesh Rheumatology Society on Pharmacological Treatment of Rheumatoid Arthritis With Synthetic and Biologic Disease-Modifying Drugs.

Rheumatoid arthritis (RA) is the most common inflammatory polyarthritis in Bangladesh. Bangladesh Rheumatology Society (BRS) proposes these management recommendations to treat the considerable burden of RA in the resource-constrained situation based on the best current evidence combined with societal challenges and opportunities. BRS formed a task force (TF) comprising four rheumatologists. The TF searched for all available literature, including updated American College of Rheumatology (ACR), European Alliance of Associations for Rheumatology (EULAR), and Asia-Pacific League of Associations for Rheumatology (APLAR) and several other guidelines, and systematic literature reviews until October 2023, and then a steering committee was formed, which included rheumatologists and internists. We followed the EULAR standard operating procedures to categorize levels of evidence and grading of recommendations. This recommendation has two parts -- general (diagnosis of RA, nomenclature of disease-modifying anti-rheumatic drugs [DMARDs], disease activity indices) and management portion. The TF agreed on four overarching principles and 12 recommendations. Overarching principles deal with early diagnosis and disease activity monitoring. Recommendations 1-5 discuss using glucocorticoids, NSAIDs, and conventional synthetic DMARDs (csDMARD). Recommendations 6-9 stretch the use of targeted synthetic DMARDs (tsDMARDs) and biological DMARDs (bDMARDs). The suggested DMARD therapy includes initiation with methotrexate (MTX) or another csDMARD (in case of contraindication to MTX) in the first phase and the addition of a tsDMARD in the second phase, switching to an alternative tsDMARDs or bDMARDs in the subsequent phases. The TF included the Padua prediction score for the thromboembolism risk estimation. Recommendations 10-12 cover infection screening, vaccination, and DMARD tapering. Bangladesh has a higher prevalence of RA. This recommendation will serve as a tool to treat this high burden of patients with RA scientifically and more effectively.

Evaluation of feasibility phase of adaptive version of locally made bubble continuous positive airway pressure oxygen therapy for the treatment of COVID-19 positive and negative adults with severe pneumonia and hypoxaemia.

Background: Bubble continuous positive airway pressure (bCPAP) oxygen therapy has been shown to be safe and effective in treating children with severe pneumonia and hypoxaemia in Bangladesh. Due to lack of adequate non-invasive ventilatory support during coronavirus disease 2019 (COVID-19) crisis, we aimed to evaluate whether bCPAP was safe and feasible when adapted for use in adults with similar indications. Methods: Adults (18-64 years) with severe pneumonia and moderate hypoxaemia (80 to <90% oxygen saturation (SpO2) in room air) were provided bCPAP via nasal cannula at a flow rate of 10 litres per minute (l/min) oxygen at 10 centimetres (cm) H2O pressure, in two tertiary hospitals in Dhaka, Bangladesh. Qualitative interviews and focus group discussions, using a descriptive phenomenological approach, were performed with patients and staff (n = 39) prior to and after the introduction (n = 12 and n = 27 respectively) to understand the operational challenges to the introduction of bCPAP. Results: We enrolled 30 adults (median age 52, interquartile range (IQR) 40-60 years) with severe pneumonia and hypoxaemia and/or acute respiratory distress syndrome (ARDS) irrespective of coronavirus disease 2019 (COVID-19) test results to receive bCPAP. At baseline mean SpO2 on room air was 87% (±2) which increased to 98% (±2), after initiation of bCPAP. The mean duration of bCPAP oxygen therapy was 14.4 ± 24.8 hours. There were no adverse events of note, and no treatment failure or deaths. Operational challenges to the clinical introduction of bCPAP were lack of functioning pulse oximeters, difficult nasal interface fixation among those wearing nose pin, occasional auto bubbling or lack of bubbling in water-filled plastic bottle, lack of holder for water-filled plastic bottle, rapid turnover of trained clinicians at the hospitals, and limited routine care of patients by hospital clinicians particularly after official hours. Discussion: If the tertiary hospitals in Bangladesh are supplied with well-functioning good quality pulse oximeters and enhanced training of the doctors and nurses on proper use of adapted version of bCPAP, in treating adults with severe pneumonia and hypoxaemia with or without ARDS, the bCPAP was found to be safe, well tolerated and not associated with treatment failure across all study participants. These observations increase the confidence level of the investigators to consider a future efficacy trial of adaptive bCPAP oxygen therapy compared to WHO standard low flow oxygen therapy in such patients. Conclusion: s Although bCPAP oxygen therapy was found to be safe and feasible in this pilot study, several challenges were identified that need to be taken into account when planning a definitive clinical trial.

Difference in presentation, outcomes, and hospital epidemiologic trend of COVID-19 among first, second, and third waves: a review of hospital records and prospective cohort study.

This study aimed to examine the differences in epidemiologic and disease aspects among patients with coronavirus disease-19 (COVID-19). Methods: The authors reviewed the hospital records between April 2020 and September 2021 and followed up on the patients for post-COVID complications. Findings: Older adult patients were predominantly affected during the third wave, and middle-aged patients were predominantly affected during the first and second waves. Men were predominantly admitted, considering the three waves, although more women were admitted in the second wave. Cough was more common in the second and third waves than in the first wave 522 (59.7%). Respiratory distress was the most common in the third wave, 251(67.1%), and least common in the first wave, 403 (46.1%). Anosmia was more common in the third wave 116 (31.2%). In the third wave, patients presenting in a critical state 23 (6.2%) and with severe disease 152 (40.8%) were more common. The hospital admission median (IQR) was longer in the first wave, 12 (8-20), than in other waves. More patients were admitted in the first wave (52%) than in the other waves, and patients received more oxygen in the third wave (75%) than in the other waves. Death occurred more commonly in the first wave (51%) than in the other waves. The positivity rate was higher in the third wave (22.8%) than in the other waves. In the third wave, the positivity rate was higher in women (24.3%) than in men. Post-COVID cough increased in the second wave, and fatigue was higher in the third wave than in the other waves. Tiredness and memory loss were greater during the second wave than in other waves. Conclusion: The authors found differences in the presentation, outcomes, and hospital epidemiologic trend of COVID-19 among the three waves.

Post-discharge quality of life of COVID-19 patients at 1-month follow-up: A cross-sectional study in the largest tertiary care hospital of Bangladesh.

There is increasing evidence of the post-COVID-19 suffering and decreased quality of life in the COVID-19 patients. This study aimed to assess the quality of life and associated factors of COVID-19 patients at one month after discharge from the hospital. This was a cross-sectional study that was conducted at the post-covid clinic of Dhaka Medical College Hospital (DMCH) where RT-PCR-confirmed adult COVID-19 recovered patients were enrolled one month after discharge from the same hospital. They were consecutively selected from January 01 to May 30. A pretested semi-structured questionnaire was used for the data collection for clinical variables. The generic multi-attributable utility instrument EQ-5D-5L was used for assessing health-related quality of life (HRQoL). A total of 563 patients were enrolled in the study. The patients had a mean age with standard deviation (±SD) of 51.18 (±13.49) years and 55.95% were male. The mean (SD) EQ-5D-5L index score and EQ-VAS scores were 0.78 (±0.19) and 70.26 (±11.13), respectively. Overall, 45.77%, 50.99%, 52.79%, 55.14% and 62.16% had problems (slight to extreme) in the mobility, self-care, usual activities, pain/discomfort and anxiety/depression dimensions, respectively. Patients aged ≥60 years had significant problem in mobility (odds ratio [OR] 3.24, 95% confidence interval [CI]: 1.07-9.77). Female participants were 5.50 times (95% CI: 2.22-13.62) more likely to have problems in their usual activities. In comparison to urban area, living in a peri-urban setting was significantly associated with problems in mobility (OR 1.89, 95% CI: 1.13-3.20), pain/discomfort (OR 1.82, 95% CI: 1.04-3.12) and anxiety/depression (OR 2.16, 95% CI: 1.22-3.84). Comorbid patients were 1.75 times (95% CI: 1.07-2.85) more likely to report problems in the pain/discomfort dimension. Presence of symptom(s) was associated with problems in self-care (OR 3.27, 95%CI: 1.31-8.18), usual-activity (OR 3.08, 95%CI: 1.21-7.87), pain/discomfort dimensions (OR 2.75, 95%CI: 1.09-6.96) and anxiety/depression (OR 3.35, 95%CI: 1.35-8.30). Specific management strategies should be planned to address the factors associated with low health-related quality of life in post-acute care of COVID-19 patients.

Health hazards related to using masks and/or personal protective equipment among physicians working in public hospitals in Dhaka: A cross-sectional study.

BACKGROUND: Wearing masks or personal protective equipment (PPE) has become an integral part of the occupational life of physicians due to the coronavirus disease 2019 (COVID-19) pandemic. Most physicians have been developing various health hazards related to the use of different protective gears. This study aimed to determine the burden and spectrum of various health hazards associated with using masks or PPE and their associated risk factors. METHODS: This cross-sectional survey was conducted in Dhaka Medical College from March 01-May 30, 2021, among physicians from different public hospitals in Dhaka, Bangladesh. We analyzed the responses of 506 physicians who completed case record forms through Google forms or hard copies. FINDINGS: The mean (SD) age of the respondents was 35.4 [7.7], and 69.4% were men. Approximately 40% were using full PPE, and 55% were using N-95 masks. A total of 489 (96.6%) patients experienced at least one health hazard. The reported severe health hazards were syncope, severe dyspnea, severe chest pain, and anaphylaxis. Headache, dizziness, mood irritation, chest pain, excessive sweating, panic attack, and permanent facial disfigurement were the minor health hazards reported. Extended periods of work in the COVID-19-unit, reuse of masks, diabetes, obesity, and mental stress were risk factors for dyspnea. The risk factors for headaches were female sex, diabetes, and previous primary headaches. Furthermore, female sex and reusing masks for an extended period (> 6 h) were risk factors for facial disfigurement. The risk factors for excessive sweating were female sex and additional evening office practice for an extended period. CONCLUSIONS: Healthcare workers experienced several occupational hazards after using masks and PPE. Therefore, an appropriate policy is required to reduce such risks.

Safety and efficacy of favipiravir for the management of COVID-19 patients: A preliminary randomized control trial.

Background: The novel coronavirus disease, commonly called COVID-19, has already killed millions of lives. Our study aimed to identify a safe and right drug for the management of such globally threatened COVID-19. Methods: This preliminary double-blinded randomized controlled trial was done among 57 hospitalized COVID-19 patients in the early stage of their illness. Of them, 29 patients received Favipiravir (FVP) and the remaining 28 patients received a placebo under the standard of care. Among the patients, 4 from Favipiravir (FVP) group and 3 from the placebo group were discontinued. The patients were observed regularly for a period of 10 days. Result: In our study, the FVP treated group showed accelerated viral clearance compared to the placebo-treated group. Assessment of chest X-ray showed remarkable improvement of pheumonia patient in group A compared to Group B. Hematological and Biochemical parameters such as total WBC count, neutrophil and lymphocyte counts were examined. No significant differences in the hematological parameters such as WBC count, neutrophil and lymphocyte counts in Group A and Group B patients. Liver transaminases levels were also stable in FVP treated group (average ALT ranges 39.4-46.2; AST 28.2-32.8). Conclusion: The drug Favipiravir displayed remarkable improvements in the clinical conditions and recovery of COVID-19 patients at the early stages of their infections.

Convalescent plasma transfusion therapy in severe COVID-19 patients- a safety, efficacy and dose response study: A structured summary of a study protocol of a phase II randomized controlled trial.

OBJECTIVES: General: To assess the safety, efficacy and dose response of convalescent plasma (CP) transfusion in severe COVID-19 patients Specific: a. To identify the appropriate effective dose of CP therapy in severe patients b. To identify the efficacy of the therapy with their end point based on clinical improvement within seven days of treatment or until discharge whichever is later and in-hospital mortality c. To assess the clinical improvement after CP transfusion in severe COVID-19 patients d. To assess the laboratory improvement after CP transfusion in severe COVID-19 patients TRIAL DESIGN: This is a multicentre, multi-arm phase II Randomised Controlled Trial. PARTICIPANTS: Age and sex matched COVID-19 positive (by RT-PCR) severe cases will be enrolled in this trial. Severe case is defined by the World Health Organization (W.H.O) clinical case definition. The inclusion criteria are 1. Respiratory rate > 30 breaths/min; PLUS 2. Severe respiratory distress; or SpO2 ≤ 88% on room air or PaO2/FiO2≤ 300 mm of Hg, PLUS 3. Radiological (X-ray or CT scan) evidence of bilateral lung infiltrate, AND OR 4. Systolic BP < 90 mm of Hg or diastolic BP <60 mm of Hg. AND/OR 5. Criteria 1 to 4 AND or patient in ventilator support Patients' below18 years, pregnant and lactating women, previous history of allergic reaction to plasma, patients who have already received plasma from a different source will be excluded. Patients will be enrolled at Bangabandhu Sheikh Mujib Medical University (BSMMU) hospital, Dhaka medical college hospital (DMCH) and Mugda medical college hospital (MuMCH). Apheretic plasma will be collected at the transfusion medicine department of SHNIBPS hospital, ELISA antibody titre will be done at BSMMU and CMBT and neutralizing antibody titre will be checked in collaboration with the University of Oxford. Patients who have recovered from COVID-19 will be recruited as donors of CP. The recovery criteria are normality of body temperature for more than 3 days, resolution of respiratory symptoms, two consecutively negative results of sputum SARS-CoV-2 by RT-PCR assay (at least 24 hours apart) 22 to 35 days of post onset period, and neutralizing antibody titre ≥ 1:160. INTERVENTION AND COMPARATOR: This RCT consists of three arms, a. standard care, b. standard care and 200 ml CP and c. standard care and 400 ml CP. Patients will receive plasma as a single transfusion. Intervention arms will be compared to the standard care arm. MAIN OUTCOMES: The primary outcome will be time to clinical improvement within seven days of treatment or until discharge whichever is later and in-hospital mortality. The secondary outcome would be improvement of laboratory parameters after therapy (neutrophil, lymphocyte ratio, CRP, serum ferritin, SGPT, SGOT, serum creatinine and radiology), length of hospital stay, length of ICU stay, reduction in proportion of deaths, requirement of ventilator and duration of oxygen and ventilator support. RANDOMISATION: Randomization will be done by someone not associated with the care or assessment of the patients by means of a computer generated random number table using an allocation ratio of 1:1:1. BLINDING (MASKING): This is an open level study; neither the physician nor the patients will be blinded. However, the primary and secondary outcome (oxygen saturations, PaO2/FiO2, BP, day specific laboratory tests) will be recorded using an objective automated method; the study staff will not be able to influence the recording of these data. NUMBER TO BE RANDOMISED (SAMPLE SIZE): No similar study has been performed previously. Therefore no data are available that could be used to generate a sample size calculation. This phase II study is required to provide some initial data on efficacy and safety that will allow design of a larger study. The trial will recruit 60 participants (20 in each arm). TRIAL STATUS: Protocol version 1.4 dated May 5, 2020 and amended version 1.5, dated June 16, 2020. First case was recruited on May 27, 2020. By August 10, 2020, the trial had recruited one-third (21 out of 60) of the participants. The recruitment is expected to finish by October 31, 2020. TRIAL REGISTRATION: Clinicaltrials.gov ID: NCT04403477 . Registered 26 May, 2020 FULL PROTOCOL: The full protocol is attached as an additional file, accessible from the Trial's website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocol.

Assessment of risk perception and risk communication regarding COVID-19 among healthcare providers: An explanatory sequential mixed-method study in Bangladesh.

Background: Any public health emergency demands adequate risk communication with the vulnerable population along with their optimized perception about the impending risk to ensure proper risk management and crisis control. Hence, this study will be conducted to explore healthcare providers' perceptions regarding risks of coronavirus disease 2019 (COVID-19), as well as how they are being communicated to about the risk, and how they practice risk reduction measures. Methods: A two-phased explanatory sequential mixed-method study will be conducted among physicians and nurses from randomly selected tertiary healthcare facilities in Dhaka, the capital of Bangladesh. In the first phase, the general pattern and quantifiable measures of risk perception, risk communication, and infection prevention practices will be assessed quantitatively. Multiple linear regression analyses will be performed to explore how much variability of risk perception is predicted by risk communication methods and contents. In the second phase, qualitative data will be collected for in-depth understanding and exploration of participants' experiences and insights regarding COVID-19 risk through interviews and document reviews. Thematic content analysis of the qualitative data will be done manually. Findings from both quantitative and qualitative phases will then be triangulated to illustrate the research objectives. Discussion: Based on the psychometric dimensions of risk perception and psycho-social theory of the health belief model, perception of COVID-19 risk among healthcare providers will be evaluated in this study. The relationship between risk perception and infection prevention and control practices among healthcare providers will also be investigated. The explanatory sequential design of this study is expected to generate hypotheses on how risk perception is being shaped in a time of uncertainty and thus, will help to build a proper risk communication strategy to minimize risk perception among healthcare providers.

Mass Psychogenic Illness: Demography and Symptom Profile of an Episode.

Background. Mass psychogenic illness has been a recurrent phenomenon in Bangladesh over recent times. Objectives. This study was aimed at investigating the demographic characteristics and symptom profile of an outbreak of mass psychogenic illness occurring in a girls' high school. Methods and Materials. In 14 April 2013, a total of 93 students of a girls' high school suddenly developed various symptoms following intake of tiffin cake which resulted in panic and hospital admission. A descriptive, cross-sectional observational survey was done to define various characteristics of the outbreak. Results. No organic explanation for the reported illnesses was found. 93 female students were included who were hospitalized during the incident. Trigger factor was found in 98% of students. Most of the students were 13 years old. Average interval between exposure to the trigger and onset of symptoms was 151.5 minutes. Commonest symptoms were abdominal pain (83%), headache (73%), chest pain (69%), body ache (63%), nausea (69%), and generalized weakness and fatigue (61%). Hospital stay following the incident was about 12 hours on average. Conclusion. To avoid unnecessary panic in the community a prompt, coordinated response is important in resolving widespread community anxiety surrounding these episodes.

Feeding practice in acute stroke patients in a tertiary care hospital.

BACKGROUND: Feeding is a basic component of care and it is the most common and difficult management issue for stroke patients. Objective of this study was to know the practice of feeding (oral & nasogastric tube feeding), different types of food used and their caloric value in stroke patients. MATERIALS & METHODS: This direct observational study was done from June 2010 to November 2010, in different medicine wards of Dhaka Medical College Hospital, and included 100 acute stroke patients confirmed by CT scan or MRI of brain and duration of hospital stay for at least 24 hours. RESULTS: Out of 100 cases, 22% took their feeding orally and 78% cases through nasogastric tube. Artificial milk powder 66% cases (NG tube vs. Orally, 58% vs. 8%), juice 18% (NG tube 13% vs. orally 5%), horlicks & juice & soup 10% (NG tube vs. Orally, 7% vs. 3%), khichury 2% orally, bread & egg & shuji 4% cases orally. In 100 cases studied, none of them fulfilled the calorie requirement up to the standard level according to the guideline of Nutrition & Food Science Institute, of Dhaka University, Bangladesh. CONCLUSION: Though this study was small scale but the magnitude of under nutrition among stroke patients revealed is alarming and needs urgent attention.