Patient self-referral patterns in a developing country: characteristics, prevalence, and predictors.

BACKGROUND: Efficient healthcare delivery and access to specialized care rely heavily on a well-established healthcare sector referral system. However, the referral system faces significant challenges in developing nations like Bangladesh. This study aimed to assess self-referral prevalence among patients attending tertiary care hospitals in Bangladesh and identify the associated factors. METHODS: This cross-sectional study was conducted at two tertiary care hospital, involving 822 patients visiting their outpatient or inpatient departments. A semi-structured questionnaire was used for data collection. The patients' mode of referral (self-referral or institutional referral) was considered the outcome variable. RESULTS: Approximately 58% of the participants were unaware of the referral system. Of all, 59% (485 out of 822) of patients visiting tertiary care hospitals were self-referred, while 41% were referred by other healthcare facilities. The primary reasons for self-referral were inadequate treatment (28%), inadequate facilities (23%), critical cases (14%), and lack of expert physicians (8%). In contrast, institutional referrals were mainly attributed to inadequate facilities to treat the patient (53%), inadequate treatment (47%), difficult-to-treat cases (44%), and lack of expert physicians (31%) at the time of referral. The private facilities received a higher proportion of self-referred patients compared to government hospitals (68% vs. 56%, p < 0.001). Among patients attending the study sites through institutional referral, approximately 10% were referred from community clinics, 6% from union sub-centers, 25% from upazila health complexes, 22% from district hospitals, 22% from other tertiary care hospitals, and 42% from private clinics. Patients visiting the outpatient department (adjusted odds ratio [aOR] 3.3, 95% confidence interval [CI] 2.28-4.82, p < 0.001), residing in urban areas (aOR 1.29, 95% CI 1.04-1.64, p = 0.007), belonging to middle- and high-income families (aOR 1.34, 95% CI 1.03-1.62, p = 0.014, and aOR 1.98, 95% CI 1.54-2.46, p = 0.005, respectively), and living within 20 km of healthcare facilities (aOR 3.15, 95% CI 2.24-4.44, p-value < 0.001) exhibited a higher tendency for self-referral to tertiary care facilities. CONCLUSIONS: A considerable number of patients in Bangladesh, particularly those from affluent urban areas and proximity to healthcare facilities, tend to self-refer to tertiary care centers. Inadequacy of facilities in primary care centers significantly influences patients to opt for self-referral.

Health-care-seeking behaviour in patients with hypertension: experience from a dedicated hypertension centre in Bangladesh.

Objective: The study aimed to assess health-seeking behaviour (HSB) and associated factors among hypertensive patients in Bangladesh.Methods: This cross-sectional study was conducted in the Hypertension & Research Centre, Rangpur, Bangladesh, between January 2022 and June 2022. A total of 497 hypertensive adults were recruited consecutively. A pre-tested structured questionnaire was deployed by the research team for data collection. Multivariable logistic regression analysis was used to explore the predictors of HSB.Results: The mean age of the hypertensive patients was 52 ± 11 (SD) years. Most of them were aged between 51 and 60 years (33%), female (55%), came from rural areas (57%), and belonged to middle socioeconomic class (68%). One-fourth of the patients (27%) had chosen informal healthcare providers for their first consultation. Fear of stroke (244, 45%), headache (170, 36%), and neck pain (81, 17%) were the three most common compelling causes of their visit to the hypertension centre. Age (aOR 0.78, 95% CI 0.68 - 0.89), male sex (aOR: 1.79, 95% CI 1.05 - 3.10), living in semi-urban (aOR 4.68, 95% CI 1.45 - 15.10) and rural area (aOR 1.68, 95% CI 1.01 - 2.80), farmers as occupation (aOR: 3.24, 95%CI: 1.31 - 8.06) and belonging to lower social economic class (aOR 4.24, 95% CI 1.68 - 10.69) were predictors of visiting informal providers of hypertensive patient. One-fourth of the hypertensive patients received consultation from informal healthcare providers.Conclusions: Raising awareness among patients and proper referral to specialised hypertension centres could promulgate the patients towards appropriate behaviour.

The 2023 Dengue Outbreak in Bangladesh: Exploring the Epidemiology in Hospitalized Patients.

For the past two decades, Bangladesh has faced recurrent dengue outbreaks, with the most recent occurring in 2023. We investigated the socioeconomic, clinical, and laboratory aspects of patients diagnosed with dengue during this outbreak. This observational study was conducted from July to September 2023 at Dhaka Medical College Hospital and Chittagong Medical College Hospital, and included 450 confirmed cases of dengue. Sociodemographic information was collected via face-to-face interviews, clinical examinations, and laboratory testing, which was done within 24 hours of admission. Dengue severity was classified according to the 2009 WHO dengue guidelines. Notably, 17% of patients experienced severe dengue, and 89% of those with nonsevere cases exhibited at least one warning sign. Most patients were young adults (mean age, 33 years), with a nearly equal male-to-female ratio. Common clinical presentations included fever (95%), myalgia (62%), and headache (58%), whereas warning signs such as vomiting (54%) and abdominal pain (39%) were prevalent. Plasma leakage indicators, including ascites, pleural effusion, and edema, were found predominantly in severe cases. Laboratory findings revealed leukopenia, thrombocytopenia, and elevated hepatic enzymes (alanine aminotransferase and aspartate aminotransferase) in nearly half the patients. An elevated hematocrit level was associated with severe dengue. We report that a substantial number of patients developed severe dengue during the epidemic in 2023, and provide detailed clinical-epidemiological profiles of the patients, offering valuable insight into management of dengue cases.

Violence against physicians working in public tertiary care hospital of Bangladesh: a facility-based cross-sectional study.

BACKGROUND: Violence against physicians in the workplace is a prevalent global issue, and Bangladesh is no exception. Such violence significantly disrupts healthcare delivery and the attainment of universal health coverage. This study aimed to comprehensively evaluate the prevalence, nature and associated risk factors of workplace violence (WPV) against physicians in Bangladesh. METHODS: This descriptive cross-sectional study was conducted at a public tertiary care hospital involving 441 physicians with a minimum tenure of 6 months. Data were gathered through a structured self-reported questionnaire, and statistical analyses were performed by using SPSS V.25. RESULTS: Out of the surveyed physicians, 67.3% (n=297) reported experiencing violence, categorised as 84.5% psychological, 13.5% physical and 2% sexual in nature. Predominant forms of psychological violence included bullying (48.8%) and threats (40.1%). The mean age of exposed physicians was 32.5±4.3 (SD) years. Those working in the emergency unit (45.8%), surgery and allied departments (54.2%), engaging in rotating shift work (70%), morning shifts (59.6%) and postgraduate trainees (68%) were frequently subjected to violence. Factors significantly associated with WPV included placement in surgery and allied departments (p<0.001), working rotating shifts (p<0.001), marital status (p=0.011) and being a male physician (p=0.010). Perpetrators were primarily identified as relatives of patients (66%). Working in rotating shifts (adjusted OR(AOR):2.6, 95% CI:1.2 to 5.4) and surgery and allied departments (AOR:5.7, 95% CI:3.4 to 9.8) emerged as significant risk factors of violence against physicians. CONCLUSION: A higher proportion of physicians at the early to mid-level stages of their careers, especially those in rotating shifts and surgery-related departments, reported incidence of WPV. Urgent intervention from policy-makers and healthcare entities is imperative to implement preventive measures. Strengthening security measures, establishing antiviolence policies and providing comprehensive training programmes are crucial steps towards ensuring a safer work environment for healthcare professionals.

Subcutaneous angiogenesis induced by transdermal delivery of gel-in-oil nanogel dispersion.

Subcutaneous transplantation aims to enhance the growth and functionality of transplanted cells for therapeutic outcomes in tissue engineering. However, the limited subcutaneous vascular network poses a challenge. Conventional methods involve co-transplantation with endothelial cells or angiogenic scaffold implantation, but they have drawbacks like tissue inflammation, compromised endothelial cell functionality, and the risk of repeated scaffold transplantation. Effective techniques are needed to overcome these challenges. This study explores the potential of G/O-NGD, a gel-in-oil nanogel dispersion, as a transdermal carrier of proliferative factors to promote angiogenesis in subcutaneous graft beds before cell transplantation. We observed robust subcutaneous angiogenesis by delivering varying amounts of bFGF using the G/O-NGD emulsion. Quantitative analysis of several parameters confirmed the efficacy of this method for building a subcutaneous vascular network. G/O-NGD is a biodegradable material that facilitates localized transdermal delivery of bFGF while maintaining its activity. The findings of this study have significant implications in both medical and industrial fields.

A case of Pierre Robin syndrome in a child with no soft palate and complications from pneumonia in Bangladesh.

Key Clinical Message: Children with Pierre Robin syndrome (PRS) often have trouble breathing and eating as soon as they are born. If conservative therapy fails to alleviate airway obstruction, surgical surgery may be considered. Patients with PRS require multidisciplinary approaches for treatment. Abstract: Pierre Robin syndrome is a common craniofacial abnormality that causes glossoptosis and blockage of the upper airway. This renders it difficult to feed, which leads to severe malnutrition. This condition is also often marked by an absence of a soft palate. We mention a newborn with Pierre Robin syndrome with the absence of a soft palate and pneumonia complications, whose impending respiratory failure was treated successfully. To solve the complex problems that these babies and their families are facing, a multidisciplinary approach is needed.

Prevention and Repair of Ultraviolet B-Induced Skin Damage in Hairless Mice via Transdermal Delivery of Growth Factors Immobilized in a Gel-in-Oil Nanoemulsion.

Ultraviolet (UV) radiation from the sun or artificial sources is one of the primary causes of skin damage, including sunburns, tanning, erythema, and skin cancer. Among the three different types of UV rays, UVB rays have a medium wavelength that can penetrate the epidermal layer of the skin, resulting in sunburn, suntan, blistering, and melanoma in case of chronic exposure. This study aimed to evaluate the preventive and therapeutic effects of a gel-in-oil nanogel dispersion (G/O-NGD) as a transdermal delivery biomolecular carrier for skin damage caused by UVB light. The efficacy of this carrier against UVB-induced skin damage was investigated in vivo by delivering different growth factors (GFs) encapsulated in a G/O-NGD. Artificial UVB light was used to induce skin damage in nude mice, followed by the transdermal application of five GF [vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), epidermal growth factor (EGF), transforming growth factor (TGF)-1, and insulin-like growth factor (IGF)-α]-immobilized G/O-NGD. Among these GFs, VEGF and bFGF promoted angiogenesis, while EGF, TGF-1, and IGF-α promoted the repair and regeneration of damaged cells. The results showed that G/O-NGD was superior to heparin-immobilized G/O-NGD in reducing UVB-induced skin damage, such as erythema, epidermal water reduction, inflammation, and dermis thickening. In addition, G/O-NGD could prevent and treat abnormal follicle proliferation caused by UVB rays and exhibited potential to repair lipid glands. Overall, our results demonstrate the potential of G/O-NGDs for the treatment of UVB-induced skin damage.

Spatial association of Aedes aegypti with dengue fever hotspots in an endemic region.

Background and objective: Dengue is a vector-borne viral disease usually transmitted by Aedes mosquitoes. Around the world, the relationship between local vector density and frequency of dengue cases is being explored and needs further evidence. This study aimed to analyze the potential spatial relationships between the dengue vector (Aedes aegypti) and dengue cases in the megacity of Bangladesh during the 2019 dengue outbreak. Methods: Vector density measures were used to estimate spatial associations with dengue case distribution. Location was determined for 364 dengue cases who were admitted to Dhaka Medical College Hospital over a period of 4 months. Data were collected using a semi-structured questionnaire, and prior consent was ensured before participation. The Moran global index, Getis-Ord Gi∗, ordinary least squares regression, geographically weighted regression and count data regression methods were used for spatial analysis. Results: We found that dengue case distribution was not associated with immature Aedes aegypti mosquito (larvae) density across the city. The relationship between larval density measured by the Breteau Index (BI) and House Index (HI) with dengue cases was nonstationary and not statistically significant. Conclusion: The location of dengue cases appears to be unrelated to vector distribution and vector density. These findings should prompt the search for other transmission risk factors.

Sketch of 2018 dengue outbreak in a megacity, Bangladesh.

BACKGROUND: Dengue has become a major public health threat in Bangladesh since 2000, when the first outbreak was reported. Each outbreak has distinct characteristics, and thus, the report of the outbreak helps to understand the disease process and subsequent clinical management of these patients. On that ground, the study was designed to sketch the clinico-epidemiological characteristics of the 2018 dengue outbreak in Bangladesh. METHODS: This hospital-based cross-sectional study was conducted in one of the largest public medical college hospitals and a single private hospital located in the southern and northern parts of the megacity of the country. A total of 297 confirmed dengue cases were assessed with a preformed pretested questionnaire. Clinico-epidemiological and laboratory parameters were reported along with sociodemographic details. Statistical analysis was performed with SPSS 20. RESULTS: Male patients were predominantly affected by dengue infection. The mean age of the patients was 31.24 ± 13.99 (SD) years, with a range from 2 to 85 years. Eighty-two percent of patients reported from the Dhaka metropolitan city. The highest percentage of cases (37.1%) was isolated from Bansree, Dhaka city, followed by Rampura (21.4%) and Khilgaon (6.2%). In addition to common symptoms, e.g., fever (90.6%), headache (90.6%), chills (81.8%), anorexia and vomiting (76.4%), backache, and redness of the eyes were two prominent symptoms that affected more than two-thirds of the study population. On the other hand, less common symptoms, such as cough, abdominal pain, and respiratory distress, were present in 39.7%, 33.7%, and 15.5% of patients, respectively. Overall, 17.6% of patients were hypotensive during admission, with a mean systolic blood pressure of 107.65 ± 18.17 (SD) mmHg. Other prominent signs were dehydration (80.5%) and rash (33%). CONCLUSION: This outbreak was especially characterized by gastrointestinal symptoms, which were predominant along with other typical features.

Delivery of Hydrophobic Drugs to the Posterior Ocular Region by Gel-in-Water Nanoemulsion.

Purpose: The aim of this study was to develop a nanogel emulsion as a minimally invasive, safe, and effective treatment alternative for posterior ocular diseases. Methods: A gel-in-water (G/W) nanoemulsion was developed by ultrasonication using beeswax as an organogelator. Different physicochemical properties were evaluated along with particle size analysis by dynamic light scattering. In vitro biocompatibility of G/W nanoemulsion using rat hepatocytes and human umbilical vein endothelial cells (HUVECs) and in vivo corneal permeability as eye drops were investigated. Results: The nanogel emulsion was monodispersed with a polydispersity index and particle diameter of approximately 0.2 and 200 nm, respectively. The zeta potential value of -8.1 mV suggested enhanced stability and improved retinal permeability of nanoparticles. The prepared nanoemulsion was found to be biocompatible with hepatocytes and HUVECs in vitro. Moreover, in vivo study demonstrated high permeability of G/W nanoemulsion to the retinal layer with no ocular irritation. Conclusions: G/W nanoemulsions have the potential for topical drug delivery in the posterior eye segment with maximum therapeutic efficacy. Translational Relevance: Organogel nanodispersion is a new concept to deliver hydrophobic drugs to the posterior segment of eyes as a novel drug delivery system.

Gel-in-water nanodispersion for potential application in intravenous delivery of anticancer drugs.

Organogels are semi-solid systems that can gel organic liquids at low concentrations. The use of organogels in drug delivery has grown rapidly in the last decade owing to their fibrous microstructure and suitability for different routes of administration. The current study is characterized by nanogel dispersion (NGD) development based on emulsion technology. The efficiency of this organogel based NGD as a carrier for anticancer drugs was assessed both in vitro and in vivo. 12-Hydroxystearic acid formed an organogel with lipiodol and encapsulated the anticancer drug paclitaxel. The gel-in-water (G/W) nanodispersion was prepared via ultrasonication and stabilized by a nonionic surfactant. The results showed that the organogel enabled sustained drug release from G/W nanodispersion over time, along with enhanced cellular uptake. The prepared G/W nanodispersion was found to be biocompatible with mouse hepatocytes and fibroblast cells in vitro, whereas paclitaxel-loaded G/W nanodispersion showed cytotoxicity (p <0.05) against lung cancer (A549) cell lines. Similarly, intravenous administration of paclitaxel-loaded G/W nanodispersion exerts an anticancer effect against lung cancer in vivo, with a significant decrease in tumor volume (p <0.05). Therefore, the proposed G/W nanodispersion could be a promising carrier for chemotherapy agents with sustained drug release and better therapeutic outcomes against cancer.

Development and characterization of gel-in-water nanoemulsion as a novel drug delivery system.

The effective delivery of anti-cancer drugs with minimal side effects and better therapeutic efficacy has remained an active area of research for many decades. Organogels have gained attention in recent years as potential drug delivery systems due to their high bioavailability, no first-pass metabolism and rapid action. Considering this, in the current study an organogel based nanoemulsion was developed aiming to effectively deliver hydrophobic drugs via encapsulation within in situ gellable organogel droplets, termed as gel-in-water (G/W) nanoemulsion. G/W nanoemulsion was prepared using a combination of lipiodol and organogelator 12-hydroxystearic acid (12-HSA) as inner gel phase; dispersed in water by ultrasonication and stabilized with polyoxyethylene hydrogenated castor oil (HCO-60) as a surfactant. The prepared nanoemulsion showed high drug loading efficiency (≈97%) with a mean diameter of 206 nm. Lower polydispersity index (PdI) value (≈0.1) suggests monodispersed nature of G/W nanoemulsion in the continuous phase. G/W nanoemulsion was found stable over six months in terms of particle size, zeta potential and pH at different storage temperatures. There was no cytotoxic effect of prepared G/W nanoemulsion on primary hepatocytes in vitro. In contrast, paclitaxel-loaded G/W showed a significant decrease in melanoma cell growth (*p < 0.05) both in vitro and in vivo. Our results support the hypothesis that organogel based nanoemulsions can be a promising drug delivery system.

Development of a gel-in-oil emulsion as a transdermal drug delivery system for successful delivery of growth factors.

Growth factors (GFs) are indispensable in regenerative medicine because of their high effectiveness. However, as GFs degenerate easily, the development of a suitable carrier with improved stability for GFs is necessary. In this study, we developed a gel-in-oil (G/O) emulsion technology for the transdermal delivery of growth factors. Nanogel particles prepared with heparin-immobilized gelatin that can bind growth factors were dispersed in isopropyl myristate. The particle size of the G/O emulsion could be controlled by changing the surfactant concentration, volume ratio of the water phase to the oil phase, and gelatin concentration. In vitro skin penetration studies showed better penetration through the stratum corneum of fluorescent proteins containing G/O emulsions than of the aqueous solution of GF. Similarly, an in vivo study showed an angiogenesis-inducing effect after transdermal application of GF-immobilized G/O emulsion. Angiogenesis in mice was confirmed owing to both an increased blood vessel network and higher hemoglobin content in the blood. Therefore, the G/O emulsion could be a promising carrier for GFs with better stability and can effectively deliver GFs at the target site.

Antibody Response to ChAdOx1-nCoV-19 Vaccine Among Recipients in Bangladesh: A Prospective Observational Study.

PURPOSE: The aim of the study was to assess the antibody response to the ChAdOx1-nCoV vaccine in individuals who were not previously infected by COVID-19. PATIENTS AND METHODS: All people aged 18-65 years who received their first vaccination with ChAdOx1-nCoV from March to May 2021 were approached for inclusion. Individuals with sufficient antibody titers against SARS-CoV-2 infection before vaccination were considered previously infected and were excluded from the analysis. We observed viral spike protein RBD-S1-specific IgG antibody levels at day 28 of the first dose of vaccination and day 14 of the second dose of vaccination (74 days from index vaccination). An optical density ratio (ODR) of >1.1 was considered to have a positive antibody response, 0.8 to 1.1 borderline and <0.8 was denoted as negative. Informed consent was ensured before enrollment, and ethical principles conformed with the current Declaration of Helsinki. RESULTS: This observational study comprised 769 infection-naïve individuals (mean age 40.5 years, 38.9% female). Spike-specific IgG antibody responses elicited after the first and second doses of vaccine were 99.9% and 100%, respectively. The median ODR was 5.43 (interquartile range [IQR]: 4.32-6.98) and 10.90 (IQR 9.02-11.90) after the first and second doses. Higher age was associated with lower antibody levels after both dosages. However, no sex-specific variation was seen. People with comorbidity had a lower antibody level after the second dose. Tenderness (51.46%) and fever (19.30%) were the most common local and systemic side effects after vaccination. CONCLUSION: This study was one of the earlier attempts in the country to assess the antibody response to ChAdOx1-nCoV vaccine recipients. The results imply that general people should be encouraged to take the vaccine at their earliest.

Etiologies and posttreatment conditions of thyrotoxic patients in Sylhet division, Bangladesh: A clinical series.

OBJECTIVE: The endeavor of the study was to analyze the posttreatment (postradioactive iodine therapy [RAI]) conditions of thyrotoxic patients in a tertiary level hospital. MATERIALS AND METHODS: A retrospective study of 186 patients was conducted from 2012 to 2014 in Institute of Nuclear Medicine and Allied Sciences (INMAS), Sylhet MAG Osmani Medical College Campus. Patients' information regarding the etiologies and their disease status after getting RAI therapy was recorded. RESULTS: In this study, 29.57% patients were male and 70.43% were female where the mean ages were 44.57 and 43.46 accordingly. The most vulnerable group was in between 41 and 50 years of age, which is 25.81%. The patients were categorized according to the etiologies as Graves' disease (GD), multinodular goiter (MNG), and single toxic nodule (STN). In primary stage, 60.22% patients had GD, 26.88% had MNG, and 12.90% had STN. After 6 months of RAI therapy, the disease status of 51.61% patients became euthyroid, 19.35% became hypothyroid, and 29.03% remained thyrotoxic. Thus, a second dose of RAI therapy was given to those patients for next 6 months. After 12 months from the beginning of the therapy of each patient, the total recovery was found to be 72.04%. However, though all the GD patients improved to either euthyroid or hypothyroid state after 6 months, on a 12-month observation, 17.86% of them regained the thyrotoxicosis due to discontinuation of the treatment. CONCLUSION: The findings show an overall significant recovery of thyrotoxic patients taking RAI therapy in INMAS and important points to improve the rate.