Factors Associated with Delayed Hospital Arrival of Patients Presenting with Acute Myocardial Infarction: A Cross-Sectional Study in Bangladesh.

Delay in seeking medical care of the patients with acute myocardial infarction (AMI) could affect the outcome. Therefore, it is important to recognize and reduce pre-hospital in initiating treatment of these patients. The objective of the study was to evaluate the factors associated with delayed hospital arrival of patients with AMI. This cross-sectional study was carried out among 385 patients with AMI attended in the Department of Cardiology, Dhaka Medical College Hospital (DMCH), Dhaka, Bangladesh. The delay in arrival to the hospital was recorded along with socio-demographic data, conditions of the patients during onset and other relevant data. The mean age of the patients 59.7±9.9 years with a male-female ratio of 2.4:1. About 22% of patients with AMI arrived at the hospital within 6 hours of symptoms onset and only around 13% arrived within 2 hours of onset of symptoms. Comparatively younger (p=0.037), unmarried (p=0.008) and Muslim (p=0.008) patients were more likely to present for hospital care sooner (p=0.037). Patients coming from upper middle class of socioeconomic status (p<0.001) and those with college or post college level of education (p<0.001) were more likely to present earlier for hospital care. Prehospital delay was larger in non-manual worker patients (p<0.001) as well as in patients with onset of chest pain during rest period (p<0.001) and while at home (p<0.001). Pre-hospital delay was shorter in patients with onset of chest pain from 12am to 6am and 6am to 12pm (p<0.001). Lack of awareness of AMI symptoms and benefits of its early treatment, long distance and mode of transport were shown as the most common causes of delayed arrival of patients at hospital (p<0.001). This study has identified the factors associated with AMI in context of Bangladesh. Effective measures including increasing awareness of AMI symptoms should be taken for better outcome of the patients.

A Middle-Aged Woman Presented with Catastrophic Anti-phospholipid Syndrome in Nephrology Department of BSMMU.

A life threatening rare condition called catastrophic antiphospholipid syndrome leading to multiple organ failure is characterized by vascular thrombosis in the presence of anti-phospholipid antibody which often appear as a medical emergency. Antiphospholipid antibody syndrome whether primary or secondary cause thromboembolic manifestation resulting recurrent fetal loss, but catastrophic antiphospholipid antibody syndrome may not present in such a way, rather multi-system involvement occurs within a short period of time. We would like to present a case of 50 years old female who is hypertensive, non-diabetic, a known case of hypothyroidism for two years, who was admitted to our hospital after developing fever for 7 days and black discoloration of lateral three fingers of left hand for short period of time. The patient had no medical problems and had been in her usual state of health until 7 days before admission. Patient is anaemic and found to have severe renal failure. She was found high titer antiphospholipid antibody both IgM and IgG positive and anti-cardiolipin antibody positive. Her routine investigations revealed very high neutrophilic leukocytosis, high acute phase reactant, urinary findings revealed no active sediment; we thought that our patient might have sepsis that may trigger catastrophic antiphospholipid syndrome. Multi-disciplinary consultation gave us valuable opinion. Considering her septicemia, she was given broad spectrum antibiotic. Anticoagulation was given with unfractionated heparin followed by warfarin and as an immunosuppressive protocol methylprednisolone followed by prednisolone along with pulse cyclophosphamide was given. Treatment option with plasma pheresis and monoclonal antibody was not attempted, but she was given several session of hemodialysis, within a few days her biochemical parameters improved. Severe renal failure in this patient may be explained by septicemia or thrombotic micro-angiopathy that was reversed with anti-coagulation or proper antibiotic. Amputation of three digit of left hand was done by orthopedic surgeon but unfortunately two weeks after admission the patient expired due to sudden stroke.

Knowledge, Attitude, and Perception About Renal Transplantation of CKD Patients, Caregivers, and General Population.

INTRODUCTION: In this study knowledge about kidney disease and the option of transplantation was assessed in chronic kidney disease (CKD) patients and their care givers. PATIENTS AND METHODS: A knowledge, attitude, and perception (KAP) questionnaire comprising 33 items was developed. It had 4 classes: knowledge of kidney disease (9 items), transplantation (10 items), attitude (6 items), and perception (8 items). There were 3 possible answering options (yes/no/don't know) indicating "agree/disagree/no idea" or "optimal understanding/some understanding/no idea," allocating a score of 4/2/0, respectively. A higher score indicated good KAP. CKD patients, accompanying caregivers, and healthy controls from the general population were included. RESULTS: In 218 subjects, 108 were CKD patients (78 pre-end-stage renal disease and 30 maintenance hemodialysis), 40 were caregivers, and 70 were controls. The majority had a primary level of education (52%) and earned low to middle income (67%). Only 34% claimed to have adequate knowledge; information sources were doctors (61%) and relatives (21%); 63% agreed to involve in transplant program; 58% had no knowledge about types of kidney donors; and 71% believed in no religious restrictions to transplantation. The average KAP score for all in total 25 scoring items (59 ± 23) and separately in knowledge of kidney disease (75 ± 34), transplantation (48 ± 28), attitude (64 ± 28), and perception (51 ± 28) showed a generally low score especially in the field of transplantation. Education level (school vs. higher: 50 ± 23 vs. 70 ± 19, P < .001), income (low-middle vs. higher: 52 ± 23 vs. 72 ± 17, P < .001) and location (rural vs. urban: 53 ± 19 vs.74 ± 19, P < .001) conferred higher KAP scores. CONCLUSION: Knowledge, attitude, and perception towards renal transplantation is positively influenced by a person's educational level and economic status.

Etiology of Early Renal Allograft Dysfunction and Comparison between Dysfunction and Function Group: A Single Center Study.

Over a period of two years thirty five renal allograft recipients & donors were evaluated to find out the aetiology of early renal allograft dysfunction, in the Department of Nephrology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from March 2010 to February 2012. A comparison was made between dysfunction & functioning graft group. Mean age of recipients were (36.4±9.4) years, mean age of donors were (41.7±8.3) years, with a male and female ratio of 3:1. Fifty percent recipients showed one heliotype match, ninety percent recipients were anti CMV antibody IgG positive, few were anti CMV antibody IgM positive. All kidney transplant recipients received same immunosuppressive drugs. Primary disease of the renal allograft recipients demonstrates that majority 88.58% had glomerulonephritis, 5.72% had polycystic kidney disease, 2.85% had chronic pyelonephritis and another 2.85% had diabetic nephropathy. Among 35 renal allograft recipients 23(66%) showed early graft dysfunction, 12(34%) showed normal graft function. The etiology of early graft dysfunction showed, 50% developed acute rejection, 17% acute cyclosporine toxicity, 17% acute tubular necrosis, 8% had graft thrombosis and 8% developed recurrent glomerulonephritis. Sub-clinical rejection was detected in 20% cases. Comparison of donor characteristics between dysfunctioning and functioning graft groups revealed that age and sex were identically distributed between the groups (p=0.183 and p=0.087 respectively). The mean serum creatinine of donor was significantly higher in the graft dysfunction group than that in the functioning graft group (113.5±12.6 vs. 99.6±17.3; p=0.025), as well as the mean creatinine clearance rate was significantly less in the former group than that in the later group (82.1±13.5 vs. 93.9±18.6, p=0.040). The mean cyclosporine (C2) level on 7th POD were 1593.2±320.4ng/ml in graft dysfunction group and 1439.1±199.5ng/ml in the functioning graft group which decreased to 1364.8±263.7ng/ml and 1114.2±145.1ng/ml after three months in the dysfunction and the functioning graft groups respectively. There was no significant difference in the cyclosporine level between groups on 7th POD and 14th POD, 1st and 2nd month. However, at 3rd month the level of cyclosporine was higher in the dysfunction group than that in the function group. Proteinuria on 14th POD was almost similar between dysfunction and function graft groups (p=0.704). However, higher incidence of proteinuria was observed in subsequent months in the graft dysfunction group compared to the function graft group. All the postoperative variables like systolic blood pressure, diastolic blood pressure, fever and tremor were higher in dysfunction group in comparison to functioning graft group. Per operative biopsy of donor kidney, some showed increased number of sclerotic glomeruli which is more common in dysfunction group. Among 35 recipients 2(16.7%) died due to infection in dysfunction group compared to 1(4.3%) in functioning graft group.

Presentation and Treatment Outcomes of 100 Lupus Nephritis Patients: Single Center Study.

Over a period of 3 years (January 2011 to December 2013) 100 cases of Lupus nephritis patients admitted in nephrology department of Bangabandhu Sheikh Mujib Medical University (BSMMU) were evaluated. Their clinical characteristics, biochemical parameters, renal histology according to WHO classification were categorized and their treatment modalities and outcome was observed. Among 100 patients, 84 were female and 16 were male, with F:M ratio 5:1. Mean age of female were 23±4 years and male were 29±4 years, mean BP in male was systolic 135±8 mmHg, diastolic 80±9mmHg and in female systolic was 130±7mmHg, diastolic 75±6 mmHg, mean Serum Creatinine for male was 180±12µmol/L and mean serum creatinine in female was 170±20µmol/L. Sixty five percent (65%) patient showed extra renal manifestation. All patients presented with proteinuria, among them 45% were nephrotic presentation, 25% patients presented with acute nephritic illness, 15% were nephritic nephrotic, 10% patients had rapidly progressing glomerulonephritis (RPGN), and 5% were with asymptomatic proteinuria. Renal biopsy of 100 patient according to WHO classification showed class I - 5%, class II - 20%, class III - 26%, class IV - 35%, class V - 8%, class VI - 6%. Immunosuppressive protocol used was prednisolone and cyclophorphamide in the majority of patients in class III to class VI LN patients. Few patients received prednisolone and mycophenolate mofetil. Twenty four percent (24%) patients were in complete remission during this study period and 12% developed end stage renal disease (ESRD). Seventy six percent (76%) patients passed through various stages of CKD, majority of them were in CKD stage IV and stage III, and few were in CKD stage I and stage II. About 70% of the participants had suffered from one or more complications, where majority were infections. Infections and renal failure were the leading cause of death in our study.

Role of protocol biopsy in early graft dysfunction in renal transplant recipient.

This study was designed to evaluate the role of protocol biopsy in renal allograft recipients. A total of thirty five kidney transplant recipients with a mean age of 35±5 years included in this study. Mean age of donor was 41±8 years. The study was performed from April 2008 to November 2009 in the Department of Nephrology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh. Immunosuppressive protocol used for transplant patient was, Cyclosporine 8mg/kg/day, Mycophenolate mofetil (MMF) 500mg twice daily, Prednisolone 0.5mg/kg/day. Protocol biopsy done on day 0 (Peroperative), day 14 and day 90. Stains used H&E and PAS. Cyclosporine blood level was done on 7th and 14th postoperative day and monthly for 3 months. Serum creatinine was done daily for 14 days & then weekly upto 3 months. Among 35 patients 23(66%) showed normal graft function and 12(34%) early graft dysfunction. Aetiology of early graft dysfunction includes 50% clinical rejection, 17% acute tubular necrosis (ATN), 17% cyclosporine toxicity, 8% graft thrombosis and 8% recurrence of GN. Per operative protocol biopsy showed normal histology in 28(80%) cases, in 4 cases 11% glomeruli showed sclerosis and in 3 cases 9% glomeruli showed sclerosis. At 14th post operative day 60% patients showed normal histology, 14% had clinical rejection (elevated serum creatinine along with histological features of rejection), another 14% had sub clinical rejections (normal serum creatinine with histological changes), cyclosporine toxicity 5.6%, ATN 5.6%, and recurrent glomerulonephritis in 3% cases. Among clinical rejection, according to Banff numerical classification, Grade-1 (20%), Grade-2 (60%), Grade-3 (20%) and among sub clinical rejections Banff Grade-1 (80%), Grade-2 (20%). Biopsy after 3 months showed normal histology 54.28%, clinical rejection 11.42%, sub clinical rejection 5.7%, borderline change 5.7%, cyclosporine toxicity 5.7% & 2.8% recurrent glomerulonephritis. According to Banff numerical classification in clinical rejection Banff Grade-1 (25%), Grade-2 (50%) and Grade-3 (25%). Among subclinical rejection Banff Grade-1 (70%), Grade-2 (30%).

Chronic kidney disease specific cardiovascular risk factors among non dialytic patients with chronic kidney disease stage-V--an experience of a specialized hospital.

The study was carried out to see prevalence of Chronic Kidney Disease (CKD) specific cardiovascular risk factors and cardiovascular events among patients with Chronic Kidney Disease stage-V (CKD-V) before starting dialysis therapy in the department of Nephrology of National Institute of Kidney Diseases & Urology (NIKDU), Dhaka, Bangladesh. Among CKD specific cardiovascular risk factors, anemia showed the highest prevalence (96.7%) in study population. More than fifty percent of CKD-V patients had both hypocalcaemia and hyperphosphataemia. Calcium-Phosphate Product (CaXP) was elevated among 23 percent of the population. C-reactive protein, an acute phase protein was positive in 78% of CKD-V patients. Besides, among traditional risk factors, Hypertension and Diabetes Mellitus were present in 83.3% and 23% of the study population respectively. The prevalence of cardiovascular events among CKD-V patients showed that 18.3% had ischemic heart disease, 38% heart failure, 4.7% arrhythmia and 9% left ventricular hypertrophy. Females were significantly prone to develop cardiovascular events than their male counterpart (p=0.028). Diabetes was significantly higher in patients with cardiovascular complications than in patients without cardiovascular complications (p=0.021).

Awareness about organ donation among school girls.

Prevalence of organ failure is high through out the world. Organ transplantation, the definitive treatment option of organ failure keeps very low due to scarcity of organ. Most of the people are not aware about organ donation. Adolescent girls will be the mother of future nation and they can motivate family members for organ donation. This study was carried out to see attitudes towards organ donation and determine the negative factors of organ donation prevailing among school girls. One hundred sixty eight girls from class VIII to class X of a higher secondary school were participated. A structured questionnaire was filled up by the girls. The data were processed from questionnaire and analyzed. Among study population, most of them (64%) had no idea about on going organ donation and transplantation. The positive attitude of the girls towards organ donation was low when they are live (16%) and their attitudes also kept low even after their death (14%). The girls who did not agree to donate organ were further asked to mention the reasons. The reasons of negative attitude were religious belief, fear of illness and social and familial reservation. The result of this study suggests that among girls, awareness and attitudes about organ donation is poor. There were several reasons identified for low consent rates. Multidisciplinary actions should be taken to improve the awareness of the people about organ donation and motivate them for donation.