Incidence, Risk Factors, and Outcome of Acute Kidney Injury in the Intensive Care Unit: A Single-Center Study from Jordan.

BACKGROUND: Acute kidney injury (AKI) is a common serious problem affecting critically ill patients in intensive care unit (ICU). It increases their morbidity, mortality, length of ICU stay, and long-term risk of chronic kidney disease (CKD). METHODS: A retrospective study was carried out in a tertiary hospital in Jordan. Medical records of patients admitted to the medical ICU between 2013 and 2015 were reviewed. We aimed to identify the incidence, risk factors, and outcomes of AKI. Acute kidney injury network (AKIN) classification was used to define and stage AKI. RESULTS: 2530 patients were admitted to medical ICU, and the incidence of AKI was 31.6%, mainly in stage 1 (59.4%). In multivariate analysis, increasing age (odds ratio (OR) = 1.2 (95% CI 1.1-1.3), P = 0.0001) and higher APACHE II score (OR = 1.5 (95% CI 1.2-1.7), P = 0.001) were predictors of AKI, with 20.4% of patients started on hemodialysis. At the time of discharge, 58% of patients with AKI died compared to 51.3% of patients without AKI (P = 0.05). 88% of patients with AKIN 3 died by the time of discharge compared to patients with AKIN 2 and 1 (75.3% and 61.2% respectively, P = 0.001). CONCLUSION: AKI is common in ICU patients, and it increases mortality and morbidity. Close attention for earlier detection and addressing risk factors for AKI is needed to decrease incidence, complications, and mortality.

Bangladesh national guidelines on the management of tuberculosis and diabetes mellitus co-morbidity (summary).

Tuberculosis (TB) and diabetes mellitus (DM) have synergetic relationship. People with diabetes are 2-3 times at higher risk of getting active TB disease. On the other hand, TB or anti-TB treatment may cause glucose intolerance. The dual disease of DM and TB is more likely to be associated with atypical disease presentation, higher probability of treatment failure and complications. In most of the health-care delivery systems of the world, DM and TB are managed separately by two vertical health-care delivery programs in spite of clear interaction between the two diseases. Thus, there should be a uniform management service for TB-DM co-morbidity. Realizing this situation, Bangladesh Diabetic Samity (BADAS), a nonprofit, nongovernment organization for the management of diabetes in Bangladesh, with the patronization of TB CARE II Project funded by U.S. Agency for International Development (USAID), launched a project in 2013 titled BADAS-USAID TB Care II, Bangladesh with the goal of "Integrated approach to increase access to TB services for diabetic patients." One of the project objective and activity was to develop a national guideline for the management of TB-DM comorbidity. Thus, under the guidance of National Tuberculosis Control Program, of the Directorate General of Health Services, Government of the People's Republic of Bangladesh and World Health Organization (WHO), this guideline was developed in 2014. It is based on the existing "National Guidelines and Operational Manual for TB Control" (5th edition) and guidelines for management of DM as per WHO and International Diabetes Federations. Along with that, expert opinions from public health experts and clinicians and "Medline"-searched literature were used to develop the guidelines. These guidelines illustrate the atypical presentation of the TB-DM co-morbidity, recommendations for screening, treatment, and follow-up of these patients and also recommendations in case of management of TB in patients with kidney and liver diseases. Thus, these guidelines will be a comprehensive tool for physicians to manage TB in diabetic patients.

Seroprevalence of human brucellosis among the population at risk in rural area.

This study was performed to evaluate the seroprevalence of brucellosis among the risk group of population. A cross sectional study was carried out in the Department of Microbiology, Mymensingh Medical College in collaboration with the Department of Medicine under the Faculty of Veterinary Science, Bangladesh Agricultural University, Mymensingh, between the period from July 2007 to June 2008. A total of 210 samples were included in this study from risk group of population. A variety of serological tests have been applied for detection of antibodies against Brucella spp. Among the 210 subjects from risk group of population, 9(4.28%), 7(3.33%) and 7(3.33%) were positive for brucellosis by slide agglutination test, rose bengal plate agglutination test (RBPA) and standard tube agglutination test (STAT) respectively. Out of total specimen 10 positive and 29 negative serum as detected by slide agglutination, rose bengal plate agglutination test (RBPT) and STAT were also examined by Enzyme linked immunosorbent assay (ELISA) for detection of IgG. Among them, 10 were positive by ELISA IgG. Seroprevalence among occupational groups were 11.11% in veterinary personnel, 6.45% in dairy workers and 4.67% in animal farmers. This study indicated that brucellosis is not uncommon at rural area of Mymensingh region in Bangladesh. It was suggested to conduct community survey and to plan properly the measures of control and prevention.

Preliminary report on anaerobic culture at Mymensingh Medical College Hospital in Bangladesh.

Puerperal sepsis is an important cause of maternal morbidity and mortality in developing countries. This study was undertaken to isolate and identify the anaerobic bacterial agents of puerperal sepsis among the patients admitted in Mymensingh Medical College Hospital (MMCH) during the period from July 2006 to June 2007. Endocervical swabs/secretions were collected from 50 cases of puerperal sepsis and were cultured anaerobically. Anaerobiasis was done by using gas pack (BD GAS PAK TM EZ) in anaerobic jar. Out of 50 samples, 42(84%) yielded growth in cultures. Among 42 culture positive cases, 20(40%) were Aerobic organisms and 22(44%) were mixed, i.e., Aerobic and Anaerobic bacteria. The isolated Anaerobic organisms were Peptostreptococcus 14(63.63%), Bacteroides fragilis 3(13.64%), Prevotella melaninogenica 3(13.64%) and Clostridium perfringens 2(9.09%). As a preliminary study, it was observed that anaerobic culture could be carried out with available logistic arrangement. So, it was recommended to design further study on anaerobic bacterial isolation with particular emphasis on their antimicrobial susceptibility.

Role of immunochromatographic test for rapid diagnosis of malaria.

The study was conducted to compare among the different diagnostic procedures for malaria in the department of Microbiology, Mymensingh Medical College, Mymensingh during the period from July 2005 to June 2006. In this study a total of 98 malaria patients were included as cases. Another 30 age and sex matched healthy people were included as controls. Blood sample from each of the case and control was collected and examined for malarial parasite by microscopic examination of peripheral blood film. Subsequently antigen and antibody were detected by immuno-chromatographic test (ICT). Out of 98 clinically suspected cases 59(60.20%) were positive for malarial parasite by microscopic examination of peripheral blood film, 57(58.16%) were positive by ICT for antigen and 58(59.19%) were positive by ICT for antibody. Sensitivity and specificity of ICT for antigen were 93.22% and 94.87% respectively. For antibody, sensitivity and specificity were 89.83% and 87.17% respectively. From this study, sensitivity and specificity of ICT for malaria was found quite satisfactory, so it is suggested that ICT for malaria could be an alternative to peripheral blood film for the diagnosis of malaria where parasite could not be detected in peripheral blood film.

Antibiotic susceptibility pattern of Staphylococcus epidermidis.

The present study was done to evaluate the antibiotic susceptibility pattern of Staphylococcus epidermidis isolated from different clinical specimens and healthy controls in the department of Microbiology, Mymensingh Medical College from July, 2007 to June, 2008. A total of 62 Staphylococcus epidermidis were isolated from 230 specimens. Among them 32(23%) S. epidermidis were isolated from 200 cases and 30(100%) were isolated from 30 healthy controls. Antimicrobial susceptibility test of the isolates was carried out by disk diffusion method as per recommendation of Clinical and Laboratory Standard Institute, 2007. Isolates of S. epidermidis from cases showed multidrug resistance as follows-penicillin 94%, oxacillin 56%, gentamycin 44%, erythromycin 41%, doxycycline 37%, cephradine 34%, ciprofloxacin 28%, ceftriaxone 28%, fusidic acid 22% and cefuroxime 19%. On the other hand, isolates of S. epidermidis from controls were susceptible to all antibiotics except penicillin, which was only 10% resistant. A remarkable difference was observed in the resistance pattern of S. epidermidis isolated from cases and healthy controls. However in our study no isolates of S. epidermidis was resistant to rifampicin and vancomycin, which can be used as last line of drugs to treat nosocomial S. epidermidis infection.

Pattern of aerobic bacteria with antimicrobial susceptibility causing community acquired urinary tract infection.

Since antibiotic resistance among uropathogens have gradually been rising, so it is important to have knowledge about the pattern and antimicrobial susceptibility to choose the correct treatment regimen. A cross sectional study was carried out in the Department of Microbiology, Mymensingh Medical College between July 2007 to June 2008 to determine the prevalence, relationship between pyuria and urine culture and antibiotic resistance pattern among the bacterial isolates of community acquired UTI (CUTI). A total of 100 urine samples were subjected to microscopy and culture. Antimicrobial susceptibility of isolates was done by disk diffusion method according to Clinical and Laboratory Standard Institute (CLSI) 2007. Of the total samples, 45(45%) were culture positive and among them female were more (71.1%) than the male (28.9%). The predominant age group was 15-29. Having pus cell >5/HPF, 93.3% culture positive patients showed significant pyuria. The isolated microorganisms were Escherichia coli (73%) followed by Staphylococcus saprophyticus (11.1%), Klebsiella spp (6.7%), Enterobacter spp (4.4%), Pseudomonas aeruginosa (2.2%) and Proteus spp (2.2%). All the bacterial isolates were sensitive to imipenem, while they showed variation in sensitivity to other commonly used antibiotics. Imipenem, nitrofurantoin and gentamicin were found to be effective for Gram-negative isolates and imipenem, azithromycin, vancomycin, ceftazidime for Gram-positive isolates. Our study emphasized over the changing etiology and emergence of drug resistance of the UTI within our country.

Prevalence of VP7 and VP4 genotypes of human group A rotavirus in infants and children with acute diarrhea in a northern city of Bangladesh.

The objective of this cross sectional prospective study was to determine rotavirus etiology and prevalence of the different rotavirus genotypes causing acute gastroenteritis in infants and children (

Comparison between DOT EIA IgM and Widal Test as early diagnosis of typhoid fever.

A recently developed DOT enzyme immunoassay known as "Typhidot" for detecting IgM antibody against 50 KDa OMP antigen of Salmonella typhi, was evaluated on 100 clinically suspected typhoid fever cases and 40 age-sex matched controls, in the Department of Microbiology, Mymensingh Medical College during, the period from June 2006 to July 2007. Blood culture, Widal test, and DOT EIA for IgM test were performed in all patients. Among 100 clinically suspected typhoid fever cases, 35 were subsequently confirmed on the basis of positive blood culture for S. typhi and/or significant rising titre of Widal test. The DOT EIA IgM test could produce results within 1 hour. The result of the DOT EIA IgM test showed a good diagnostic value for typhoid fever. The sensitivity, specificity, positive and negative predictive value of the test was found as 91.42%, 90.00%, 88.88% and 92.30% respectively. On the other hand corresponding values for Widal test were of 42.85%, 85.00%, 71.42% and 62.96% respectively. Thus, The DOT EIA IgM seems to be a practical alternative to Widal test for early diagnosis of typhoid fever.

Anti H.pylori IgM in symptomatic and asymptomatic population.

To evaluate the usefulness of specific IgM in the diagnosis of Helicobacter pylori infection, a cross sectional study was carried out in the Department of Microbiology, Mymensingh Medical College between July 2006 to June 2007. A total of 45 patients having upper gastrointestinal symptoms underwent endoscopy and were subsequently diagnosed as patients with gastritis, peptic ulcer (PU) and non-ulcer dyspepsia (NUD) and another 45 asymptomatic individuals aged 18-65 years, were included in the study. The serum samples of participants were tested for presence of anti-H pylori IgM by using ELISA method. The ELISA for anti H. pylori IgM provided sensitivity and specificity of 73.33%, 93.33% respectively.

PCR for mecA gene of methicillin resistant Staphylococcus aureus.

The study was under taken to detect mecA gene of methicillin resistant Staphylococcus aureus (MRSA) by PCR. It was carried out in the department of Microbiology, Mymensingh Medical College in collaboration with the Department of Medicine under the Faculty of Veterinary Science, Bangladesh Agricultural University, Mymensingh between the periods from July 2006 to June 2007. A total of 40 S. aureus strains were used in this study. Isolates of S. aureus were identified by standard microbiology technique and their antimicrobial susceptibility test was done by disk diffusion method according to NCCLS. Minimum inhibitory concentration (MIC) of oxacillin was determined for all isolates by standard agar plate dilution method. All strains were tested for mecA gene by PCR. Out of 40 S. aureus strains 15(37.5%) were detected as MRSA by disk diffusion and agar dilution method but 10(25%) yielded mecA gene by PCR. Detection rate of MRSA by disk diffusion and agar dilution test showed significant difference to that by PCR (p<0.001).

Genetic characterization of Staphylococcus aureus isolates carrying Panton-Valentine leukocidin genes in Bangladesh.

To assess the spread and genetic characteristics of Panton-Valentine leukocidin (PVL) gene-carrying Staphylococcus aureus in Bangladesh, we investigated 59 strains (49 isolates from clinical specimens and 10 isolates colonized in the nasal cavities of medical staff), including 26 methicillin-resistant S. aureus (MRSA) strains. The PVL gene was detected only in methicillin-susceptible S. aureus (MSSA) strains (7 clinical strains and 2 colonizing strains). PVL gene-positive MSSA strains were found to belong to coagulase serotypes III or VI and were classified into sequence types ST88 (CC88), ST772, and ST573 (CC1) by multilocus sequence typing, and agr types 2 or 3. These types were different from those determined for MRSA (coagulase serotypes I and IV, ST240 and ST361, and agr type 1). PVL gene-positive MSSA possessed a larger number of virulence factor genes than MRSA, although they were susceptible to more antimicrobials. These findings suggest that the PVL gene is distributed to limited populations of S. aureus clones with specific genetic traits that are distinct from MRSA in Bangladesh, but genetically close to CA-MRSA clones in the CC1 lineage reported in the United States and European countries.

Utility of fiberoptic bronchoscopy for retrieval of aspirated headscarf pins.

BACKGROUND: Headscarf pin aspiration is a common and unique form of foreign body aspiration among young Moslem women. Rigid bronchoscopy (RB) is considered the standard procedure for retrieval. There are little data on the role of flexible fiberoptic bronchoscopy (FOB) in the retrieval of aspirated headscarf pins. OBJECTIVES: The aim of this study is to prospectively evaluate the utility of FOB for the retrieval of aspirated headscarf pins. METHODS: Patients with the diagnosis of headscarf pin aspiration admitted to King Abdullah University Hospital from December 2002 to December 2005 were included in the study. Standard FOB procedure under local anesthesia and conscious sedation was performed as the primary tool for retrieval. RESULTS: A total of 16 cases was admitted during the study period. The mean age was 19 years. The aspirated pin was successfully retrieved in 9/16 cases (56%) during the first attempt of FOB. In another 3 cases, although the pin was successfully retrieved from the bronchial tree, it was lost in the throat and swallowed, and then recovered by esophagogastroduodenoscopy. However, FOB was not successful in 4/16 cases. In 3 cases, the aspirated pins were successfully retrieved by RB under general anesthesia and the fourth case required thoracotomy. CONCLUSIONS: Headscarf pin aspiration is a relatively common form of foreign body aspiration among young Moslem Jordanian women. FOB under local anesthesia can be a useful first-step tool in retrieval, provided facilities for esophagogastroduodenoscopy and RB are readily available.

Knowledge and attitude of clinical students on problem based learning.

An intervention study was carried out in Mymensingh Medical College between December 2002 to November 2003 to determine knowledge and attitude of clinical students on problem based learning (PBL) before and after exposure to a PBL course. This is an intervention study. A total of 17 health problems were discussed in the integrated small group tutorials in the departments of Pediatrics and Medicine. Two problems were discussed in a week & each PBL class was lasted for 2 hours. Pretest was done before exposure of the students to the PBL course using self-administered questionnaire and posttest was done immediately after finishing the PBL course. Significance of proportions was calculated by Chi-square (X2) test. PBL course increased knowledge of clinical students on PBL significantly (P < 0.001). Increased number of clinical students also stated that PBL is effective in problem solving (70% before and 97% after the PBL course), and the difference is highly significant (P < 0.001). Increased number of students (about 72% before & 83% after the PBL course) stated that PBL is better than traditional ward teaching (P < 0.01). Majority of our students (about 61% before & 88 % after the PBL course) stated that PBL enhances self-directed learning (P < 0.005). A good number of students (about 63% before & 81% after PBL course) recommended PBL to be included in Undergraduate Medical Curriculum (P < 0.05). It can be concluded that exposure of students to PBL course can improve knowledge, attitude & practice of clinical students significantly. Regular exposure (at least twice a year) of clinical students to symposium centered on PBL is recommended

Sensitivity of splenic and bone marrow aspirate study for diagnosis of kala-azar.

Fifty adult patients of kala-azar were included in this prospective study from Medicine Unit-I of Mymensingh Medical College Hospital. Splenic and bone marrow aspiration were done simultaneously to compare the sensitivity and other related merits and demerits of each procedure. Splenic aspiration appeared to be more sensitive procedure than bone marrow aspiration. Leishman - Donovan (LD) bodies were found in 90 percent and 72 percent of the spleen and bone marrow aspirates respectively. Splenic aspiration was found more acceptable to patients (96%) as it was less painful. Both the procedures were hazardless. There was no major complication except mild pain after splenic aspiration; even a few patients had history of epistaxis. Splenic aspiration was also more acceptable by the physicians because of an easy and reliable diagnostic procedure.

Thoracic actinomycosis.

Thoracic actinomycosis represents about one-fourth of all cases of the disease. Isolated pleural effusion due to Actinomycosis is rare. We report a case of right sided pleural effusion with discharging sinus in the right anterior chest wall. Actinomycosis was suspected and confirmed by microscopic identification of "sulfur granules" in the discharge of the sinus tract and also identification of gram-positive filamentous bacteria in the specimen of discharging sinus. The patient improved clinically and radiologically after treatment with intravenous penicillin G followed by oral penicillin and aspiration of pleural fluid.

Increasing trend of ciprofloxacin resistance amongst common bacterial isolates at Mymensingh Medical College and Hospital.

Ciprofloxacin resistance among common bacterial pathogen comprising Esch.coli, Staph.aureus and Pseudomonas spp. isolated from different clinical samples of Mymensingh Medical College Hospital during the periods of September, 1999 to March, 2001 and September, 2001 to August, 2002 were recorded. Values of two periods were compared and increased rate of ciprofloxacin resistance were noted in every bacterial species, e.g. 32.0% in Esch.coli, 8.7% in Staph.aureus and 5.1% in Pseudomonas spp. It was suggested to be aware and careful regarding use of ciprofloxacin in clinical practice so as to limit emergence of bacterial strains resistance towards the drug.

A preliminary report on culture of Leishmania donovani in Mymensingh Medical College and evaluation of new immuno-chromatography test (ICT).

A total of 51 inpatients having prolonged low grade irregular fever with anaemia, hepatosplenomegaly, emaciation and other allied features were evaluated by findings of haematologic, seroimmunologic, microscopic examination for LD body and culture for L. donovani. The study was done during the period from September' 1999 to January' 2000. Bone marrow or splenic aspirates were examined for LD bodies and those samples were cultured in modified NNN media following a standard method. Out of 51 samples, 36 (70.5%) were positive for LD bodies in stained smears and 38 (74.5%) were positive in culture. The mean time of culture positivity was 5 +/- 2 days. Specific antileishmanial antibody were detected by Immunochromatography Test (ICT) in all 38 confirmed cases, whereas Aldehyde test (AT) were negative in 3 such cases. ICT was positive in 1 and AT in 7 cases where no parasite could be detected. So, sensitivity of ICT was 100% with a specificity of 92.3% and sensitivity of AT was 92.1% with a specificity of 46.1%.