Comparison of Risk Factors and Angiographic Profile between Younger and Older Patients with Acute Myocardial Infarction.

Acute myocardial infarction (AMI) in younger adults (≤40 years) is being increasingly encountered in recent years among the South Asian population. Data regarding the presentation, risk factors and angiographic findings on this important subset of patients is lacking in our country. The aim of this study was to compare the risk factors and pattern of Coronary artery involvement in younger patients presenting with AMI with that of the older age group. This was a cross-sectional observational study conducted during the period from October 2018 to June 2019. Seventy consecutive AMI patients age ≤40 years and another 70 consecutive AMI patients age >40 years undergoing Coronary Angiogram (CAG) were included in the study. After taking informed written consent; demographic, anthropometric, risk factors, CAG findings were recorded in a pre-designed case record form. The severity of Coronary Artery Disease (CAD) was calculated by using Gensini score. The mean age of the younger and older patient groups was 36.89±4.4 years and 57.00±8.4 years respectively. Among the risk factors, smoking (67.1% versus 45.7%, p=0.017), positive family history CAD (38.6% versus 22.9%, p=0.040) and obesity (34.3% versus 20.0%, p= 0.05) were more common in younger group. Whereas, Hypertension (41.4% versus 72.9%, p=0.010) and DM (28.6% versus 50.0%, p=0.024) were more common in older patients. Younger patients mainly presented with STEMI (60.0% versus 48.6%) and predominantly had single vessel disease (42.9%), whereas older patients readily presented with NSTEMI (51.4%) and had a higher incidence of double vessel disease (32.9%) and triple vessel disease (30.0%). The Median Gensini score was significantly higher among the older patients than in the younger age group. Patients in younger age group showed a different pattern of risk factors and coronary artery involvement in comparison to the older age group. Thus, offering younger individuals to make them aware of these risk factors and their early detection, as well as an effective intervention may help to prevent AMI in younger people.

Compliance on existing WASH facilities in community clinics of Bangladesh: A comparative study.

Provisions of water sanitation and hygiene (WASH) facilities are essential to make accessible and sustainable through Community Clinics (CCs) to control infection in primary health care service. However, there is scarcity of literature to observe the scenario. This cross-sectional study with mix-method approach conducted a comparative analysis with a focus on compliance with WASH facilities between two categories of CCs in Meherpur and Kustia District in Bangladesh. There were total 420 respondents out of which 400 were selected purposively from the 20 renovated and non-renovated CCs for quantitative approach and 20 respondents for qualitative approach. Data were collected using face-to-face interview method. The study revealed that all of the renovated CCs had safe drinking water source, functioning toilet, hand washing and dust bin facilities except for a few cases with technical problem in water supply. But the reverse scenario was observed in non-renovated CCs. Compliance on WASH facilities in renovated CCs was two times higher than the non-renovated CCs. Clients aged ≤40 years (AOR = 0.41, renovated CCs), and married (AOR = 4.03, non-renovated CCs) did not comply the use of safe drinking water in CCs. Noncompliance of toilet use (AOR = 12.15, renovated CCs and AOR = 8.96, non-renovated CCs) and hand washing facility use (AOR = 8.46, renovated CCs and AOR = 16.8, non-renovated CCs) significantly found higher among respondents who had no formal education. Non-renovated CCs need to develop their WASH facilities as well as ensure maintenance whereas the renovated CCs need dedicated human resource as well as effective policies to maintain the sustainability.

Predictive Value of Waist Height Ratio, Waist Hip Ratio and Body Mass Index in Assessing Angiographic Severity of Coronary Artery Disease in Myocardial Infarction Patients.

Coronary artery disease (CAD) is the leading cause of mortality and morbidity both in developed and developing countries. The body mass index (BMI), waist hip ratio (WHR) and waist height ratio (WHtR) are some of the clinical tools enabling clinicians to assess obesity. Although for decades there have been controversy regarding the relationship between obesity and CAD; it has been assumed that high BMI is a risk factor for CAD. However, the findings of some recent studies were paradoxical. The aim of this study was to identify the best tool among BMI, WHtR and WHR to evaluate angiographically severe CAD in myocardial infarction patients. This was a cross-sectional analytical study carried out in the Department of Cardiology, Chattogram Medical College and Hospital (CMCH), Chattogram, Bangladesh from January 2017 to December 2017. Three hundred and thirty two consecutive MI patients undergoing CAG during the study period were included in the study as per inclusion and exclusion criteria. Severity of CAD was calculated by using Gensini score. Patients were categorized and compared according to anthropometric indices and CAD severity. The mean±SD of the age of study population was 53.62±10.36 years (range 25-92) and 276(83.1%) were male. Regarding cardiovascular risk factors, 113(34%) patients had diabetes mellitus, 108(32.5%) had dyslipidaemia, 137(41.3%) had hypertension, 205(61.7%) were current or ex-smokers and 59(17.8%) had a family history of CAD. The mean±SD of the patients' BMI was 24.05±3.24kg/m² (range 16.14-32.72), mean±SD of their WHR was 0.964±0.052 (range 0.823-1.125) and mean±SD of their WHtR was 0.546±0.059 (range 0.389-0.748). The mean±SD of the severity of CAD according to the Gensini score was 41.11±28.66 (ranged from 2 to 244). Study findings showed a positive correlation between the severity of CAD with WHtR and WHR but not with BMI, according to Gensini scores (p=0.004, p=0.023 and p=0.43 respectively). Receiver Operating Characteristics (ROC) curve analysis revealed that waist height ratio had the highest area under the curve (AUC) among the three anthropometric parameters for predicting presence of severe CAD. Study showed the superiority of WHtR over WHR and BMI for predicting angiographic severity of CAD in patients with MI. WHtR should therefore be considered as a screening tool.

Cardiovascular risk assessment among rural population: findings from a cohort study in a peripheral region of Bangladesh.

OBJECTIVES: The incidences of non-communicable diseases including cardiovascular diseases (CVDs) is increasing in Bangladesh. The reasons for this increasing trend need to be explored. The aim of this study is to assess the risk of CVDs among a peripheral rural Bangladeshi population and to explore the sociodemographic, anthropometric and clinical variables associated with increased risk. STUDY DESIGN: Cohort study. METHODS: From a cohort of 190,471 individuals of all ages, originally included in a diabetic eye disease program initiated in 2008-2009, a purposive sub-cohort of 66,710 individuals, aged 31-74 years was recruited. During 2011-2012 these participants were assessed for CVDs using the WHO's risk assessment tool designed for primary care settings in low resource societies. Participant characteristics associated with higher risk were explored using univariable and multivariable regression analysis. RESULTS: Out of all (95.5% participation rate) participants 1170 (1.84%) were found to be at high risk for CVD. The prevalence of hypertension (HTN), pre-HTN, obesity, underweight and self-reported DM were 8.9%, 15.2%, 9.6%, 7.8% and 0.5% respectively, among the study population. In multivariable regression analysis female sex, older age, temporary housing structure (i.e., tin shed), extremes of BMI (both underweight and obese) and central obesity were associated with higher risk for CVDs. CONCLUSIONS: The prevalence of CVD risk factors and high CVD risk individuals in this cohort was found to be lower than previous studies. It may be the effects of urbanization are yet to reach this relatively traditional rural population. This study adds to the literature on use of the WHO risk assessment tool.

Problems leading to conversion in laparoscopic cholecystectomy.

In prospective study, the various reasons for conversion in laparoscopic cholecystectomy were shown and recommended various measures to decrease the incidence of conversion and associated complications with this procedure. Fifty cases of conversion in laparoscopic cholecystectomy were studied in Dhaka Medical College Hospital & Bangabandhu Sheikh Mujib Medical University from July 2002 to July 2004. The commonest cause of conversion was dense pericholecystic adhesion or unclear anatomy (24%). Next common cause was accidental injury to surrounding structures (18%) and uncontrolled bleeding (14%) and thick fibrosed gall bladder (14%). Other causes were gall bladder wall perforation (6%), carcinoma gall bladder (6%) and choledocholithiasis (6%), anatomic variation (4%), equipment failure (4%), cholecystoduodenal fistula (2%) and choledochal cyst (2%). Proper case selection, good laparoscopic skill and adequate experience of the surgeon are the prerequisites for safe laparoscopic cholecystectomy and thereby reducing conversion rate.

Effect of hydration with or without n-acetylcysteine on contrast induced nephropathy in patients undergoing coronary angiography and percutaneous coronary intervention.

Contrast induced nephropathy (CIN), an acute decline in renal function after the administration of intravenous contrast in the absence of other causes, is the third leading cause of acute renal failure in hospitalized patients. Antioxidant N-acetylcysteine prevents acute contrast nephrotoxicity in patients with impaired renal function who underwent coronary angiography (CAG) and percutaneous coronary intervention (PCI). Hydration is the cornerstone in preventing CIN. N-acetylcysteine has additive preventive affect. We compared N-acetylcysteine plus hydration with hydration alone in preventing CIN. Patients were assigned to receive either premedication with hydration with normal saline (1ml/kg/hour-12 hour before and 12 hour after CAG and intravenous PCI) alone or to receive both hydration and oral N acetylcysteine (600mg bid for 2 days, starting day before CAG and PCI). Main out come was occurrence of ≥25% or ≥0.5mg/dl increase in serum creatinine level within 24 to 48 hours after contrast administration; change in creatinine clearance and serum creatinine level. Six patients (12%) of hydration group i.e. Group A and none of the patients of N-acetylcysteine All group i.e. Group B develop CIN (p=0.012). Baseline serum creatinine level was slightly higher in N-acetylcysteine group than hydration group (1.52±0.32 and 1.44±0.22). After 24 hours of CAG and PCI serum creatinine level lower than base line in N-acetylcysteine group but slightly higher than base line in hydration group (1.42±0.39 and 1.51±0.38). Difference in serum creatinine in both the groups were statistically significant (p=0.006 in N-acetylcysteine group and p=0.029 in hydration group). Creatinine clearance rate significantly improved in N-acetylcysteine group after coronary intervention. In conclusion, N-acetylcysteine and hydration prevent CIN better than hydration alone in high risk patients.

Contrast induced nephropathy in patients with pre-existing renal impairment undergoing coronary angiogram and percutaneous transluminal coronary angioplasty.

Contrast induced nephropathy is the third leading cause of acute renal failure in hospitalized patients. However, its incidence and risk factors in Bangladeshi population undergoing coronary angiogram and percutaneous coronary intervention is not clear. This study was to assess the incidence of contrast induced nephropathy in patients, with or without pre existing renal impairment, undergoing coronary angiogram and percutaneous transluminal coronary angioplasty in Bangladeshi population. Two hundred patients undergoing coronary angiogram and percutaneous were included in the study .Patients having history of contrast allergy and patients on renal dialysis were excluded from the study. Serum creatinine level was estimated before the undergoing procedure. Creatinine clearance rate was calculated by applying Cockcroft Gault formula to the preprocedure serum creatinine level. Patients were assigned to one of the two groups, that is with or without chronic renal insufficiency. Serum creatinine levels were again estimated at the end of 24 hours of contrast exposure. The rise of serum creatinine by ≥0.5mg/dl or ≥25% occurring within 24 hours of contrast administration was defined as contrast induced nephropathy. The incidences of Contrast induced nephropathy (CIN) in these groups were compared. We tried to analyze whether there is relation between the incidence of CIN with contrast volume, chronic renal insufficiency, diabetes mellitus, and coronary procedures undergone. We enrolled 120 pre existing chronic renal insufficiency patients and 80 patients without pre existing chronic renal insufficiency. In this study 21.7% of pre existing chronic renal insufficiency group and 6.3% of no pre existing chronic renal insufficiency group developed contrast induced nephropathy (p=0.003). Contrast induced nephropathy is an iatrogenic disorder and pre existing renal impairment is one of the risk factors for developing contrast induced nephropathy.

Association of cardiac ischemic score and coronary collateral circulation.

Coronary collateral circulation maintains myocardial perfusion in coronary atherosclerotic disease. The indicators of cardiac ischemia, (Angina pectoris on exertion, during emotion, previous myocardial infarction and prior coronary intervention) are associated with presence of coronary collateral circulation. In this prospective observational cross sectional study, 128 patients with history of angina pectoris on exertion and or during emotion and or myocardial infarction and or previous coronary intervention were enrolled. The cardiac ischemic score (range 1-4) was calculated by adding 1 point for each of the above four clinical factors, which can be easily assessed. Presence of coronary collaterals in coronary angiogram was defined as Rentrop grade ≥1. Patients were divided into two groups. Group A patients having Rentrop grade 0 and Group B patients are with collateral circulation, having Rentrop grade 1-3. Patients having cardiac ischemic score (range 1-4) are compared in these groups. Maximum (83.3%) patients of Group B with coronary collateral circulation had cardiac ischemic score 2-4, but majority (86.4%) of Group A patients without collaterals showed the score only 1. Thus the cardiac ischemic score is strongly associated with the presence of coronary collaterals.

Prevalence of cigarette and bidi smoking among rickshaw pullers in Dhaka city.

OBJECTIVE: Rickshaw pullers in Dhaka city, Bangladesh are exposed to severe air pollution due to their long stay on city roads. In addition, smoking could further jeopardize their health status. The objective of this study is to estimate the prevalence of cigarette and bidi smoking among the rickshaw pullers in Dhaka city. METHODS: One thousand rickshaw pullers (100 from each of the 10 blocs of Dhaka city) were randomly chosen and underwent interviewer administered questionnaire survey during August-October 2003. Data on demographics, education, rickshaw-pulling, smoking status, duration, and daily consumption were collected by 4 trained interviewers using pre-tested questionnaire. Prevalence of cigarette and bidi smoking, and their sociodemographic correlates were examined using bivariate and multivariate analyses. RESULTS: The overall prevalence of current smoking was 75.9%, while the prevalence of cigarette, bidi and both smoking were 39.2%, 15.7% and 20.9%, respectively. Multinomial logistic regression analysis showed that those who were older, had lower mean schooling years and smoked more sticks per day are more likely to be bidi or both smokers. CONCLUSION: The prevalence of smoking among rickshaw pullers is very high compared to that in general population. Immediate intervention programs are warranted to reduce the future burden of smoking related morbidity among them who are already exposed to tremendous pollution on city roads.

Single dose intravenous regional antibiotic in clean orthopaedic procedures.

Patients undergoing clean orthopaedic operations with tourniquet in Orthopaedic Department of a tertiary level hospital in Dhaka during August 1999 to March 2002 were consecutively enrolled in a prospective clinical study to explore the efficacy and safety of regional prophylaxis with single dose antibiotic. Eighty two patients with 83 operations received 750-mg cefuroxime in 40 & 20 ml of distilled water, into a dorsal vein of the foot or hand respectively to be operated on immediately after the tourniquet was inflated. Patients with bilateral operation, regional administration of cefuroxime were also repeated for the operation on the other extremity. Follow up ranged from 3 weeks to 2 years & 7 months. None of the patients experienced local or systemic adverse effects following regional administration of cefuroxime. Also none developed early infection (superficial or deep) during the follow-up period. Infective complications at distant sites like UTI were observed in one case with bilateral corrective osteotomy for knocked knee deformity. It was probably due to catheterization in the immediate post-operative period, which was rapidly cured following antibiotic treatment and removal of catheter. Regional administration of single dose antibiotic appears to be a safe and effective prophylaxis for the control of early infection in clean orthopaedic procedures. Late infection is blood borne and that can not be controlled by prophylactic use of antibiotic.

Thyroid storm as a cause of loss of consciousness following anaesthesia for emergency caesarean section.

A previously undiagnosed thyrotoxic patient was anaesthetised for an emergency Caesarean section. The recovery period was complicated by an acute thyroid crisis resulting in loss of consciousness following an apparently normal recovery from general anaesthesia.