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.

Demographic and Clinical Characteristics of Persons With Spinal Cord Injury in Bangladesh: Database for the International Spinal Cord Injury Community Survey 2023.

The study aims to explore the demographic and clinical characteristics of persons with spinal cord injury (SCI) in Bangladesh. A total of 3035 persons with SCI spanning from 2018 to 2022 were included in this cross-sectional study. Information about demographic and clinical variables was obtained from the medical records and verified through telephone calls to ensure accuracy and consistency. Approximately half (48.30%) of the study participants were located in Dhaka Division. The average age of persons with SCI was 38.3 years, with a standard deviation of 15.9 years, and the largest proportion (33.4%) fell within the age range of 18-30 years. Males outnumbered females by nearly 2.5 times. In the study, 59.6% had suffered traumatic injuries, whereas 40.4% had SCI attributable to disease-related causes; 58.1% were diagnosed with tetraplegia and 40.1% with paraplegia. Fall from height (42.1%) and road traffic trauma (27%) were the most common causes of traumatic injuries. Degenerative myelopathy (41.1%) was the most frequent cause of non-traumatic SCI, followed by tumors (27.7%) and tuberculosis (TB; 14.8%). Both traumatic (58.3%) and degenerative (56.7%) causes of SCI commonly affected the cervical spine, whereas TB (24.4%) and tumors (47.5%) had a higher incidence of affecting the dorsal spine. In the absence of a registry or national database for patients with SCI in Bangladesh, this study would serve as representative data for future studies.

Relations between indoor rehabilitation and basic health services in a developing country.

Background: and Introduction: Physical rehabilitation is vital for patients to regain maximum function. Approximately 80% of people with a disability live in developing countries, where they face multiple challenges in rehabilitation. The goal of the study was to conduct an analysis of indoor rehabilitation programs based on the demographics and medical conditions of the admitted patients and to relate to the available basic health and rehabilitation facilities. Methods: This was a mixed method study conducted in an inpatient rehabilitation ward of a tertiary level academic university hospital in a developing country. All admitted patients who stayed for a period of minimum two weeks were included in the study. Demographic and clinical data were obtained by means of a retrospective medical record review utilizing a standardized data extraction form. The study was further strengthened by an online literature search for the available documents for analysis, relation, and discussion. Results: Among the 1,309 admitted patients was male- female ratio was 10:7, with the majority (31.4%) cases falling between the ages of 46 and 60yrs. Rehabilitation outpatient department was the principal mode of admission (78%), and musculoskeletal and neurological conditions represented the maximum number (79.8%). Majority of patients (60.8%) were discharged home on completion of the rehabilitation program with a large number of patients who were absconded. Poor health budget allocation and lack of prioritization of the rehabilitation sector face multiple challenges, including the rehabilitation team functioning resources, space crisis for expansion which was further impacted by the COVID-19 pandemic. Conclusions: The country's current health-related rehabilitation process and socio-demographic variables have a negative relationship. There was a large number of missing data in the medical records and many patients were lost prematurely from the indoor rehabilitation program. Musculoskeletal disorders were common, and the majority of patients were discharged home once the program was completed.

Ethical issues and dilemmas in spinal cord injury rehabilitation in the developing world: a mixed-method study.

STUDY DESIGN: Mixed-method study (small group discussions and online literature search). OBJECTIVES: Identify the ethical issues and dilemmas faced by rehabilitation professionals involved in the service delivery to the persons with spinal cord injury (SCI) in the low income and lower-middle-income countries (LIC/LMIC) located in Asia. SETTING: Small group discussions in three biomedical conferences in Dhaka, Bangladesh and Kualalampur, Malaysia. METHODS: Three small group discussions (30-45 min each) were held during three international conferences in 2019. The conferences brought together experts in the fields of neurology, rehabilitation, neurorehabilitation, and bioethics. A summary of SCI practice points and dilemmas were documented including goals of care, duties of rehabilitation professionals, health care worker-patient relationships, roles, and expectations of family members at different care settings. RESULTS: There is a paucity of literature on this topic. The application of the principles of contemporary bioethics in the pluralistic societies of LIC/LMIC can be challenging. The ethical dilemmas faced by rehabilitation professionals working in LIC/LMIC are diverse and different from those reported from the Western and developed countries. Ethical issues and dilemmas identified were understanding patient autonomy in decision making, lack of insurance for SCI rehabilitation, financial challenges, challenges of providing emerging technology in SCI rehabilitation and SCI rehabilitation during disasters. CONCLUSIONS: We have summarized the possible ethical issues and dilemmas which rehabilitation professionals in LIC/LMIC may encounter during delivery of SCI rehabilitation services. We hope it generates a discussion on an often-neglected aspect of SCI care in the LIC/LMIC and helps identify the complexities of ethical dilemmas unique to persons with SCI living in a developing country.

"Leadership in Rehabilitation Teamwork: Challenges for Developing Countries".

Physical rehabilitation medicine is a diverse specialty; its main objective is to provide comprehensive rehabilitation involving multiple health care professionals to optimize function and improve the quality of life for people with disabilities. There is an increase in the number of people with disabilities, and people with disabilities in lower income countries do not receive the required rehabilitation. Rehabilitation intervention includes functional assessment, rehabilitation goal setting, composition of the focused team and coordination of the team works, all of which require a highly skilled team leader. No single professional is likely to have all the necessary skills to achieve optimal results alone. There is a knowledge gap between the theory, existing situation, and practice in rehabilitation team functioning. In this short communication challenges for quality rehabilitation services were highlighted, including the importance of the leadership role of team functioning.

The Impact of COVID-19 and the Challenges of Post-COVID Rehabilitation in a Developing Country.

The coronavirus disease 2019 (COVID-19) and its impact on human functioning are gaining increased interest. Like many other lower-income countries, the Bangladesh health and rehabilitation sector was adversely affected by COVID-19. Multiple challenges were identified for preparedness and medical rehabilitation during COVID-19 surges. Appropriate supervision of multispecialty long COVID clinics and attention to rehabilitation teamwork are important. Rehabilitation plays a key role in the management of patients with COVID-19 and can reduce the length of hospital stay and improve health outcomes. While waiting for people to be fully vaccinated; ensuring equitable access to COVID-19 vaccination, health care, and rehabilitation services among people with disabilities should be a part of the core mission during the pandemic. All levels of care including, critical, post-acute, or long covid clinic scale-up of rehabilitation services are needed. A physiatrist-led rehabilitation team approach is vital for the adaptation of rehabilitation interventions to improve the functional outcomes of persons with impairment and disability affected by COVID-19.

2017 Bangladesh landslides: physical rehabilitation perspective.

PURPOSE: This report describes the general impact and direct health effects including death and traumatic injuries on populations impacted by the 2017 landslides in the affected hilly and coastal districts in southeastern Bangladesh. The medical response including emergency treatment and rehabilitation provided at pre-hospital and hospital care sites is also described. MATERIALS AND METHODS: An electronic literature search of appropriate databases was performed to identify relevant articles on landslides in Bangladesh, Southeast Asia, and other developing countries from 1990-2017. Summary landslide impact data was extracted from official government and non-government reports and injury data from selected district and tertiary level hospitals was reviewed. RESULTS AND CONCLUSIONS: Most fatalities in the 2017 Bangladesh landslides were due to suffocation and asphyxiation from burial. In Rangamati District, 6343 persons with minor injuries were treated in 22 emergency shelters. One hundred fifty-four injuries were treated at Rangamati General Hospital and 12 of the most severely injured persons were referred to regional tertiary Chittagong Medical College Hospital for specialized injury and rehabilitation management. Physical rehabilitation capacity and services in future landslides may be increased by providing rehabilitation technical skills training to responders and augmenting the emergency response with individual rehabilitation specialists and/or teams of rehabilitation professionals.Implications for rehabilitationLandslides may result in significant direct health effects including death and rehabilitation conditions such as severe traumatic physical injuries and less severe musculoskeletal conditions.Pre-hospital and hospital emergency medical response systems may lack capacity to adequately manage the surge of rehabilitation conditions in landslides.Physical rehabilitation treatment capacity in future landslides may be increased by providing rehabilitation technical skills training to responders and augmenting the emergency response structure with individual rehabilitation specialists and/or teams of rehabilitation professionals.Rehabilitation, disability, emergency management, and other stakeholders are advised to employ such training and workforce strategies to reduce rehabilitation-related health effects in Bangladesh and other South-East Asian countries which are heavily impacted by landslides due to seasonal monsoons.

Rehabilitation in Bangladesh.

Physical rehabilitation medicine started in Bangladesh 50 years ago, but there is no documentary evidence stating its origin, history of progression as a specialty, and work with agenda items. A gap exists between disability-related health and participation, which affects service delivery systems offered to persons with disability (PwD). Disability prevalence ranges from 0.47% to 14.4%. Illiteracy, maldistribution of wealth, and increasing prevalence of chronic diseases add to the burden of existing disability. It is necessary to involve all stakeholders in disability management to strengthen medical rehabilitation teams and improve service delivery while advocating for the rights and needs of PwD.

Applicability of traumatic brain injury rehabilitation interventions in natural disaster settings.

Objective: To evaluate published traumatic brain injury (TBI) clinical practice guidelines (CPGs) and assess rehabilitation intervention recommendations for applicability in disaster settings. Methods: Recommendations for rehabilitation interventions were synthesized from currently published TBI CPGs, developed by the Department of Labor and Employment (DLE); Scottish Intercollegiate Guidelines Network (SIGN); Department of Veterans Affairs/Department of Defence (DVA/DOD); and American Occupational Therapy Association (AOTA). Three authors independently extracted, compared, and categorized evidence-based rehabilitation intervention recommendations from these CPGs for applicability in disaster settings. Results: The key recommendations from a rehabilitation perspective for TBI survivors in disaster settings included patient/carer education, general physical therapy, practice in daily living activities and safe equipment use, direct cognitive/behavioral feedback, basic compensatory memory/visual strategies, basic swallowing/communication, and psychological input. More advanced interventions are generally not applicable following disasters due to limited access to services, trained staff/resources, equipment, funding, and operational issues. Conclusions: Many recommendations for TBI care are challenging to implement in disaster settings due to complexities related to the environment, resources, service provision, workforce, and other reasons. Further research is needed to identify and address barriers for implementation.

Clinical practice guidelines for rehabilitation in traumatic brain injury: a critical appraisal.

This review aim to provide an overview of recommendations and quality of existing clinical practice guidelines (CPGs) for the management of traumatic brain injury (TBI) from the rehabilitation perspective. Comprehensive literature search, including health databases, CPG clearinghouse/developer websites, and grey literature using Internet search engines up to September 2017. All TBI CPGs published in the last decade were selected if their scope included management of TBI, systematic methods for evidence search, clear defined recommendations, and supporting evidence for rehabilitation interventions. Three authors independently critically appraised the quality of included CPGs using the Appraisal of Guidelines, Research, and Evaluation II (AGREE II) Instrument. Four of 13 potential CPGs met the inclusion criteria. Despite variation in scope, target population, size, and guideline development processes, all four CPGs assessed were good quality (AGREE score of 5-7/7). Key rehabilitation recommendations included education, physical rehabilitation, integrated computer-based management, repetitive task-specific practice in daily living activities, safe equipment usage, cognitive/behavioral feedback, compensatory memory/visual strategies, swallowing/communication, and psychological input for TBI survivors. In conclusion, although rehabilitation is an integral component in TBI management, many published CPGs do not include rehabilitation. These CPGs, however, recommend comprehensive, flexible coordinated multidisciplinary care and appropriate follow-up, education, and support for patients with TBI (and carers).