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SIR SALIMULLAH MEDICAL COLLEGE JOURNAL
VOL. 26, NO. 1, JANUARY 2018
An Official Journal
of
Sir Salimullah Medical College Teachers’ Association
EDITORIAL BOARD
Address of Correspondence:
Prof. Enamul Kabir, Editor-in-Chief, Sir Salimullah Medical College Journal
Department of Medicine, Sir Salimullah Medical College & Mitford Hospital, Dhaka-1100.
Mobile: 880-1819259347, email: np_saha@yahoo.com
Date of Publication: August 2018
Chairman
Prof. Dr. Md. Billal Alam
Editor-in-Chief
Prof. Dr. Enamul Kabir
Joint Editors
Prof. Dr. Nazneen Akhter Banu
Dr. Sunirmal Roy
Dr. Sudip Das Gupta
Prof. Dr. Begum Sharifun Naher
Assistant Editors
Dr. Afshan Zareen
Dr. Muna Shalima Jahan
Dr. Amiruzzaman
Members
Prof. Dr. Uttam Kumar Paul
Prof. Dr. Manilal Aich
Prof. Dr. Farhat Hossain
Prof. Dr. Shanjoy Kumar Paul
Prof. Dr. Md. Nasimul Islam
Prof. Dr. Monindro Nath Roy
Prof. Dr. Chandra Shekhar Majumder
Prof. Dr. Iram Shahriar
Prof. Dr. Sukhamoy Kongsha Banik
Prof. Dr. Ahmed Hossain
Dr. Ranajit Sen Chowdhury
The Sir Salimullah Medical College Journal a biannual (January &
July) Journal published by the Editorial Board on behalf of Sir
Salimullah Medical College Teachers’ Association. Each issue
includes editorial, original articles, review articles and case reports
of exceptional merit on any discipline of medical science.
Submission of manuscripts
Papers are accepted for publication with an understanding that
they are submitted solely to the Sir Salimullah Medical College
Journal. Statements and opinions expressed in the papers,
communications, and letter herein are those of author(s) and not
necessarily those of editor or publisher. Three hard / printed copies
in A4 size paper should be sent to the Editor. In addition an
electronic/digital version of the article should also be submitted.
Preparation of Manuscripts
Manuscripts should be typed on one side of good quality paper, with
margins of at least 25mm and using double space throughout. Each
component of the manuscript should begin on a new page in the
sequence of title page, abstract, text, references, tables, and legend
for illustrations. The title page should include the title of the paper,
name of the author(s), name of the department(s) to which the work
should be attributed. The text should be presented in the form of
Introduction, Materials and Methods, Results, and Discussion.
The authors should sign a covering letter mentioning that final
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should mention the name of the person (with address and telephone
number) responsible for negotiation concerning the manuscript.
Abstracts
Provide on a separate page an abstract of not more than 250 words.
They should briefly describe the problem being addressed in the
study, how the study was performed, the salient results, and what
the authors conclude from the results.
Table
Each table should be typed in on separate sheet. Table should have
brief title for each, should be numbered consecutively using Roman
numbers and be cited in the in consecutive order internal horizontal
and vertical rules should not be used.
Results should be presented in logical sequence in the text, tables or
illustration. Do not repeat in the text all data in the tables or
illustrations; emphasize or summarize only important observations.
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Generic names should generally be used. When proprietary brands
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Figure should be professionally designed symbols, lettering and
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Photographs and photomicrographs should be supplied as glossy
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should be submitted in separate sheets. All photographs, graphs,
and diagrams should be referred to as figures numbered consecutively
in the text.
President
Prof. Dr. Mani Lal Aich
Vice President
Prof. Dr. Sanya Tahmina Jhora
General Secretary
Prof. Dr. Md. Belayet Hossain Khan
Treasurer
Prof. Dr. Uttam Kumar Paul
Joint Secretary
Dr. Md. Abdus Satter Sarkar
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Dr. Sunirmal Roy
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Cultural & Entertainment
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Dr. Abul Fazal Md. Helal Uddin
Members
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Prof. Dr. Farhat Hossain
Prof. Dr. Chandra Shekhar Majumder
Dr. Bebekananda Halder
Dr. Afsan Zareen
Dr. Ishrat Jahan
Sir Salimullah Medical
College Teachers’
Association
EXECUTIVE COMMITTEE
Published by
Dr. Sunirmal Roy
Publication Secretary
On behalf of Sir Salimullah Medical
College Teachers’ Association.
Instruction to Contributors
Discussion
Emphasize the new and important aspects of the study
and the conclusion that follow from them. The detail
data or other material given in the Introduction or the
Results section should not be repeated. The
implications of the findings and their limitations,
including implication for future research should be
included in the Discussion section. The observations
should be compared and related to other relevant
studies. New hypothesis is appreciated, however they
should be clearly labeled as such. Recommendations
may be included only when appropriate.
References
References should be numbered consecutively in the order
in which they are first mentioned in the text. Identify
references in the text, tables and legend by Roman numerals
in parenthesis. Use the styles of the example below, which
are based on the formats used by the US National Library
of Medicine (NLM) in the Index Medicus.
Avoid using abstracts as references. References to paper
accepted but not yet published should be designated as
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permission to cite such papers as well as verification that
they have been accepted for publication. Information from
manuscripts submitted but not accepted should be cited
as "unpublished observations" with written permission
from the source. Avoid using a "personal communication"
unless it provides essential information not available from
a public source. For scientific articles, authors should
obtain written permission and confirmation of accuracy
from the source of a personal communication.
The references must be verified by the author(s) against
the original documents.
1. Articles in Journal
a. List all six authors when six or less;
Vega KJ, Pina I, Krevsky B. Heart transplantation
is associated with an increased risk for
pancreatobiliary disease. Ann Intern Med 1996;
124 : 980-3.
b. When seven or more, list the first three and
then add et al; Parkin DM, Clayton D, Black
RJ et al. Childhood leukemia in Europe after
Chernobyl 5-year follow-up. BR J Cancer 1996;73 : 1006-12.
c. No author given
Cancer in South Africa (editorial). S Afr Med J
1994; 84 : 15.
d. Organization as author
The Cardiac Society of Australia and New
Zealand. Clinical exercise stress training. Safety
and performance guideline. Med J Aust 1996;
164 : 282-4.
2. Books and Others Manuscripts
a. Personal author
Laurence DR, Bennett PN, Brown MJ. Clinical
Pharmacology Eighth ed. New York : Churchill
Livingstone; 1997.
b. Editor(s), (s) as author
Katzung BG, editor,. Basic & Clinical
Pharmacology. 6th ed. Connecticut : Appleton
& Lange; 1995.
c. Organization as author and publisher
World Health Organization, Ethical criteria for
Medical Drug Promotion: World Health
Organization; 1988.
d. Chapter in a book
Philips SJ, Whisnant JP. Hypertension and
stroke. In : Laragh JH, Brenner BM, editors.
Hypertension: pathophysiology, diagnosis, and
management. 2nd ed. New York : Raven Press;
1995; p. 465-78.
e. Dissertation
Kaplan SJ. Post-hospital home health care :
the elderly's access and utilization
(dissertation). St. Louis (MO) : Washington
Univ; 1995.
3. Other published material
a. Newspaper article
Lee G. Hospitalizations tied to ozone pollution
: study estimates 50,000 admissions annually.
The Washington Post 1996; June 21; Sect. A : 3
(col. 5).
b. Dictionary and similar references
Student's medical dictionary. 26th ed.
Baltimore : Williams & Wilkins; 1995.
Apraxia; p. 119-20.
4. Unpublished material
a. In press
Leshner Al. Molecular mechanisms of cocaine
addition. N Engl J med In Press 1997.
5. Electronic Material
a. Journal articles in electronic format
Morse SS. Factors in the emergence of
infectious diseases. Emerg Infect Dis I Serial
online I 1995 Jan-Mar I cited 1996 June 5 I;
1(1) : 24 screens I.
Available from : URL : http: //www.cdc.gog/
ncidod/ EID/eid.htm
Permissions
A written statement must accompany materials taken
from other sources from both author and publisher giving
permission to the Journal for reproduction. Obtain
permision in writing from at least one author of papers
still in press unpublished data, and personal
communications.
Review and Action
All submitted manuscripts will be reviewed by the
Editorial Board and reviewer. Rejected manuscripts will
not be returned. Ethical aspects will be considered in
the assessment of the paper.
The HOW of Sustainable Blood Safety in
Bangladesh
Editorial
Blood Transfusion is a vital component of every
country’s health care delivery system. It can be a
life saving intervention, but it may also result in
acute or delayed complications and carries the risk
of the transmission of infections. Between 5% and
10% of HIV infections worldwide are transmitted
through the transfusion of infected blood and blood
products. Many more recipients of blood products
are infected by hepatitis B and C viruses, syphilis
and Malaria. Despite all the technological marvels
that humanity is experiencing, a reliable and safe
Blood supply, is still out of reach for the untold
millions of peoples because of the following lackings:
1. Low priority given to Blood safety by the
National Health Authority.
2. Chronic shortages of VBDs as the source of safe
Blood.
3. Absence of QMTs in the BTCs.
4. Recourse of PDs as FDs and/or RDs.
5. Lack of awareness of CUB by Physicians.
6. Social culture/stigma yet not to be as compatible
with Blood safety.
The main reason for starting AVD is to ensure self-
sufficiency in Blood/Products from voluntary,
anonymous and non-remunerated, regular Donors
in accordance with the recommendations of WHO.
In the past strategies to promote blood safety tended
to focus primarily on screening of donated blood for
transfusion transmissible infections (TTIs).
However while systematic screening is essential it
is insufficient in itself to ensure the safety of the
blood supply.
Evidence from all regions of the world indicates that
the absence of a nationally coordinated blood
programme, lack of safe blood donors and the
unnecessary clinical use of transfusion are equally
important contributory factors to the transmission
of infection by transfusion.
The WHO strategy for blood safety emphasizes an
integrated four fold approach. Effective quality
assurance should form an essential part of this
approach:
1. The establishment of a coordinated blood
transfusion service that can provide adequate
and timely supplies of safe blood for all patients
in need
2. The collection of blood only from voluntary non
remunerated blood donors from low risk
populations and the use of stringent donor
selection procedures.
3. The screening of all donated blood for transfusion
transmissible infections. including HIV,
hepatitis viruses, syphilis and other infectious
agents, and blood grouping compatibility testing
and processing of blood
4. Reduction in unnecessary Transfusion through
appropriate CUB including use of alternative I/
V fluids to Transfusion wherever possible.
In developed countries, the blood supply comes from
voluntary non-remunerated blood donors. Globally,
developing countries contribute only 16% of the
voluntary non-remunerated blood donors which
shows that the blood supply depends on a very high
proportion of family/replacement/paid donors in
these countries. Voluntary non-remunerated blood
donors are at significantly lower risk for transfusion-
transmissible infections than family/replacement
donors and paid donors.In addition, many
transfusions are clinically unnecessary, providing
little or no benefit to the patients who received them
and wasting a scarce resource that may result in a
shortage of blood products for patients in real need.
Eleven Proposals For a Sustainable
Safe Blood Transfusion Service:
1. Formalization of government commitment and
support
2. Development of a national blood policy and plan
3. Development of necessary legislation/regulation
2 Sir Salimullah Med Coll J Vol. 26, No. 1, January 2018
for the BTS
4. Formation of an organization with responsibility
and authority for the BTS
5. Formation of a BTS management committee
6. Appointment of a medical director
7. Appointment of a quality manager
8. Appointment, when necessary of specialist BTS
advisory groups
9. Appointment and raining of staff experienced
in each key aspect of the BTS
10. Development and implementation of a budgeting
and finance system to ensure a sustainable blood
programme through cost recovery and / of
annual budget allocation
11. Establishment of national quality system,
including guidelines, standard operating
procedures (SOPs), accurate records, monitoring
and evaluation.
Prof. Dr. Munshi M. Habibullah
Professor of Blood Transfusion
Original Articles
Photo-anthropometric Study of Nasal Breadth
Among Tribal (Garo) and Non-Tribal Adult
Bangladeshi female of greater Mymensingh DistrictsIsrat Jahan Tania1, Humaira Naushaba2, Fahmida Zaman3, Kohinur Sultana4, Zinat Rezina Sultana5
Abstract
Background: Anthropometry is a series of systematized measuring techniques that expresses
quantitatively the dimensions of the human body and skeleton which play an important role in
distinguishing a pure race. It provides quantitative data in identifying people having different
physical characteristics in diagnosing people having craniofacial abnormality and to compare
between patient and normal population. The nose is a person’s most defining feature because it
is at the center of the face. The shape of the nose differs from race to race, tribe to tribe and from
one environmental region of the world to the other.
Materials & Methods: Cross sectional analytical study was conducted in the department of
Anatomy, Sir Salimullah Medical College, Dhaka, from January 2015 to December 2015.The
study subjects consisted of two hundred (200) adult Bangladeshi female of greater Mymensingh
districts among them, 100 were tribal (Garo) female and 100 non-tribal female.
Results: The mean (±SD) nasal breadth from ‘ ala to ala’ was higher in tribal(Garo) female than
non- tribal female (p<0.001).
Conclusion: Nasal breadth from ‘ ala to ala, was higher in tribal(Garo) female compared to
non- tribal female.
Key words: photo - anthropometry, nasal breadth, tribal (Garo) female, non-tribal female,
greater Mymensingh districts.
(Sir Salimullah Med Coll J 2018; 26: 3-6)
1 Assistant Professor, Department of Anatomy, City Dental College, Dhaka.
2. Professor and Head, Department of Anatomy, Sir Salimullah Medical College, Dhaka.
3. Assistant Professor, Department of Anatomy, M H Samorita Medical College , Dhaka.
4. Assistant Professor, Department of Anatomy, Community Medical College , Dhaka.
5. Associate Professor, Department of Anatomy, Medical College for Women and Hospital , Dhaka.
Correspondence : Dr. Israt Jahan Tania, Assistant Professor, Department of Anatomy, City Dental College, Dhaka.
Introduction
The word anthropometry comes (from Greek
anthropos, ‘man’ and metron, ‘measure’). Photo-
anthropometry is the process of obtaining
measurements by mean of photographs. Digital
photographic techniques potentially offer a highly
practical, convenient and cost effective method. The
reliability of the photographic technique is
satisfactory. 2D digitilization method is accurate
and can be applied for both clinical practice and
research. In digital photography, there is no need
to locate landmarks prior to image taking1. Another
advantage of digital photography is the opportunity
to preserve the material, which allows to repeat the
measurements anytime and to add new parameters
in later measurements.
Variation is one of the most important phenomenon
occurring in human population on the globe.
Anthropometry is the hallmark technique that deals
with the study of body proportion and absolute
dimensions and vary with age and sex within and
between racial groups. The dimensions of human
body are affected by ecological, biological,
geographical, racial, personality, body habitus, age
factors and gender2.
Growth and development of craniofacial structures
are important as many clinical disciplines depend on
it for understanding their processes for diagnosis,
timing and planning of treatment. The knowledge of
nasal measurement is important to clinicians such
as reconstruction of rhinoplasty and craniofacial
surgeons enabling them in detection of normal or
abnormal changes, assistance in diagnosis and
planning of treatment3. It is also important in
forensic science. The normal values of nasal
parameters are vital measurements in the evaluation
and diagnosis of craniofacial deformities4.
Populations vary genetically and geographically in
their craniofacial features. Therefore, a single
standard of anthropometric variable is not
appropriate for being applied to diverse racial and
ethnic groups. Though Bangladesh is a relatively
small country, people of different religions and ethnic
groups live here and these different groups have
differences in their physical characteristics. There
are as many as 30 tribal communities living in
different parts of Bangladesh .The Garos are one of
them. The total population of Garos residing in
Bangladesh are approximately two lacs and sixty
four thousands They mostly live in Mymensingh,
Sherpur, Tangail, Sylhet and Sunamgonj districts
of our country. Out of them two lacs Garos are
found in Mymensingh district of Bangladesh.The
Garos are an ethnic group of ‘Tibbeti Borman’,
belonging to the Mongolian human race5.
The face of the tribal(Garo) are round with deep
eyebrows, small black eyes , flat nose and high jaws.
In Bangladesh, studies on craniofacial
measurements are limited to mostly on tribal
population. Also there is very few comparative study
between tribal (Garo) and non-tribal Bangladeshi
female. It will be useful for researchers,clinicians
and forensic experts in respect to their field of study.
Materials and Methods
The study was performed on one hundred were adult
tribal( Garo) female and one hundred non-tribal
Bangladeshi female age ranging from 25 to 45 years
of greater Mymensingh district. Date of birth of each
subject was recorded from their national identity
cards. Bangladeshi female who were mixed in origin-
a history of marriage between tribal and non- tribal
people or with any other tribes within the last three
generations-prior history of oculofacial trauma,
congenital craniofacial anomaly (ie; cleft lip, cleft
palate), post traumatic deformities that might affect
craniofacial measurements were excluded from the
study.
Before going to the measurement procedure each of
the subject was greeted politely. Then her national
identity card was checked to confirm her age. After
a short briefing on the objective of the present study,
the subject was asked to give a voluntary consent
on the consent form. Each subject was made seated
comfortably on a chair. The digital camera was fixed
on its stand at the same level of the study subject’s
head having a distance of 120 centimeter between
the two. The face of each study subject was well
illuminated and photograph was taken keeping the
study subject looking straight to the camera, both
eyes opened and mouth closed.Then the photograph
of the subject was uploaded in the computer having
program named Adobe Photoshop Version-8 and
Adobe Illustrator Version-11. Nasal breadth was
taken as the horizontal distance between the outer
surfaces of two ala of the nose6.
After collecting the data, the data was checked and
edited. Later the data was statistically analyzed by
a software package, SPSS for Windows (version 7.0).
Fig.-1: Showing photographic measurement of
nasal breadth (al-al), al-rt (red dot) indicates right
ala, al-lft(blue dot) indicates left ala.
Statistical tests such as unpaired Student’s‘t’test
was done.
Statistical significance was accepted at p-value equal
to or less than 0.05 (p<0.05).
Ethical clearance:
The study was carried out after the protocol was
4 Sir Salimullah Med Coll J Vol. 26, No. 1, January 2018
approved by the Institutional Ethics Committee of
Sir Salimullah Medical College, Dhaka.
Results:
Results of the study are expressed in Table I and
Fig. 1 & 2.
Table 1
Nasal breadth of the study subjects
Nasal breadth Mean±SD
in cm (n=100 in each group)
Tribal (Garo) female 3.62±0.60
(2.62 4.92)
Non tribal female 3.00±0.31
(2.30 3.90)
p value 0.0001***
Figures in parentheses indicate range. Comparison
between groups done by unpaired Student’s ‘t’ test, ***
= significant at p<0.001
The selection of study area was on the basis of
density of tribal population and was considered
on the basis of same socioeconomic and nutritional
status . It is understandable that the economic status
is likely to influence the nutritional status of an
individual and thereby may affect the facial
dimensions. To minimize the possible effect of
economic condition on the anthropometric data,
female of broadly the same economic status were
chosen for the present study .
The findings of the present study were compared
with the findings of other researchers where female
of Nepal, Japan, China, India (West Bengal,
Rajasthan, Andaman) were included. They are
Mongoloid by race. Similarity and dissimilarity have
been found with the findings of other researchers.
As Bangladeshi tribal (Garo) belonged to Mongoloid
and non-tribal female are mixture of Austric, Indo-
Aryan, Mongoloid and Dravidian so, it is understood
that Bangladeshi people has contribution from
more than one race and there are wide variations
in their physical features.
Choe et al. (2006) worked on Korean American
female and the mean value of nasal breadth was
not significant (p>0.05) when compared to the
findings of the the present study on tribal female7.
Mostafa (2013) conducted a study on adult
Bangladeshi Buddhist Chakma female of mixed
race and significant (p<0.01) difference was found
when compared with the findings of the present
study. On non-tribal female Farkas et al. (2005)
carried out a study on Indian, Chinese of
Singaporean, Vietnamese, Thai and Japanese. On
comparison with the findings of the present study
on tribal and non-tribal female the mean value of
nasal breadth in Indian, Chinese of Singaporean,
Vietnamese and Japanese were samilar but Thai
female had significant (p<0.01) difference when
compared with the findings of the present study on
tribal female9.
Conclusion
The study revealed that the significant (p<0.001)
difference was found between tribal female (Garo)
and non-tribal female in nasal breadth from ‘ala to
ala’. In this study some comparisons were made
with other populations. This type of study might
help to understand the relative status of Garo
Discussion:
It has widely been recognized that craniofacial
anthropometry is affected by geographical, racial,
ethnical, gender and age factors. So each population
should have specific standards to optimize the
accuracy of identification.
Fig.-2: Nasal Breadth of the study subjects
Photo- anthropomeric Study of Nasal Breadth Among Tribal (Garo) Israt Jahan Tania et al 5
population in the context of the anthropometric
variations around the world , especially among the
Mongoloid population.
References:1. Rajih and Khatib., 2010. Facial three dimensional
surface imaging. Archives orofacial sciences,5 (1) , pp.1-
8.
2. Shrestha,O. et al., 2009. Craniofacial anthropometric
measurements among Raj and Limbu community of
Sunsari District, Nepal. Nepal Medical College Journal,.
11 (3), pp.183-185.
3. Akhter, Z. et al., 2013. Photo anthropometric study on
face among Garo adult females of Bangladesh.
Bangladesh Medical Research Council Bulletin, 39 (2)
pp. 61-64.
4. Raji, J. et al., 2010. Morphological evaluation of head
and face shape in a North Estern Nigerion Population.
Australion Journal of Basic and applied Sciences, 4
(8), pp.3338-3341.
5. Das, K.T and Islam, Z .H. M. S., 2005. Psycho-social
dimentions of ethnicity: The situation of Garo
community in Bangladesh. Asian Affairs, 27(3), pp.45-
54.
6. Kolar, J. C and Salter, E. M., 1996. Craniofacial
anthropometry Practical measurements of the head
and face for clinical, surgical and rescarch use, Charles
C Thomas publisher Ltd, Springfield, Illionis. USA,
pp.66-187.
7. Choe, K.S et al., 2006. The Korean American woman’s
nose and in depth nasal photogrammatic analysis.
Archives of facial plastic surgery, 8 , pp.319-323.
8. Mostafa, A, et al., 2013. Craniofacial profile of adult
Bangladeshi Buddhist Chakma females. Journal of
Anthropology, 4(1), pp.1-7.
9. Farkas, G. L., Katic, J .M and Forrest, R. C., 2005.
International Anthropometric Study of Facial
Morphology in Various Ethnic Groups/Races. The
Journal of Craniofacial Surgery,Vol.16 (4), pp. 615-
645.
6 Sir Salimullah Med Coll J Vol. 26, No. 1, January 2018
Prevalence and Risk Factors Affecting Low Birth
Weight in a Tertiary Level Hospital of Dhaka CityFahmida Haque1, Mahbuba Akhter Banu², S.F. Nargis³ , Nilufa Nasrin (Ava)2
Abstract
Background: Low birth is one of the major health problems worldwide. The management of
children with LBW is not the same in countries with different resources. It is closely related to
neonatal mortality and morbidity, may causes growth and developmental delay and may result
in chronic ill health in adult life. Many factors affect intrauterine fetal growth and thus the
birth weight. It is important to identify the factors that play a role in the occurrence of this
adverse pregnancy outcome. The present study is conducted to assess the prevalence and to
explore the associated risk factors of term LBW that will helpful to address effective measure to
reduce the incidence of LBW babies.
Methods: The study was conducted at SSMC and MH during the period of Jan 2017 to Dec
2017. A sample size of 300 term live birth over a period of 6 months were analyzed. The women
who delivered the term baby were enrolled in the study according to selection criteria and
information regarding maternal age, weight gain during pregnancy, parity, income of family,
gestational age, maternal occupation, degree of literacy, birth interval was collected. Birth
weight was recorded within 6 hrs of delivery. The statistical analysis was done by SPSS-22.
Results: Sample size 300 was calculated by taking 25% as the minimum prevalence of low birth
weight with 20% permissible error. The prevalence of LBW was found as 11.67% in 300 mothers.
Significant association was found between Low birth weight and weight gain in pregnancy.
Conclusion: Though the prevalence of LBW is lower than national level, it is the need of the
hour to strengthen the existing maternal services at the basic level of community to improve the
birth weight of neonate.
Keywords: Low birth weight, risk factors, prevalence.
(Sir Salimullah Med Coll J 2018; 26: 7-11)
1. Assistant Professor, Department of Obs & Gynae, SSMC Mitford Hospital, Dhaka
2. Associate Professor, Department of Obs & Gynae, SSMC Mitford Hospital, Dhaka.
3. Professor, Department of Obs & Gynae, SSMC Mitford Hospital, Dhaka.
Correspondance: Dr. Fahmida Haque, Assistant Professor, Department of Obs & Gynae, SSMC Mitford Hospital, Dhaka
Mobile: 01712122898
Introduction
Babies with a birth weight of less than 2500gm,
irrespective of the period of their gestation are
termed as Low Birth Weight (LBW) babies.1 It is
an important factor to determine whether child is
ready to adjust his surroundings.2 It leads to
inhibited growth, cognitive development and also
associated with chronic diseases later in life.3
In Bangladesh the proportion of LBW babies was
25.49%. The most of the LBW babies (30.77%) were
identified in low income group.4In 2011, Indian
Statistical Institute reported nearly 20% of new born
have LBW in India.5 The perinatal mortality among
LBW infants is about eight times higher than that
in infants weighing more than 2.5kg.6
The low birth weight is an index of our status of
public health, maternal health and nutrition in
particular. The major challenge in the field of public
health is to identify the factors influencing low birth
weight and to institute remedial measures.7 LBW
is a multi-faceted problem with some known and
few unknown reasons. The etiology of LBW is also
complex with demographic, nutritional,
reproductive, and socio-economic factors each
potentially playing a role. These causes can be
enlisted as maternal Hemoglobin (Hb) level, hard
manual work during antenatal period, maternal
nutrition, economic condition, antenatal care,
parent’s education, tobacco use, maternal age, and
parity.8
Hence, this study was conducted to know the
prevalence and to identify risk factors affecting low
birth weight in this hospital.
Materials and Methods
The present cross sectional hospital based study was
conducted in a tertiary level hospital from Jan 2017
to Dec 2017. The sample size 300 was calculated
taking minimum 25% prevalence of low birth weight
with 20% permissible error. All 300 postnatal
mothers who delivered term baby in the hospital
during study period were included in the study
except still births. They were interviewed using
predesigned and pretested questionnaires and the
information regarding the study variables were
collected after obtaining consent.
The birth weight of child was measured in grams
within six hours after delivery using pre-calibrated
Salter weighing machine (UNICEF). Birth weight
less than 2500 gm was used to label a child as LBW.
Mother’s height was measured up to the accuracy
of 0.5 cm and weight was recorded up to the accuracy
of 0.5 kg.
The socio-demographic variables were addressed
such as mothers age in years, mother’s education,
husband’s education with occupation, per capita
income, type of family, area of living, parity. Other
variables were height of mother in cm, weight gain
during pregnancy, any eventful antenatal period,
hard physical work during pregnancy, current type
of delivery, previous type of delivery, previous child
birth weight in kg.
Data was processed by using software SPSS-22 .The
information was analyzed by appropriate statistical
tests. Results were expressed in percentages, odds
ratios, 95% confidence interval of odds ratio and chi
square tests (÷2). The p value less than 0.05 were
taken as statistically significant.
Results
The prevalence of Low birth weight in this study
was found as 11.67%. LBW babies were found in
2(8.33%) mothers with age less than 20 years. There
were 33(94.29%) literate mothers and 34(97.14%)
literate fathers with LBW babies. The family of
25.41% mothers with LBW babies had per capita
income less than 15000 Tk. In nuclear type of
family, there were 12(34.29%) LBW babies whereas
23(65.71%) babies in joint and three generation type
of families. The proportion of LBW babies were more
in mothers from rural area (71.43%) than urban
area (2.86%).
The socio-demographic variables such as maternal
age less than 20 years, husband education, per capita
income less than 15000 Tk, type of family and
residence of the mother, had no significant
association but illiterate mother had significant
association with low birth weight (Table-1).
Table - I
Distribution of Low Birth Weight babies according to socio-demographic variables
Variable LBW n=35 Normal Birth Odds Ratio (95% confidence P
No(%) n=265 No(%) interval) Value
Mothers age in years
Below 20 2(8.33) 22(91.67) 0.67(0.10-2.60) 0.90
Above 20 33(11.96) 243(88.04)
Mothers Education
Illiterate 23(22.8) 78(77.2) 4.59(2.18-9.62) <0.001*
Literate 12(6.0) 187(94.0)
Husband Education
Illiterate 1(7.14) 13(92.86) 0.57(0.07-4.50) 0.59
Literate 34(11.89) 252(88.11)
Monthly income
Less than 15000 9(12.50) 63(23.77) 1.11(0.49-0.06) 0.80
More than 15000 26(11.40) 202(88.60)
Type of family
Nuclear 12(10.00) 108(90.00) 0.76(0.36-1.59) 0.46
Joint & three gen. 23(12.78) 157(87.22)
Area of living
Urban 10(12.99) 67(87.01) 1.18(0.54-2.59) 0.68
Rural 25(11.21) 198(88.79)
8 Sir Salimullah Med Coll J Vol. 26, No. 1, January 2018
Birth interval within 2 years (59.1%), irregular iron
folic acid intake (18.9%) and hard physical work
during pregnancy (7.4%) had significant association
with low birth weight babies (p<0.05). Parity,
antenatal checkup and any eventful antenatal period
were not significantly associated with LBW babies
(Table-II).
LBW was not significantly associated with 7(18.92%)
in mothers who was less than 145 cm, mothers,
weight gain during pregnancy less than 12 kg
9(33.33%) was significant association with low birth
weight babies (Table-III).
Twenty four (28.6%) mothers who were already
given births to LBW babies in previous deliveries
had again LBW babies in current delivery, which
is significant association with LBW babies. There
were 4(11.76%) LBW babies whose delivery was
conducted by caesarean section, which is not
statistically significant association with LBW babies
(Table-IV).
Table-II
Distribution of Low Birth Weight babies according to obstetric history
Variables LBW n=35 Normal Birth Odds Ratio P
No(%) n=265 No(%) (95% confidence interval) Value
Parity
Primigravida 18(11.32) 141(88.68) 0.93(0.46-1.89) 0.84
Multigravida 17(12.06) 124(87.94)
Birth interval (yrs) (n=141)
< 2 years 13(59.1) 9(40.9) 41.5(11.2-153.9) <0.001*
> 2 years 4(3.4) 115(96.6)
Antenatal checkups
<3 visits 18(11.32) 141(88.68) 0.93(0.46-1.89) 0.84
> 3 visits 17(12.06) 124(87.94)
Any eventful antenatal period
Yes 16(11.6) 122(88.4) 0.99(0.46-2.11) 0.971
No 19(11.7) 143(88.3)
Iron folic acid intake
Regular 14(7.4) 175(92.6) 0.34(0.16-0.75) 0.003*
Irregular 21(18.9) 90(81.1)
Hard physical work during pregnancy
Yes 23(7.4) 114(92.6) 2.54(1.15-5.68) 0.011*
No 12(18.9) 151(81.1)
Table-III
Distribution of low birth weight babies according to maternal anthropometry and other risk factors
Variables LBW n=35 Normal Birth Odds Ratio P
No(%) n=265No(%) (95% confidence interval) Value
Height of mother (cm)
< 145 7(18.92) 30(81.08) 1.96(0.79-4.87) 0.14
>145 28(10.65) 235(89.35)
Weight gain during pregnancy (kg)
Less Than 12 9(33.33) 18(66.67) 4.75(1.93-11.64) <0.001*
More Than 12 26(9.52) 247(90.48)
Prevalence and Risk Factors Affecting LBW in a Tertiary Level Hospital Fahmida Haque et al 9
Discussion
The proportion of Low Birth Weight in the present
study was 11.67% while it was 21.5% from NFHS-
3 data.9 A similar prevalence was found in study by
Mumbare et al.10 and Sharma et al.,11 The variation
in the prevalence may be due to varying geographic
and socioeconomic differences among the different
communities. The LBW was 8.33% among mothers
less than 20 years of age which was lower than study
by Anand et al.12 young age of mother and
inadequate development of uterus can cause low
birth weight babies. In present study, the proportion
of LBW was found significant association with
illiterate women (22.8%). Rizvi et al and Mavalankar
et al. showed significant association between
maternal education and LBW.13,14 The less
prevalence of low birth weight in relation to illiteracy
may be linked to awareness regarding the need for
antenatal care services and their utilization. High
proportion of low birth weight was found in less than
15000 tk. per capita income (12.5%). There was no
statistical significant association between LBW and
family income. High prevalence of LBW in joint
family status have also reported in other study.15In
present study, the proportion of low birth weight
was 11.21% among those mothers residing in rural
area whereas it was 28% in study by Swarnalatha
N.16
In the present study, low birth weight was 11.32%
in primipara. The study by Acharya et al17 reported
that significant association of low birth weight with
prim parity. Proportion of LBW was high among
those mothers with narrow birth interval of less
than 2 years (59.1%). Similar finding was revealed
by the study conducted in Joshi et al.18 This may
be due to mothers cannot recover from the effect of
last pregnancy before conceiving again and her
nutritional status deteriorates with subsequent
pregnancies. Hence the birth spacing more than 2
years in preventing LBW babies is important.
The proportion of LBW was high among mothers
who had less than 3 required antenatal checkups
indicating as a determinant of LBW. Idris et al also
published the similar findings in their study.19 This
may be due to noncompliance of advice/drugs during
antenatal period. This emphasizes the need to
improve both the coverage and quality of ante-natal
care to reduce LBW. The consumption of regular
iron and folic acid (IFA) were found in mothers with
7.4% LBW babies. Therefore efforts should be made
to provide regular supplementation of iron and
dietary modification.
The prevalence of low birth weight was found to be
high in women engaged in hard physical work in
pregnancy (7.4%). A hard physical works during
pregnancy will lead to early onset of labor causing
prematurity.
In Table-IV LBW according to maternal
anthropometry and other risk factors shows the
proportion of low birth weight (18.92%) was found
to be high among those women with height >145
cm. Trivedi et al reported a significant association
between maternal height and low birth weight.20
The prevalence of low birth weight was found to be
high in women with less than 12 kg weight gain
during pregnancy (33.33%). Significant relationship
was found between maternal weight gain during
pregnancy and LBW in a study by Kamaladoss T21.
Hence it is recommended to improve the nutritional
status of a girl child throughout her life cycle as it
will improve the nutritional status of women and
will reduce the problem of LBW.
Table-IV
Relationship of low birth weight babies with previous pregnancy
Variables LBW n=35 Normal Birth Odds Ratio P
No(%) n=265No(%) (95% confidence interval) Value
Status of previous births
LBW 24(25.5) 70(74.5) 6.08(2.68-14.0) <0.001*
Normal birth weight 11(5.3) 195(94.7)
Previous delivery
Caesarean 4(11.76) 30(88.24) 1.01(0.33-3.06) 0.985
Normal 31(11.65) 235(88.35)
10 Sir Salimullah Med Coll J Vol. 26, No. 1, January 2018
Conclusion
Though the prevalence of LBW is lower than
national level, it is the need of the hour to strengthen
the existing maternal services at the basic level of
community i.e., at door steps of the beneficiaries.
Inter pregnancy interval may be improved through
different contraceptive methods of spacing. Good
pregnancy care including intake of iron and folic
acid, rest of the mother during pregnancy to improve
maternal weight gain during pregnancy to increase
the birth of neonate is necessity. Those mothers who
had history of low birth weight should be more
cautious during present pregnancy so that repetition
of LBW can be avoided.
References
1. Kramer Ms. Determinants of LBW, methodological
assessment and meta-analysis. WHO Bull, 1987; 65:
663-737.
2. Pratinidhi AK, Shrotri AN, Shah U, Bodhani ND.
Domiciliary care of low birth weight neonates. Indian J
Pediatr. 1986; 53(1): 87-92.
3. UNICEF. Low Birth Weight: Country, Regional and
Global Estimates. New York: UNICEF; 2004. p. 1-9.
4. Yasmeen S, Azim E. Status of low birth weight at a
tertiary level hospital in Bangladesh for a Selected
Period. South East Asia Journal of Public Health. 2013
Jan 8;1(1):24-7.
5. Bharati P, Pal M, Bandyopadhyay M, Bhakta A,
Chakraborty S, Bharati P Prevalence and causes of low
birth weight in India. Malays JNutr. 2011 Dec;17(3):301-
13.
6. Karan S, Mathur B, Surender YA et al. Incidence and
causes of perinatal mortality at the institute of child
health hospital. IndPaediatr 1972; 99-105.
7. Velankar DH. Maternal factors contributing to Low
birth weight babies in an urban slum community of
Greater Mumbai. Bombay Hospital Journal. 2009;
51(1):26-35.
8. Kadam YR, Mimansa A, Chavan PV, Gore AD Effect of
Prenatal Exposure to Kitchen Fuel on Birth Weight.
Indian J Community Med. 2013 Oct;38(4):212-216.
9. International Institute of Population Science, National
Family Health Survey, India; 2005-06 (NFHS-3, voll)
2007;223.
10. Mumbare SS, GirishMaindarkar, Rajesh Darade,
SurekhaYenges, Madhavkumar and KiranPatole.
Maternal Risk Factors Associated with Term Low Birth
Weight Neonates: 13. A Matched-Pair-Case Control
Study. Indian Pediatrics. 2011; May 30.
11. Sharma MK., Kumar D, Huria A & Gupta P: Maternal
risk factors of Low birth weight in Chandigarh India.
The internet Journal of Health. 2009; 9(1):DOI:10.5580/
10f1
12. Anand K, Garg BS. A study of factors affecting Low
birth weight. Indian J Com Med 2000; 25(2): 57-62.
13. Rizvi SA, Hatcher J, Jehan I and Qureshi R. Maternal
risk factors associated low birth weight in Karachi: A
case control study. Eastern Mediterranean Health
Journal 2007; 13(6): 1343-52.
14. Mavalankar DV, Gray RH, TrivediCR.Risk factors for
preterm and term low birth weight in Ahmedabad.
Indian Journal of Epidemiology 1992;21(2):263-72.
15. Kiran A, Garg BS. A study of factors affecting LBW.
Indian Journal of community medicine 2000; 25:57-62
16. Swarnalatha N, Bhuvaneswari P. An epidemiological
study oflow birth weight in a tertiary care hospital,
Tirupati, Andhra Pradesh. IJCRR. 2013; 5(16): 54-62.
17. Acharya D, Nagraj K, Nair NS, Bhat HV. Determinants
of Intrauterine Growth Retardation: A Case Control
Study in Udupi District, Karnataka. Indian Journal of
Community Medicine.2004; 29(4):181-82.
18. Joshi HS, Subba SH, Dabral SB, Dwivedi S, Kumar D,
Singh S. Risk factors associated with Low birth weight
in newborns. Indian Journal of Community Medicine.
2005; 30(4):142-3.
19. IdrisMZ,Gupta A, Mohan U, Srivastava AK, Das V.
Maternal health and LBW among institutional
deliveries. Indian J Community Med 2000; 25(4):156-
60.
20. Trivedi CR, Mavalankar DV. pidemiology of low birth
weight in Ahmedabad. Ind JPaed 1986; 53: 795-800.
21. Kamaladoss T, Abel R, Sampathkumar V. Risk correlates
of low birth weight in rural Tamil Nadu. Ind J Pediatr
1992; 59(3):299-304.
Prevalence and Risk Factors Affecting LBW in a Tertiary Level Hospital Fahmida Haque et al 11
Histopathological Changes on 105 Serial Interval
Renal Allograft Biopsies Done on 35 Renal
Transplant Patients - A Single Center StudyKBM Hadiuzzaman1, Syed Fazlul Islam2, Munirunnessa3, Rana Mokarrom Hossain4, Omar
Faruque5, Fahmida Haque6, AH Hamid Ahmed7
Abstract
To detect histological changes in renal transplant patients, renal transplant biopsies were
done and quantification of clinical and subclinical rejections were made. A total of 105
histological studies were performed among thirty five kidney transplant recipients over a
period of two years. All received cyclosporine based immunosuppressive regime. Biopsy of
every transplant patient was done on just after vascular anastomosis (per operative), further
biopsied samples were taken at fourteenth postoperative day and at the end of three months.
Per operative biopsies showed absolutely normal histology in 28(80%) cases, in 4 cases 10%
glomeruli showed sclerosis and in 3 cases 16% glomeruli showed sclerosis.
At 14th post operative day, 60% patients showed absolutely normal histology, 28% had histological
features of rejection -among them half had clinical manifestations of rejections and half were
subclinical. Cyclosporine toxicity were detected in 5.6% cases, acute tubular necrosis in 5.6%,
and recurrent glomerulonephritis in 3% cases. Biopsies after 3 months showed normal histology
in 54.28% cases, clinical rejection in 11.42% cases, sub clinical rejection in 5.7% cases, borderline
changes in 5.7% cases, Cyclosporine toxicity in 5.7% cases and recurrent glomerulonephritis in
2.8% cases. Protocol biopsy was performed in all 35 patients after 3 months of transplantation
and among them 54.28% showed normal histology, 11.42% had clinical rejection, 20% sub
clinical rejection, 5-7% borderline changes, 5.7% cyclosporine toxicity and 2.8% suffered from
recurrent glomerulonephritis. According to Banff numerical scoring of clinical rejection, Banff
grade I and III were found in 25% cases and grade II was in 50%cases. In subclinical rejection,
Banff grade I was found in 70% and grade II was found in 30% cases. Histopathology at 14th
POD and day 90, among clinical rejection cases, majority were found to have Banff grade II and
among subclinical rejection cases majority were of grade I.
Key words: Protocol Biopsy, Transplant rejection, Banff classification.
(Sir Salimullah Med Coll J 2018; 26: 12-15)
1. Associate Professor, Department of Nephrology, BSMMU. Dhaka
2. Department of Nephrology, BSMMU, Dhaka
3. Assistant Professor, Gynaecology & Obstetrics Department, Sir Salimullah Medical College & Mitford Hospital, Dhaka
4. Associate Professor, Department of Nephrology, BSMMU, Dhaka
5. Associate Professor, Department of Nephrology, BSMMU, Dhaka
6. Consultant, Islami Bank Hospital, Motijeel, Dhaka
7. Associate Professor, Department of Nephrology, BSMMU, Dhaka.
Address of Correspondence: Dr. Syed Fazlul Islam, Dept. of Nephrology, BSMMU. Dhaka, Bangladesh
Introduction
in the setting of acute graft dysfunction renal
allograft biopsies have traditionally been performed.
However, several groups have performed graft
biopsies at times of stable graft function, and more
recently, after treatment of rejection episodes. For
Banff 97, an “adequate” specimen is now defined as
a biopsy with 10 or more glomeruli and at least two
arteries1. The threshold for a minimal sample is
seven glomeruli and one artery. Rejection can be
patchy. With one core of cortical tissue, the
sensitivity is 90%, but increases to 99% with two
cores. If only medulla is present, sensitivity is
between 75 and 80% .2 In Banff classification Grade-
I is usually subclinical rejection. Subclinical
rejection (SCR) in histologically defined acute
rejection1 is characterized by tubulointerstitial
mononuclear infiltration identified from biopsy
specimen, but without concurrent functional
deterioration variably defined as serum creatinine
not exceeding 10%, 20% or 25% of baseline values.3
Banff Classification of renal transplant pathology,
diagnostic criteria-
1. Normal histology 2. Hyperacute vascular damage
with rejection, polymorphs accumulation and
thrombosis (within 72 hrs after Transplantation)
3. Borderline change No intimal arteritis, mild/
moderate focal mononuclear infiltration, foci of mild
tubulitis (<4 Mononuclear cells) 4. Acute rejection
-Grade I- significant interstitial infiltration (> 25%
of parenchyma) and foci of moderate tubulitis (> 4
cells).
Grade II- A) significant interstitial infiltration and
foci of severe tubulitis (>10 cells) and/or
B) mild and moderate intimal arteritis.
Grade III- severe intimal arteritis and/or focal
infarction or interstitial hemorrhage.
Materials and Methods
For this study, thirty five subjects were selected
from the department of Nephrology, BSMMU,
Dhaka. It is a prospective observational study. Per
operative protocol biopsy was done just after
completion of vascular anastomosis. Tissue was
obtained from upper pole of transplanted kidney by
a scalpel. Tissue was preserved in a test-tube with
10% formalin. Tissue was immediately sent for
histopathological examination. For histopathology
haemotoxylin and eosin (H&E) and periodic acid
Schiff (PAS) stain were done. A protocol biopsy of
transplanted kidney was also done at 14th POD and
at the end of three months (day 90) by 7.6 cm, 18G,
Tru-cut kidney biopsy needle. Upper pole of the
transplanted kidney was selected for biopsy.
Histopathological slides were examined (light
microscopy) by the same histopathologist. Then
histopathological slides were categorized according
to Banff 97 classification. Histological features of
Cyclosporin toxicity, recurrence of primary
golmerulonephritis and acute tubular necrosis were
well clarified by histophathologist. The slides were
reviewed to grade the acute rejections and to assign
a numerical score for the different pathological
components. Grade I (mild rejection) is a cellular
rejection with interstitial infiltrate in more than
25% of the biopsy and with moderate tubulitis.
Grade II (moderate rejection) has a significant
interstitial inflammation, severe tubulitis, mild to
moderate intimal arteritis. Grade III (severe
rejection) includes severe intimal arteritis or
evidence of focal infiltration or interstitial
haemorrhage. Cyclosporin level in blood (C2) were
done on 7th and 14th POD and then monthly for
three consecutive months. Serum creatinine was
done daily for first 14 days and then weekly for three
months.
Results
Among 35 biopsies, per operative 23 showed normal
histology (no sclerotic glomeruli), 6 showed 10%
sclerotic glomeruli and 3 showed 16% sclerotic
glomeruli.
Protocol biopsy at 14th post operative day showed
60% of patients were normal, 14.3% had clinical
rejection (elevated serum creatinine along with
histological features of rejections), 14.3% had sub
clinical rejection (normal serum creatinine with
74.28
17.14
8.57
Normal histology
10% sclerotic
glumeroli
16% sclerotic
Figure. 1: Per Operative protocol biopsy: (n=35)Figure-2: Photomicrograph showing two sclerosed
glomeruli (H&E, x20)
Histopathological Changes on 105 Serial Interval Renal Allograft Biopsies KBM Hadiuzzaman et al 13
histological features of rejections), 5.6% cyclosporine
toxicity, 5.6%, acute tubular necrosis and 2.9% had
recurrent glomerulonephritis. Banff numerical
scoring for the biopsies according to the pathological
grade of rejection showed, Banff grade I (20%),
grade II (60%) and grade III (20%) in clinical
rejection group and Banff grade I (80%) and grade
II (20%) in sub clinical rejection group.
Protocol biopsy performed in all 35 patients after
3 months of transplantation. It showed normal
histology in 54.28% cases, 11.42% had clinical
rejection, 20% had sub clinical rejection, 5-7% had
borderline changes, 5.7% revealed cyclosporine
toxicity and 2.8% underwent recurrent
glomerulonephritis. According to Banff, numerical
scoring of clinical rejection revealed grade I in
25% cases, grade II in 50% cases, and grade III
in 25% cases. In subclinical rejection, Banff grade
I was found in 70% cases and grade II in 30%
cases.
Fig: 3: Protocol biopsy at 14th POD Fig. 4: Histopathology at 14th POD
Fig.-5: Photomicrograph showing Tubular cell
degeneration, flattening and vacuolation suggestive
of ATN (H &E, x40)
54.28
20
11.42
5.7 5.72.85
0
10
20
30
40
50
60
Normal Subclinical
rejection
Clinical
rejection
Border line
change
Cyclosporine
toxicity
Recurrent GN
Showing moderate number of chronic inflammatory cells in the interstitium, mild interstitial fibrosis, tubular atropy, tubules contain hyaline cast.
Fig. 6: Protocol biopsy at day 90(n=35) Fig. 7: Histopathology at day 90.
Protocol biopsy 14th P.O.D
60
14.3 14.3
5.6 5.6 2.9
0
10
20
30
40
50
60
70
Normal Clinical
rejection
sub clinical
rejection
Cyclosporine
toxicity
ATN Recurrent GN
Showing moderate number of chronic inflammatory cells in the interstitium, tubules contain mononuclear cells infiltration (acute cellular rejection)
14 Sir Salimullah Med Coll J Vol. 26, No. 1, January 2018
Discussion
The present study described the histological changes
of renal allograft biopsies done at different interval.
Histological classification of clinical and subclinical
rejection was made by Banff 97 criteria. Histological
changes of acute tubular necrosis, cyclosporine
toxicity and recurrence of primary glomerulo-
nephritis were described adequately.
The presence of subclinical rejection by Banff criteria
was approximately 30% in the first 3 months in renal
transplant rejection. A center4 published data that
seventy renal allograft biopsies were done in 31
patients, routinely at 1, 2, and 3 months post
transplant, and as clinically indicated, using an
automated biopsy “gun.” The histological diagnosis
was made according to the Banff schema, which
emphasizes tubulitis and vascular inflammation over
mononuclear cell infiltration. Fifty-three biopsies
satisfied histological inclusion criteria. Twenty-nine
biopsies were obtained from stable patients, defined
as those in whom serum creatinine had changed <
10% in 2 weeks, and in whom immunosuppression
(cyclosporine, azathioprine, and prednisone) had not
been increased in that interval. Of these biopsies,
30% (9/29) showed rejection.4
To determine the significance of early subclinical
rejection, protocol biopsies performed on days 7 and
28 during a 4-year period. Among 115 patients with
stable graft function at the time of biopsy; 76 adequate
biopsies at day 7 and 79 at day 28 were performed.
At day 7, 10 biopsy specimens (13%) showed acute
rejection (AR) and 9 (12%) showed borderline changes.
At day 28, six biopsy specimens (8%) showed AR and
13 (16%) showed borderline changes.5
In this present study protocol, biopsy at 14th POD
showed normal histology in 60% patients. 14.3%
had clinical rejection and 14.3% had subclinical
rejection. Among clinical rejection cases majority
are of Banff grade II (50%), and among subclinical
rejection cases, majority are of Banff grade I (80%).
When Protocol biopsy were done at the end of 3
month, 54.28% showed normal histology and 11.42%
had clinical rejection. Among clinical rejection cases,
Banff grade I were 25%, Grade II were 50% and
grade III were 25% cases. Among patients having
subclinical rejection, Banff grade-I were 70% and
grade II were 30%. Sub clinical rejection detected
in a different study7 was 30% In this present study
sub clinical rejection was 14.3% at 14th P.O.D and
20% at the end of 3 months. In one report recurrent
glomerulonephritis was present in 36%-42%. Higher
rates of recurrence have been reported in pediatric
transplant recepients, in whom recurrent
glomerulonephritis has been the cause of 6% of first
allograft losses and 12% of subsequent graft losses8.
Patients who experience first allograft loss form
recurrent glomerulonephritis are also suffer from
higher risk of recurrence in subsequent graft loss,
documented up to 48%.
In this present study, recurrence of glomerulo-
nephritis was detected in 2.9% case at 14th P.O.D
biopsy and 2.85% cases at the end of 3 months biopsy.
Glomerulosclerosis greater than 20% has been
correlated with poor graft outcome.6 Data in different
study suggests that donor glomerulo-sclerosis
greater than 20% increases the risk of delayed graft
function and poor outcome. In the present study
per operative protocol biopsy 3 kidney showed 15%-
20% sclerotic glomeruli which is more common in
dysfunction group.
Conclusion
Histopathological evaluation of routine allograft
biopsy in different transplant center of Bangladesh
can detect clinical and subclinical rejection earlier.
References1. Racusen LC, Solez K, Colvin RB, Bonsib SM, Castro
MC, Cavallo T, Croker BP, Demetris AJ, Drachenberg
CB, Fogo AB et al., 1999. The Banff 97 working
classification of renal allograft pathology. Kidney Int
1999, 55(2): 713-723.
2. Wang H, Nanra RS, Carney SL, Gillies AH, Hibberd
AD, Jones BF, Murugasu R, Price A, Trevillian PR : The
renal medulla in acute renal allograft rejection :
comparison with renal cprtex . Nephrol Dial Transplant
1995, 10(8) : 1428-1431.
3. Nankivall BJ, Borrows RJ, Fungcl, O’Connell PJ, Allen
RD, Chapmen JR, 2004, Natural history, risk factors,
and impact of subclinical rejection in kidney
transplantation, 70; 242-249.
4. Rush DN, Jeffery JR, Gough J, Sequential protocol
biopsies in renal transplant patients. Transplantation
1995, 59: 51
5. Roberts lan SD, Raddy, Srikanth, Russel Christine,
Davis, David Frend Peter, Hander, Ashot, Morrris, Peter
J, 2004, Subclinical rejection and borderline changes in
protocol biopsy specimens afte4r renal transplantation.
Clinical transplantation, 77(8); 1194-1198.
6. Gaber LW, Moore LW, Alloway RR et al (1995).
glomerulosclerosis as a determinant of post transplant
function of older donor renal allografts. Transplantation
60,334.
7. Seron D, O’Valle F, Moreso F. Subclinical rejection, a
condition of an emergent interest. Nefrologia 2006;
27(supply 7): 3.
8. Tichy T, Tichy M, Zadrazil J, Krejci K, Horcicka V Jr.,
al-Jabry S, Bachleda P, Kral V, Dusek J, 2003, ‘Histologic
findings in protocol biopsies of transplant kidneys’, Cesk
Patol, 39, (1): 11-6.
Histopathological Changes on 105 Serial Interval Renal Allograft Biopsies KBM Hadiuzzaman et al 15
Frequency of Hepatitis C Virus Infection Among
Multi-Transfused Patients- A prospective studyMunshi Mohd. Habibullah1, Ayesha Khatun2, Daanish Arefin Biswas3, Farah Anjum Sonia4, Md.
Wasim5, Bepasha Naznin6
Abstract
Background: Hepatitis C virus (HCV) is a major concern in multi-transfused patients (MTPs)
all over the world. In Bangladesh, concern over Hepatitis C is increasing with time. Huge
treatment cost along with morbidity of Hepatitis C linked chronic liver disease is also important
in these patients. Facts of transfusion transmitted HCV is inadequate in Bangladesh.
Objectives: Primary objective of this study is to explore frequency of HCV infection in MTP
patients in a private blood bank & transfusion center with high turnover of such patients.
Methodology: A prospective study was conducted between January 2012 to December 2016
among the MTPs attending Quantum Blood Bank at Dhaka. A total of 972 multi-transfused
patients with unknown Hepatitis C status were included in this study. Those patients who
previously received transfusions of two or more units of blood or blood components per month
for at least last 6 months were included.
Results: The study group comprised 972 MTPs, of them 563(57.92%) were male and 409(42.07%)
were female. Anti-HCV test was reactive in 37 cases (3.80%) and rests are found to be negative.
Maximum 534 (54.93%) MTPs were within the 10-25 years’ age group followed by 167 (17.18%)
were eldest (>40 years). Maximum 560 (57.61%) patients were suffering from thalassemia with
hemophiliacs next with 181 (18.62%). 865 MTPs (89%) regularly received blood from voluntary
donors and the rest 107 (11%) had received blood from non-voluntary donors. Those had blood
from non-voluntary donorswere exposed to HCV infection more (72.9%) than those transfused
with voluntary donors. Majority of HCV reactive MTPs were bearing Rhesus negative blood
group 21(56.75%).
Conclusion: The present study was conducted in only one private transfusion center of
Bangladesh. The result does not denote the real condition of MTPs of Bangladesh. Measures
like donor education programs, more comprehensive donor selection criteria and improved
serological protocols are needed. Voluntary blood donation should be encouraged. Longitudinal
study with large sample size involving countrywide multiple centers are recommended.
Key words:Hepatitis C virus (HCV), Multitransfused patients(MTPs), Transfusion Transmitted
Infection (TTI).
(Sir Salimullah Med Coll J 2018; 26: 16-24)
1. Professor of Transfusion Medicine, Sir Salimullah Medical College, Dhaka.
2. Professor of Transfusion Medicine, BSMMU, Dhaka.
3. Associate Prof of Transfusion Medicine, Sir Salimullah Medical College, Dhaka.
4. Medical officer, Transfusion Medicine, BSMMU, Dhaka.
5. Medical Officer (Blood Bank), National Institute of Cardiovascular Diseases, Dhaka.
6. Specialist in Transfusion Medicine, Asgar Ali Hospital, Dhaka.
Address of correspondence: Prof. Munshi Mohd. Habibullah, Professor of Transfusion Medicine, Sir Salimullah Medical
College, Dhaka. Mobile no.:+8801746833309, e-mail: munshi.habib@gmail.com
Introduction
Hepatitis C virus infection is now a days recognized
as a disease of global importance. It is of concern
both to industrialized and to developing
countries.1Overall, the available data suggest that
the prevalence of HCV infection is approximately
2.2–3.0% worldwide (130–170 million people).2,3 HCV
is the most likely hepatitis virus to cause chronic
liver infection. HCV is a significant cause of
cirrhosis, hepatic failure, and hepatocellular
carcinoma.4, 5
In developed countries, voluntary blood donation,
blood donor education, history-based donor selection
and universal blood donor laboratory screening have
resulted in improved blood safety and reduced
residual risk for transfusion-transmissible infections
(TTI), including HCV.Prevalence of HCV in blood
donors in different countries of the developed world
has been reported to be between 0.3 and 1.5%.1
In contrast, HCV is higher among developing
countries, because there are problems such as low
quality in blood screening tests, unsafe medical
practices, and intravenous drug abuse with shared
needle. For example, higher HCV prevalence have
been reported in Southeast Asian countries,
including India (1.5%), Malaysia (2.3%), Philippines
(2.3%), Pakistan (8.1%), and in equatorial Africa
(6.5%), as high as 20% in Egypt.6,7MTPs in these
countries are at higher risk of infection of TTI
including HCV.8
The transmission of HCV is primarily through
exposure to infected blood and it is the most common
mode of transmission of HCV infection as it allows
a large quantum of infective virions into the
susceptible patient.9 The countries with a higher
HCV prevalence in general population had a higher
prevalence rate among MTPs patients,
too.10Transfusion-transmitted infections (TTI) are
therefore continue to be a serious problem in
underdeveloped areas and less serious in developing
areas of the world. Multitransfused patients (MTPs)
are at a particularly increased risk. Knowledge of
the prevalence of TTI among MTPs in developing
countries is an appropriate indicator of the risk of
TTI. Furthermore, a thorough understanding of the
epidemiological characteristics of TTI in heavily
transfused patients may be of major assistance in
elucidation of important aspects of the transmission
chain of these infections and so further improvement
in the safety of the blood supply and estimates of
the residual risk of transmission in countries where
complete donor screening is being carried
out.8Previous Bangladeshi studies among smaller
scale multitransfused patients showed extensive
variations from 0.024% to 31%.11 Bangladesh was
listed among countries with average national
prevalence rate of 3.4 in one study.12
This study would provide support for further
research aimed at improving blood safety in
Bangladesh. Although the incidence of transfusion-
transmitted hepatitis has been dramatically reduced
after introduction of mandatory and reliable
screening of blood donors, MTPs patients may still
develop liver dysfunction due to infection with blood
born agents like HBV &HCV.13 The purpose of the
study was to find out the prevalence of HCV in MTPs
patients.
The aims of this study are:
1) To estimate the frequency of Hepatitis C virus
infection amongst multiple blood transfused
patients of different aetiology.
2) To evaluate information regarding
multitransfuse patients in relation to age, sex,
blood group and total number of transfusion.
3) To determine association of HCV infection in
relation to number transfusions received.
Materials and Methods
It was a prospective cross-sectional study. The study
was conducted at a private blood transfusion center
named QUANTUM Blood Bank at Dhaka
Metropolitan City. This transfusion center along
with blood bank had day care facilities for on need
basis transfusion with high patient turnover rate.
The study was conducted during January 2012 to
December 2016.
Inclusion criteria:
(1) The patients who were suffering from different
diseases who were receiving regular
transfusions of two or more units of blood or
blood components per month for at least last 6
months or more.
(2) The patients who did not know their Hepatitis
C status were included.
Exclusion criteria:
(1) Patients who were previously known to be HCV
Positive.
(2) Repetition of same multitransfused patients
during this time period.
A total of 972 patients were selected. Complete
history and physical examination was carried out
in all these patients and blood sample was collected
for screening HCV. Laboratory study was carried
out in the Laboratory Division of Quantum
Foundation,Dhaka. Anti-HCV test done by standard
serological screening test of ELISA procedure using
kits from ACON Anti-HCV-PLUS version 2 as per
guideline laid down by manufacturer kits. Cut off
index of the ELISA HCV test kit was 1.000. Reactive
sera were re-tested using the same method. A
Frequency of Hepatitis C Virus Infection Among Multi-Transfused Patients Munshi Mohd. Habibullah et al 17
structured interview schedule was developed for
collection of data. Data management and screening
was done by master tabulation. Simple descriptive
analysis were done by Libre Office Xcel. Data
analysis was performed on SPSS for Windows
Version 18.(IBM Corp., New York, USA).
Results
The study group comprised 972 MTPs, of them
563(57.92%) were male and 409(42.07%) were
female.(Table 1). Nearly half 534 (54.93%) are
within the 10-25 years’ age group, followed by 167
(17.18%) were eldest (above 40 years), 139 (14.30%)
were of youngest group (<10 years) and rest
132(13.58%) from 26-40 years age group..(Table II)
Mean SD age was 17.9±6.0. Maximum 560
(57.61%) patients were suffering from thalassemia
with hemophiliacs in second place 181
(18.62%).(Table III) Most of the patients were of
blood group O 482 (49%), followed by B 20.88 (203),
A 188 (19.34%) and AB 99 (10.18%) (Table III).
Among the patients 865 (89%) regularly received
blood from voluntary or relative blood donors in
past years and the rest 107 (11%) have history of
receiving blood from non-voluntary blood
donors.(Figure 1) Maximum 623 (64.09%) patients
had received between 11-30 units of blood or
components.(Figure 2) Anti-HCV test were reactive
in 37 cases (3.80%) and rests were found to be
negative. (Figure 3) Majority of HCV reactive
MTPs were male 23 (62.16%), suffering from
thalassemia 22 (59.45%) and was of Rhesus
negative blood group 21 (56.75%).Highest
percentage (21.62% each) of HCV reactive
individuals had received between 101-150 and 201-
250 units of blood products with 18.91% received
151-200 units and 8.10% was among highest blood
product recipient. (Table IV). Majority of HCV
reactive MTPs are male 23 (62.16%) and of Rhesus
negative blood group 21 (56.75%).
Most percentage (10.29%) of HCV positive patients
were suffering from chronic kidney disease with
history of hemodialysis procedures.(Table V). In
addition, patients who received blood from
nonvoluntary donors (11%) were exposed to HCV
infection more (72.9%) tham those transfused with
voluntary donors. (Table VI).
Table I
Distribution of Sex of study subjects (n=972)
Sex Number of subjects Percentage
Male 563 57.92
Female 409 42.07
Table II
Distribution of Age of study subjects (n=972)
Age in Years Number of subjects Percentage
<10 139 14.30
10-25 534 54.93
26-40 132 13.58
>40 167 17.18
Table III
Distribution of Multitransfused patients (MTPS)
according to disease (n=972)
Diseases MTPs Percentage (%)
Thalassemia 560 57.61
Hemophilia A /B 181 18.62
Chronic Kidney Disease
Especially Hemodialysis 68 6.99
patient
Leukemias 56 5.76
Aplastic anemia 42 4.32
Malignant Post
Chemo/Radiotherapy 31 3.18
Sickle cell anemia 17 1.74
Iron deficiency anemia 09 0.92
Thrombocytopenia 08 0.82
89%
11%00
Voluntary
Non voluntary
Fig.-1 Distribution of category of donors from
whom the study subjects received blood/blood
components (n=972)
18 Sir Salimullah Med Coll J Vol. 26, No. 1, January 2018
Table IV
Distribution of ABO and Rhesus Blood Groups
of study subjects (n=972)
Blood Group Number of Percentage
subjects (%)
O 482 49.59
A 188 19.34
B 203 20.88
AB 99 10.18
Rhesus Positive 845 86.90
Rhesus Negative 127 13.06 Table V
Approximate number of transfusions (in unit) of
whole blood or blood component in life time of
patients and number reactive HCV antibody ( n = 37)
No. of units Total No. Number Percentage
Blood/component of HCV {(a/37)*
transfused in patients reactive 100)}
life time cases(a)
(Approximate)
0-50 115 01 2.70
51-100 135 05 13.51
101-150 256 08 21.62
151-200 185 07 18.91
201-250 115 08 21.62
251-300 101 05 13.51
>300 65 03 8.10
Table VI
Distribution of HCV infected patients according
to disease (n = 37)
Diseases MTPs HCV Percentage
(a) reactive(b) (a/b)*100%
Thalassemia 560 21 3.75%
Hemophilia A /B 181 6 3.31%
Chronic Kidney Disease
Especially Hemodialysis
patient 68 7 10.29%
Leukemias 56 2 3.57%
Aplastic anemia 42 1 2.38%
Malignant (Post
Chemo/Radiotherapy) 31 0 0
Sickle cell anemia 17 0 0
Iron deficiency anemia 09 0 0
Thrombocytopenia 08 0 0
Fig.-2: Distribution of patients according to number
of units transfused (n=972)
4%
96%
0%0%
HCV Positive
HCV Negetive
Fig-3: Distribution of MTPs on results of Anti HCV
test (n=972)
Frequency of Hepatitis C Virus Infection Among Multi-Transfused Patients Munshi Mohd. Habibullah et al 19
Table VII
Comparison of HCV Positive patients according to type of donor
Type of donor from Percentage Number of HCV Percentage among
whom blood was Reactive patient HCV Reactive cases
received (n = 37)
Voluntary 89% 10 27.1%
Non-voluntary 11% 27 72.9%
Table VIII
Comparison between findings reported by various authors from different parts of the world with
present study
No. Author(S) Country Year Prevalence
01 Williams et al.15 India 1992 2.2
02 Amarapurkar et al.16 India 1992 17.5
03 Cacoparado et al.17 Italy 1992 47.0
04 Choudhury N et al.18 India 1993-95(93) 23.0
05 Covas et al.19 Brazil 1993 46.8
06 Agarwal et al.20 India 1993 45.0
07 Choudhury N et al.18 India 1993-95(94) 30.7
08 Alegria et al.21 Chili 1994 52.0
09 Choudhury N et al.18 India 1993-95(95) 35.9
10 Bhatti et al.22 Pakistan 1995 63.8
11 Henschel et al.23 Germany 1996 43.0
12 Laosombat et al.24 Thailand 1997 23.8
13 Jamal et al5 Malaysia 1998 22.4
14 Poovorawan et al.25 Thailand 1998 32.6
15 Juneja et al.26 India 1998 15
16 Mollah A et al.27 Bangladesh 2001 12.5
17 Akhtar et al.28 Pakistan 2002 20.5
18 Singh H et al.29 Lucknow, India 2003 20
19 Ikram et al. 30 Rawalpindi, Pakistan 2003 42
21 Erich V et al. 31 Brazil 2005 16.7
22 Lopez L et al. 32 Uruguay 2005 12.7
23 Kapoor C et al. 33 Ouetta, India 2006 30
24 Ocak S et al. 34 Turkey 2006 4.5
25 Sheyyab M et al. 35 Amman, Jordan 2000-2001 40.5
26 Hussain H et al. 13 Pakistan 2002–2003 41.7
27 Shekhar H et al. 36 Bangladesh 2003–2004 16.7
28 Present study Bangladesh 2012-2016 3.8
20 Sir Salimullah Med Coll J Vol. 26, No. 1, January 2018
Discussion
HCV infection was the most prevalent TTI among
MTPs, and remains a major health problem for
these patients. The implementation of measures
such as donor education programs, standards for
donor selection criteria, and of improved serological
screening protocols, paralleled the decline in the
prevalence of TTI, especially of HCV, observed in
MTPs, underscoring the importance of such
measures for the reduction of the residual risk of
TTI.14
Out of 972 patients more than half were (55.0%)
within the 10-25 years age group followed by 17.14%
, 14.29% and 14.29% were above 40 years, 26-40
and less than 10 years respectively.
Anti-HCV test was positive in 3.80% (n=37) and rests
were found negative. Different studies around the
world found high prevalence of HCV infection among
the multitransfused patients with thalassemia and
hemophilia. (Table VII) Disparity among the
prevalence of HCV infection of MTPs in different
countries reflects multiple factors associated with
the fact of implementation of Anti HCV screening
program as integral part of screening of blood
products in different years in different regions of
world.
The prevalence of HCV infection among MTPs
patients in our study (3.80%) was less than most of
other studies ranging from 4.5 to 63.8.5-10 Williams
et al have lower rate of prevalence of 2.2 than our
one .The HCV prevalence among studies from
Bangladesh noted at 12.5% & 16.7%. Among Indian
studies minimum was 2.2%27 and maximum
35.9%.36 Another country of this sub-continent,
Pakistan, has much higher values of ranging 20.5
to 63.8 %. Countries from South America like Brazil,
Chili and Uruguay recorded massive variations in
prevalence, i.e. from 12.75 up to 52%. In a systemic
review from Egypt showed that multi-transfused
patients are affected with HCV ranges from 10-55%
according to multiple studies. 37
These variations in results with other studies
suggest that other factors are contributing to the
relatively low rates of HCV infection among MTPs
in our study. One possible factor could be, different
authors using different laboratory tests with variable
validity for detecting antibody to HC. Many reports
were based on only ICT tests without complementary
and confirmation tests as they were not available
in all countries few years before. However, some of
those have used ELISA and very few use used PCR
as a confirmation test.
The second reason is that the prevalence of HCV
infection found in general population in Bangladesh
is very low 0.82% and 0.88 (<1%).38,39 As a result,
rate of transfusion transmitted HCV in MTPs are
also less than others.
The third factor is the policies that implemented by
Government related agencies and blood transfusion
organization, about screening of blood to provide safe
blood to all. In Bangladesh, routine screening for
blood borne diseases has been mainly conducted
among blood and tissue donors since the 1997, and
it seems that this policy reduced infection rate since
that time.40This shows the importance of the blood
donors screening program. But still,considering the
vast population of the country, even low prevalence
amounts to large number of infected people.41
Laosombat et al in a study showed that the number
of blood transfusions received by anti-HCV positive
multitransfused thalassemic patients were
significantly higher than that by anti-HCV negative
thalassemic patients. Our results showed no linear
correlation between number of bags with increased
HCV positivity.
Nearly 11% of HCV positive patients were suffering
from chronic kidney disease with history of
hemodialysis procedures. This finding is consistent
with studies showing that HCV related liver disease
is a significant cause of morbidity and mortality in
patients with renal disease who is treated with
dialysis.42 Thalassemia patients formed the main
bulk (57.61%) of our study population. But still their
HCV infectivity is significant (3.75% of the patients.
(Table III & Table VI). After dramatically improving
the blood safety with new diagnostic tools, alternative
routes of transmission, such as direct inoculation,
may explain that in spite of blood donor screening
why HCV has been found in blood recipients. It may
be via contaminated needles, scalpels, or other
pointed or sharp objects. Some of the thalassemic
patients shared subcutaneous infusion pump for iron
chelation which might be the source of nosocromial
infection.38 Infected medical personals can also
transmit HCV.43
We think that previously reported high prevalence
of HCV infection among high-risk patients has some
Frequency of Hepatitis C Virus Infection Among Multi-Transfused Patients Munshi Mohd. Habibullah et al 21
bias including inappropriate sample size and
unreliable laboratory tests.
Conclusion
As vaccine is available in case of hepatitis B,
immunization against this virus would effectively
protect against transfusion transmitted hepatitis
B. However, since no such vaccine is so far available
against hepatitis C, the only effective protective
measure against this virus is provision of HCV
negative blood for transfusion. HCV infection is a
preventable disease. Therefore, screening of
transfused blood for HCV in not only mandatory,
but also it is essential to use the most sensitive
screening methods with least possible false negative
results.Serological screening of every
multitransfused patient can be carried out at 3
months’ interval.Moreover, by detecting HCV
infection early, antiviral treatment can be offered
earlier in the course of the disease which is more
effective than starting at a later stage. Stringent
measures in donor screening including donor
education,better donor recruitment, promoting and
encouraging 100% voluntary blood donation,
screening of blood and blood products using dual
testing strategy with high sensitivity serological
assays and NAT for HCV would considerably
improve the current and enhance the safety of the
blood intended for transfusion.Longitudinal study
with larger sample size is recommended to reflect
the real situation and for health policy making.
Provision of safe and adequate blood supply to these
MTPs is a key to improve their quality of life and
longevity.
Study limitations
The present study was conducted in a selected
transfusion center of Bangladesh. Generalization
from this study, therefore, cannot be made for the
whole country. Duration of this study was only 5
(five) years with relatively small sample size .Only
ELISA method was used for the identification of
seropositivity of the HCV. Many of the respondents
replied to questions from their memories that could
have led to recall bias. There are missing data in
records of patients about exact number of units they
have transfused, risk factors such as drug abuse,
sexual and addiction history of adults, tattooing,
and high-risk behaviors. These were not assessed
in this study.
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24 Sir Salimullah Med Coll J Vol. 26, No. 1, January 2018
Gestational Diabetes Mellitus (GDM): Patient
Profile and Management in a Tertiary Level
HospitalFlorida Rahman1, Banani Bhoumik2, Ratu Rumana Binte Rahman3Sarwar Ibne Salam4
Abstract:
The prevalence of Gestational Diabetes Mellitus is rapidly rising all over the globe at an
alarming rate. GDM is defined as any degree of glucose intolerance with onset or first recognition
during pregnancy.
Methods:All the admitted cases of GDM in Sir Salimullah Medical College & Mitford Hospital
from April 2013 to September 2013 were enrolled for the study. Informed consent was taken
from each patient. Data was collected by using a standard set of questionnaire to analyze the
patient profile and management pattern of patients with GDM.
Results: GDM was more common in the age group of 26 to 35 years and was more prevalent in
urban population (88.4%). Majority of the cases were multigravida (69.2%). More than two
third (71.2%) of the study patients were of average income group. Most of them (80.8%) were
housewives. Nearly one fourth (23.1%) of the study patients had GDM in their previous pregnancy
and more than a half (57.7%) of the cases had family history of DM. Only 11.6% of cases were
having polyhydramnios and 15.4% of cases were having UTI. Majority of study subjects (76.9%)
required caesarian section. Most of the patients (69.2%) needed insulin. Significant fetal/
neonatal complications were not observed in this study.
Conclusions:GDM is one of the most common medical problems in our country. It adversely
affects both the maternal and the perinatal outcome. All GDM patients who were diagnosed
early had less complications related to mother and child. So in developing country like
Bangladesh, it is an utmost necessity to analyze the patient profile, to identify the risk factors,
to diagnose and to adopt a management protocol. Thus it will help to reduce the maternal and
the perinatal morbidity and mortality
Key words: GDM, polyhydromnios, Macrosomia, Insulin.
(Sir Salimullah Med Coll J 2018; 26: 25-30)
1. Assistant Professor, Dept. of Gynae and Obs, Dhaka Medical college Hospital, Dhaka
2. Junior Consultant, Dept. of Obs and Gynae,Ghatail upazillza health Complex , Tangail
3. Professor, Dept. of Gynae and Obs, SSMC and Mitford Hospital, Dhaka.
4. Assistant professor, dept of Orthopaedics DMCH.
Correspondence- Dr.Florida Rahman, email-: florida_rahman@yahoo.co
Introduction:
Gestational diabetes mellitus is defined as any
degree of glucose intolerance with onset or first
recognition during pregnancy1. This definition
acknowledges the possibility that patient may have
previously undiagnosed Diabetes or may have
developed diabetes coincidentally with pregnancy.
This entity usually presents late in second trimester
or in third trimester.2
Diabetes during pregnancy possesses significant risk
to the mother and fetus. The most common problem
of mother is an increased incidence of preeclampsia
and operative interference.3Infants born to mothers
with GDM are at risk of being both large for
gestational age (macrosomia),4 and small for
gestational age and intrauterine growth
retardation.5 Macrosomia in turn increases the risk
of instrumental deliveries (e.g. forceps, ventouse)
and caesarean section or problems during vaginal
delivery (such as shoulder dystocia). Macrosomia
may affect 12% of normal women compared to 20%
of patients with GDM.6 Children of women with
GDM have an increased risk for childhood and adult
obesity, glucose intolerance and type 2 diabetes later
in life.7 This risk relates to increased maternal
glucose values8. Due to increased level of human
placental lactogen, steroid hormones there is
marked insulin resistance during pregnancy.
Glucose tolerance deteriorates in pregnancy but
about 97% to 98% of all pregnant women retain a
normal tolerance and only 2 to 3% develop GDM.9
Neonates born from women with consistently high
blood sugar levels are at risk of hypoglycemia,
polycythemia, hypocalcaemia and hypoma-
gnesaemia.10 Untreated GDM also interferes lung
maturation causing Respiratory Distress syndrome
(RDS) due to impaired surfactant synthesis. Studies
have shown that the offspring of women with GDM
are at a higher risk for congenital malformations.11
Therefore the diagnosis of GDM is very important.
Once it is diagnosed, multi-disciplinary
management is important for good pregnancy
outcomes.12
The White classification13, named after Priscilla
White, who pioneered in research on the effect of
diabetes types on perinatal outcome, is widely used
to assess maternal and fetal risk. It distinguishes
between gestational diabetes (type A) and diabetes
that existed prior to pregnancy (pre gestational
diabetes). These two groups are further subdivided
according to their associated risks and
management.
The two subtypes of gestational diabetes (diabetes
which began during pregnancy) are:
Type A1: abnormal oral glucose tolerance test
(OGTT), but normal blood glucose levels during
fasting and two hours after meals; Diet modification
is sufficient to control glucose levels
Type A2: abnormal OGTT compounded by abnormal
glucose levels during fasting and/or after meals;
additional therapy with insulin or other medications
is required. It may be complicated with pelvic vessel
atherosclerosis, nephropathy, hypertension,
retinopathy, IHD, etc.
Effect of Diabetes on Pregnancy:
Carbohydrate intolerance during pregnancy causes
significant increase in fetal and maternal mortality
and morbidity These women have a greater risk of
abortion, pre-eclampsia, infection, postpartum
hemorrhage and caesarean deliveries.
Effect of Diabetes on Fetus:
Fetal Macrosomia:
Birth weight above the 90th percentile for
gestational age or greater than 4000 gm occurring
in 15-45% of infants exposed to hyperglycemia.
Congenital Malformation or Birth Defect
It affects about 6-10% of infants of diabetic mother2.
Congenital malformation is related to severity of
diabetes affecting organogenesis; in the first
trimester. Initial maternal HbA1c level >7 is
associated with this risk. Levels of >10 are associated
with 23.5% of congenital anomalies, e.g. cardiac
(ASD,VSD, transposition of great vessels), neural
tube defect, renal agenesis, gastrointestinal and
spinal anomaly.14
Birth Injuries
Shoulder dystocia, brachial plexus injury, facial
nerve injury, and cephalhematoma are common.
Growth Restriction
Although most fetuses of diabetic mothers exhibit
growth acceleration, growth restriction occurs with
significant frequency in prepregnancy
atherosclerotic mother.
Perinatal mortality and morbidity : Congenital
malformations, respiratory distress syndrome (RDS),
extreme prematurity, hyperbillirubinemia
hypocalcaemia polycythemia and cardiomyopathy15
are main causes .
Metabolic syndrome The childhood metabolic
syndrome includes childhood obesity, hypertension,
dyslipidemia, and glucose intolerance
Screening of Diabetes in Pregnancy
Diagnostic criteria in USA is usually accomplished
by administration of 3 hour 100 gm OGTT after an
overnight fast. Diagnosis of GDM is made when 2
or more thresholds are met or exceeded. Outside of
the US a one-step approach to testing using a 2
hour 75 gm oral glucose load is widely used.
According to IADPSG (International According to
IADPSG(International Association of Diabetes and
Pregnancy Study Group) 2010, diagnosis of GDM
can be made if there is one or more abnormal value
on the 75 gm OGTT, Fasting > 92mg/dl, 1hr after
glucose 180mg/dl, 2hr after Glucose 153mg/dl.
The obstetrician should manage the patient in
collaboration with endocrinologist, nutritionist and
neonatologist. The goal should be to achieve an
optimum glycemic control as early as possible to
prevent complications.
The study was done to analyze the characteristics
of the patients, diagnosis, investigations &
26 Sir Salimullah Med Coll J Vol. 26, No. 1, January 2018
treatment of these cases. Thus maternal and fetal
outcome of these cases was evaluated.
Materials and Methods
It is a Cross Sectional study.The study was carried
out in the Department of Obstetrics & Gynecology,
Sir Salimullah Medical College & Mitford Hospital,
Dhaka from April 2013 to September 2013. All the
GDM patients who were admitted during this period
in the Obstetrics &Gynaecology department of
SSMC & MH were included.
A total of 52 cases GDM were enrolled in this study.
GDM was diagnosed according to IADPSG 2010
criteria. A purposive sampling method was used. A
questionnaire was prepared for data collection.
Known cases of pregestational diabetes and Patients
having GDM with any other co-morbidity (e.g. -
Hypertension, Chronic Nephritis) were excluded.
Patient profile, clinical presentation and maternal
& fetal outcomes were main variables.
Data Processing and Analysis: Data analysis
was systematically done by SPSS/PC, and MS Excel
was used for the graphs.
Observation and Results
Table-I
Frequency table showing distribution of GDM as
per age group (n=52)
Age in years Frequency(n=52) Percentage
20-25 8 15.4
26-30 21 40.4
31-35 15 28.8
36 -40 8 15.4
GDM is more common in the age group of 26 – 35
years.
Table-II
Frequency table showing distribution of GDM as
per gravida (n=52)
Gravida Frequency(n=52) Percentage
Primigravida 11 21.1
Multigravida 37 71.2
Grand multigravida 4 7.7
GDM is more common in multi gravid women
(71.2%).
Table-III
Frequency table showing distribution of GDM as
per socioeconomic status (n=52)
Socioeconomic Frequency Percentage
status (=52) (%)
Below average income group 6 11.5
(tk 3000)
Average Income group 36 69.2
(tk 3000-1000)
Above average income group 10 19.3
(Tk>10000)
Most of GDM cases (69.2%) belong to average income
group.
Table-IV
Frequency table showing distribution of GDM as
per residence (n=52).
Residence Frequency Percentage
(n=52)
Rural 8 15.4
Urban 44 84.6
Table 1.4 shows the distribution of GDM as per
residence. It was observed that GDM was more
common in urban group (84.6%).
Table-V
Frequency table showing distribution of GDM as
per occupational status (n=52)
Occupational status Frequency Percentage
(n=52)
Housewife 42 80.8
Service holder 10 19.2
Table V shows that most of the patients 42(80.8%)
were housewives
Table-VI
Frequency table showing the distribution of GDM
as per antenatal checkup (ANC), n=52
ANC Frequency Percentage
Regular 30 57.7
Irregular 16 30.8
No ANC 06 11.5
57.7% of the study subjects had regular antenatal
checkup.
Gestational Diabetes Mellitus (GDM): Patient Profile and Management Florida Rahman et al 27
Table-VII
Frequency table showing distribution of the
study subject as per history of GDM in previous
pregnancy (n=52)
History of GDM Frequency Percentage
in previous pregnancy (n=52)
Present 12 23.1
Absent 40 76.9
23.1% patients had history of GDM in their previous
pregnancy.
Table-VIII
Frequency table showing distribution of GDM as
per family history of DM (n=52)
Family history Frequency Percentage
of DM (n=52)
Present 30 57.7
Absent 22 42.3
57.7% had positive family history.
Table-IX
Frequency table showing maternal complications
of study subjects (n=52)
Complications Frequency Percentage
(n=52)
Polyhydramnios 06 11.6
Pre-eclampsia 02 3.8
Vulvovaginitis 04 7.7
UTI 08 15.4
Nil 32 61.5
15.4 % had UTI, 11.6% had polyhydramnios, 7.7%
had vulvovaginitis and 3.8% had pre-eclampsia.
Table-X
Frequency table showing distribution of GDM as
per mode of delivery (n=52).
Mode of delivery Frequency Percentage
(n=52)
Vaginal delivery 12 23.1
Caesarean section 40 76.9
It was observed that majority (76.9%) underwent
caesarean section.
Table-XI
Frequency table showing management of GDM
Management Frequency Percentage
(n=52)
Diet + Prescribed exercise 14 27
Diet + Insulin 36 69.2
Oral Hypoglycemic Agents 02 3.8
69.2% was managed by diet plus insulin.
Table-XII
Frequency table showing the birth weight of baby
of study subject (n=52).
Birth weight Frequency Percentage
(n=52)
Low birth weight (<2.5kg) 01 1.9
Normal birth weight(2.5-4kg) 42 80.8
Macrocosmic baby (>4kg) 09 17.3
Majority (80.8%) of babies had normal birth weight.
Table-XIII
Frequency table showing neonatal complications
of study subject (n=52).
Complications Frequency Percentage
(n=52)
Hypoglycemia 04 7.7
Hyperbilirubinemia 08 15.4
IUGR 01 1.9
RDS 01 1.9
Nil 38 73.1
73.1% neo-nate had no significant complications.
Other results are depicted in the above table.
Discussion
GDM is one of the most important medical and
endocrine disorders encountered in obstetrical
practice. Diabetes and pregnancy may mutually
affect each other over a range of interaction from
conception to delivery and possibly even later. Proper
screening, diagnosis and management can reduce
both maternal and perinatal mortality and
morbidity.
The aim of this study was to analyze the patient
profile and management of gestational diabetes
28 Sir Salimullah Med Coll J Vol. 26, No. 1, January 2018
mellitus. It would help in identifying patients at
risk and of taking appropriate measures about the
management of GDM patients.
52 cases of women with gestational diabetes mellitus
were included in this study. Their antenatal,
intranatal and postnatal periods were thoroughly
observed. Maternal and perinatal events of these
patients were recorded and analyzed systematically.
The present study findings were discussed and
compared with previously published relevant studies.
In this current study it was observed that most of
GDM cases were detected in the age group of 26-35
years which accounted more than 50% of total GDM
cases detected. It is consistent with the age group
described in the literature12.
It was observed in this study that the majority of
cases were multigravida (71.2%).Similar observation
was made by V.Seshiah,in Chennai,(2001) where
he revealed that the prevalence of GDM was
increased with the number gravida16.
In this study more than two third (69.2%) of the
study subjects were from average income group
(69.2%), 19.3% were from above average income
group and 11.5% were from below average income
group. Majority of the patients (80.8%) were
housewives.
In this current study most of the GDM patients
(57.7%) were in regular antenatal check up. There
was relationship between ANC and outcome of GDM
as it helps in early diagnosis and better
management.
In this study 23.1% patients had history of GDM in
their previous pregnancy. A study in Germany by
Schaefer-Graf showed that 10% of GDM cases had
previous history which was a little lower than the
present study17. GDM patients had significantly
higher frequency of family history of DM (57.7%) in
this study. Another study conducted by Silva showed
that 56.4% of GDM cases had family history of DM
which is quite similar to our study18.
Various maternal complications of GDM patients
were noted in this study. Among them 11.6% had
polyhydramnios, 3.8% had pre-eclampsia, 7.7% had
vulvovaginitis and 15.4% had UTI. A study in India
conducted by Jindal (2001) revealed that the
incidence of polyhydramnios was 28% in the GDM
patients. Marked dissimilarity was detected between
two studies. Though polyhydramnios was
significantly higher in Jindal’s study, infection was
common in our study19.
During antenatal period 27% patients were treated
with diet plus lifestyle modification and 69.2%
patients were treated with diet plus insulin. Giuffrida
(October 2003) in Brazil showed that 50.27% got
diet plus insulin which is comparable with the
current study.
In this study GDM patients had higher frequency
of caesarean section than vaginal delivery (76.9%
vs 23.1%). But dissimilarities were seen between
our study and Jindal’s study (2001 India) where
caesarean section was required in 44% cases19.In
this study the rate of caesarean section is higher as
it is a tertiary level hospital where most of the
complicated cases are referred.
In this current study, most of the babies (80.8%)
were born with normal birth weight (2.5-4 kg) which
is comparable with the study done by Silva where
90% of baby had normal birth weight18.
In our study there was no neonatal death. Among
neonates of GDM mothers, 7.7% had hypoglycemia,
15.4% had hyperbillirubinemia, 1.9% had IUGR,
1.9% had respiratory distress syndrome and 73.1%
had no complications. The study conducted by Silva
revealed a dissimilar data which showed
hyperbillirubinemia, hypoglycemia and RDS in
3.8%, 4.0% and 2.6% respectively with no neonatal
death18.
There is a difference between other international
studies because the present study was conducted at
a very short period of time with limited funds, most
of the patients came with labor pain or some other
complication, no control group was taken. If the
study group could be followed up for a longer time,
the result would have higher validity.
Conclusion
GDM is one of the most important medical and
endocrine disorders encountered in the obstetric
practice. It is crucial to detect women with GDM as
the condition is associated with diverse range of
adverse maternal and neonatal outcomes. In
addition, having a history of GDM puts the mother
at risk for the development of type 2 diabetes
mellitus or recurrent GDM. From the study it is
understood that if diabetes is well controlled it is no
longer a barrier to pregnancy. At the same time a
Gestational Diabetes Mellitus (GDM): Patient Profile and Management Florida Rahman et al 29
diabetic mother has a fair chance of delivering
healthy baby, provided the management is started
from the preconception period. Adequate blood sugar
control before and during pregnancy reduces the
incidence of congenital anomalies, maternal and fetal
morbidity and mortality. However, recognizing GDM
is becoming a major health challenge for clinicians
and treating it results in lowering of both maternal
and fetal complications. Also, clinicians must follow-
up women with GDM postpartum so that the
prevalence of Type 2 diabetes may start declining.
The maternal and fetal outcome depends upon the
care by the committed team of endocrinologist,
obstetricians and neonatologists. A short term
intensive care gives a long term pay off in the
primary prevention of obesity, impaired glucose
tolerance (IGT) and diabetes in the offspring, as the
preventive medicine starts before birth.
References
1. Metzger BE, Coustan DR: Summary and
recommendations of the Fourth International
Workshop-Conference on Gestational Diabetes
Mellitus. Diabetes Care 1998 ;21 (Suppl 2) : B161-167.
2. Dutta DC Text Book Of Obstetrics, 7th edn2011 :281-
282.
3. Donovan PJ (2010). “Drugs for gestational diabetes”.
Australian Prescriber (33): 141–4.
4. HAPO Study Cooperative Research Group;
“Hyperglycemia and Adverse Pregnancy Outcomes”
Metzger BE, Lowe LP, Dyer AR et al. (2008). N Engl J
Med 2008; 358:1991-2002
5. Setji TL, Brown AJ, Feinglos MN. (1 January 2005).
“Gestational Diabetes Mellitus”. Clinical Diabetes 23 (1):
17–24.
6. Kelly L, Evans L, Messenger D. (2005). “Controversies
around gestational diabetes.Practical information for
family doctors”. Canadian family physician Medecin de
famille canadien 51 (5): 688–695.
7. Boney CM, VermaA, Tucker R, Vohr BR. (2005).
“Metabolic Syndrome in Childhood: Association with
Birth Weight, Maternal Obesity, and Gestational
Diabetes Mellitus”. Pediatrics 115 (3): e290–e296.
8. Hillier TA, Pedula KL, Schmidt MM, Mullen JA, Charles
MA, Pettitt DJ. (2007). “Childhood Obesity and Metabolic
Imprinting: The ongoing effects of maternal
hyperglycemia”. Diabetes Care 30 (9): 2287–2292.
9. Kuhl C. Aetiology of gestational diabetes mellitus.
Bailliers Clin Obstet Gynaecl 1991 (June); 5 (2): 279-92.
10. Jones CW. (2001). “Gestational diabetes and its impact
on the neonate”. Neonatal network : NN 20 (6): 17–23.
11. Allen, VM, Armson BA, Wilson RD, Allen VM, Blight, C,
Gagnon A, Johnson JA, Langlois S. et al. (2007).
“Teratogenicity associated with pre-existing and
gestational diabetes”. Journal of obstetrics and
gynaecologyCanada : JOGC = Journal d’obstetrique et
gynecologie du Canada : JOGC 29 (11): 927–944.
12. Kapoor N, Sankaran S,Hyer S,Shehata H. (2007).
“Diabetes in pregnancy: A review of current evidence”.
Current Opinion in Obstetrics and Gynecology 19 (6):
586–590.
13. Ramachandran A, Snehalatha C, Shaymala P, Vijay V,
Viswanathan M. prevalence of diabetes in pregnant
women; A study from Southern India. Diabetes Res
Clin pract 1994; 25:71-74.
14. Metzger BE, Gabbe SG, et al. International Association
of Diabetes and Pregnancy Study Groups
reccomendations on the diagnosis and classification of
hyperglycemia in Pregnancy. Diabetes Care 2010; 33:
676-682
15. Ratnam SS. Obstetrics and Gynaecology, vol.1:2nd
edn.OrientLangman Limited,1991;71.
16. Seshiah V, Balaji V, Balaji MS, Sanjeevi CB, Green A.
GDM in India. JAPI 2001; 52: 707-711.
17. Schaefer-graf UM, Kjos SL, Kilavuz O. Determinants
of fetal growth at different periods of pregnancies
complicated by GDM or impaired glucose tolerance.
Diabetes care 2003; 26: 193-198.
18. Silva JK, Kaholokula JK, Ratner R, Mau M. Ethnic
differences in perinatal outcome of GDM. Dabetes Care
2006; 29: 2058-2063.
19. Jindal A, Ahmed F, Bhardawaj B, Chaturvedi B.
Prevalence, clinical profile and outcome of GDM. J
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30 Sir Salimullah Med Coll J Vol. 26, No. 1, January 2018
Role of Lipid Profile and Bmi in The Evaluation
Of Newly Diagnosed Type 2 Diabetes MellitusS Saber1, Md Hossain2, Ma Hossain3, MM Hossain4
Abstract:
Type 2 diabetes mellitus (T2DM) is the most prevalent metabolic condition and one amongst
major health and socioeconomic problems worldwide. It represents more than 90% of total
prevalence of diabetes in the world and is responsible for 9% of the global mortality per year.
The abnormal lipid profile observed in type 2 DM is said to be related to insulin resistance
which has been closely associated with diabetic dyslipidemia, hypertension and enormous risk
of vascular diseases. Obesity is considered as part of the metabolic syndrome in the pathogenesis
of type 2 diabetes. Newly detected type 2 diabetic patients in Medicine and Endocrinology
departments of Bangladesh Medical College and Hospital (BMCH), Dhaka were the target
population and those who fulfilled the inclusion and exclusion criteria were enrolled as the
study sample. Out of 200 cases, 82 were males and 118 were female patients. Most of individuals
were obese, females more than males. Most individuals had poor glycemic control. In this study
maximum number of cases (94%) had serum HDL-C in low range and only 6% of cases were in
high group. Prevalence of low HDL-C was 94%. Female diabetic patients had low HDL-C
compared to males, which is an important risk factor for Coronary Heart Disease (CHD). This
study has revealed that BMI abnormalities, dyslipidemia, uncontrolled glycemic status were
highly prevalent in newly diagnosed type 2 diabetes mellitus. Most of our patients had
dyslipidemia irrespective of glycemic control. Female patients had high frequency of low HDL-
C, which is an important risk factor for CHD.
(Sir Salimullah Med Coll J 2018; 26: 31-36)
1. Dr. Sadia Saber, Asst. Professor (cc) of Medicine, BMC,
2. Dr. Md. Dabir Hossain, Asso. Professor of Medicine, BMC.
3. Dr. Amir Hossain, Asso. Professor of Cardiology, BMC.
4. Dr. Mohammad Monower Hossain, Medical Officer of Medicine, BMCH.
Address of Correspondence: Dr. Sadia Saber, Asst. Professor (cc) of Medicine, BMC, E-mail: sadiasaber201477@gmail.com
Introduction:
Type 2 diabetes mellitus (T2DM) is the most
prevalent metabolic condition and one amongst
major health and socioeconomic problems
worldwide.1-3 It represents more than 90% of total
prevalence of diabetes in the world4 and is
responsible for 9% of the global mortality
corresponding to 4 million deaths per year. Untreated
diabetes may result in limb amputation, blindness,
kidney failure and neuropathy. T2DM is also
associated with 4-fold increased risk of
cardiovascular events and risk factor for
cardiovascular death.5-7
Obesity is considered as part of the metabolic
syndrome in the pathogenesis of type 2 diabetes.
Body mass index (BMI) has gained favor as a better
measure for adiposity (8, 9) that is frequently used
as a measure for body fatness in large epidemi-
ological studies.10
The abnormal lipid profile observed in type 2 DM is
said to be related to insulin resistance which has
been closely associated with diabetic dyslipidemia,
hypertension and enormous risk of vascular
diseases.11 Dyslipidemia characterized by the
elevation of plasma total cholesterol (TC),
triglycerides (TG) and TG-rich very-low-density
lipoprotein cholesterol (VLDL-C), reduced high-
density lipoprotein cholesterol (HDL-C), and
increased low-density lipoprotein cholesterol (LDL-
C) contributes significantly to the excess risk of
CVD.12 It has been observed that HDL may be the
best predictor of Coronary Artery Disease (CAD) in
T2DM followed by TG and total cholesterol.
Methodology:
This descriptive cross sectional study was done in
the Department of Medicine, and Endocrinology of
Bangladesh Medical College Hospital, Dhaka during
the period from 1st July 2015 to 30th June 2017.
32 Sir Salimullah Med Coll J Vol. 26, No. 1, January 2018
Study Population:
Newly detected type 2 diabetic patients in Medicine
and Endocrinology departments of Bangladesh
Medical College and Hospital (BMCH), Dhaka were
the target population and those who fulfilled the
inclusion and exclusion criteria were enrolled as the
study sample.
Inclusion Criteria:
1. Newly diagnosed DM on the basis of ADA criteria
2. Age more than 20 years
3. Informed written consent.
Exclusion Criteria:
1. Previously known diabetic patient
2. Patients with coexisting hypothyroidism, liver
disease, nephrotic syndrome, pregnancy,
alcoholism, infections, cerebrovascular accident
3. Patients with known inherited disorders of lipids
4. Any severely ill patients whose sensorium and
higher functions are altered
5. Medical conditions like multiple myeloma that
may interfere with laboratory estimation of lipid
profile.
Sampling Technique:
Consecutive convenient (purposive) sampling.
Data Collection:
Data were collected in a pre-designed data collection
sheet designed for the study.
Procedure of data collection:
All newly detected type 2 diabetes mellitus, inpatient
and outpatient fulfilling the criteria were included
in this study.
Data Analysis:
After collection of all information, these data
analysis was performed using the SPSS/PC software
and graph and chart by MS excel.
Quantitative data were expressed as mean and
standard deviation.
Qualitative data were expressed as frequency,
percentage, proportion and ratio. Statistical analyses
will be done by using appropriate statistical tool like
‘chi-square’ test, student‘t’ test, where applicable.
A P value of <0.05 was considered statistically
significant and a P value of >0.05 (p>0.05) was
considered statistically not significant.
Results:
Out of 200 cases, 82 were males and 118 were female
patients (Figure1). Maximum numbers of patients
were in between the age group 35 to 45 years (Table
1, Figure 2). Most of individuals were obese, females
more than males (Table 2). Most individuals had
poor glycemic control.
Fig 1: Pie chart showing sex distribution among
study population
In our cases maximum numbers of cases were in
between 35-44 years (33%) and 45 – 54 years (30%).
Mean age was 51.69 +/- 11.184 years.
Table I
Comparison of BMI between male and female
Variables Gender P value
Bmi Male Female
24.72+/-3.82 26.33+/-4.62 0.069
Compared to males, females were more obese
(24.72+/-3.82 vs. 26.33+/-4.62) which is not
statistically significant (Table 1).
In this study maximum number of cases (35%) had
fair glycemic control, 23% had good control and 21%
of cases were in each poor and very poor group
(Figure 2).
2630
1610
20
40
2632
MALE FEMALE
Fig 2: Glycemic control among cases
Role of Lipid Profile And Bmi In The Evaluation of Newly Diagnosed Type 2 Diabetes Mellitus S Saber et al 33
Table-II
Difference in serum cholesterol (TC)
Cholesterol (mg%) Male Female Total
Desirable: <200 32(39.0) 44(37.3) 76(38)
Borderline high: 30(36.6) 40(33.9) 70(35)
200-239
High: >240 20(24.4) 34(28.8) 54(27)
Total 82 118 200(100)
In this study maximum number of cases (38%) had
serum cholesterol in desirable range, 35% of cases
were in borderline high and 27% cases were in high
group. Prevalence of hypercholesterolemia was 62%
with no significant difference between male and
female patients (Table II).
In this study maximum number of cases (37%) had
serum TG in normal range, 33% of cases were in high,
20% of cases were in borderline high, and only 7% cases
were in very high group. Prevalence of
hypertriglyceridemia was 63% with no significant
difference between male and female patients (Table II).
Table-III
Differences in serum Triglycerides
Triglycerides (mg%) Male Female Total(%)
Normal: <150 36(43.9) 38(32.2) 74(37)
Borderline high: 12(14.6) 28(23.7) 40(20)
150-199
High: 200-499 26(31.7) 46(39.0) 72(33)
Very high: >500 8(9.8) 6(5.1) 14(7)
Total 82 118 200(100)
In this study maximum number of cases (29%) had
serum LDL-C in near optimal range, 28% of cases
were in borderline high range, 24% of cases were in
optimal range, only 8% cases were in very high
group. Prevalence of raised LDL-C was 76%
(Table-IV).
Table-IV
Difference in serum LDL cholesterol
LDL Cholesterol (mg%) Male Female Total
Optimal: <100 20(24.4) 28(23.7) 48(24)
Near optimal: 100-129 28(34.1) 30(25.4) 58(29)
Borderline high: 130-159 22(26.8) 34(28.8) 56(28)
High: 160-189 8(9.8) 14(11.9) 22(11)
Very high: >190 4(4.9) 12(10.2) 16(8)
Total 82(100) 118(100) 200(100)
In this study maximum number of cases (94%) had
serum HDL-C in low range and only 6% of cases
were in high group. Prevalence of low HDL-C was
94%. Female diabetic patients had low HDL-C
compared to males with statistically significant
difference, which is an important risk factor for
Coronary Heart Disease (CHD) (Figure 3).
Fig 3: Difference in serum HDL cholesterol (mg %)
There was no statistically significant difference
between male and female for raised TC, TG, LDL-
C, but HDL-C was low in female than male which
was statistically significant (p < 0.05) (Table 5)
Male Female
4 8
78
110
High: > 60
Low: Male < 40, Female <50
Table-V
Dyslipidemia in male and female diabetic patients
Variable Male Female p-value
Raised Total Cholesterol > 200mg/dl 247.9 +/- 45.1 (n = 25) 240.2 +/- 30.1 (n = 37) 0.422
Raised TG > 150mg/dl 330.3 +/- 213.3 (n = 23) 273.58 +/- 141.8 (n = 40) 0.21
Raised LDL-C >100mg/dl 136.52 +/- 30.7 (n = 31) 144.93 +/- 32.0 (n = 45) 0.256
Low HDL-C < 40mg/dl 33.61 +/- 4.8 (n = 18) 39.42 +/- 6.3 (n = 50) 0.001
34 Sir Salimullah Med Coll J Vol. 26, No. 1, January 2018
Discussion:
A total 200 newly detected type 2 diabetes mellitus
cases were studied. Out of 200 cases, 82 were males
and 118 were females. Maximum numbers of
patients were in between age group 35 to 45 years
with mean total age 51.69 +/- 11.18 years. The mean
age in this study was slightly less compared with
other studies. Females were more than males in
this study and results were as same as study done
in Malaysia.13
The age of newly detected type 2 diabetic patients
observed to be more than 40 years confirmed earlier
works that proves the age plays a significant role in
the risk of developing type 2 diabetes mellitus
especially after 40 years.14
Most of the patients were obese. Females had higher
BMI (26.33 +/- 4.62) when compared to males (24.72
+/- 3.82). This study has identified higher BMI as
an association with newly detected type 2 diabetes
mellitus and the role of BMI has been previously
described.15
In the present study, plasma glucose concentration
was increased with increasing BMI and the
percentage of poorly controlled diabetes was
increased with increasing BMI which means that
poorly controlled diabetes were more in obese
patients than non-obese patients. It is well
documented that the higher levels of fat prevent
the action of insulin or down regulate its receptors
and so produce insulin resistance state that leads
to type 2 diabetes mellitus.16
Dyslipidemia was found in 74% newly detected type
2 diabetic patients studied, which is similar to
prevalence found in other studies like 79.1% in Lagos
in Nigeria and 80.3% in South Africa. (17-19)
According to National Cholesterol Education
Programme (NCEP), 97% of adults with diabetes
have one or more lipid abnormalities while the
prevalence of diabetic dyslipidemia varies from 25%
to 60% in other studies.20 This variation in
prevalence may be due to differences in BMI and
possibly genetic variations.
A study conducted in Nish tar Hospital, Multan by
Ahmed et al showed that 41% patients with type 2
diabetes had raised total cholesterol (>200mg/dl) and
61.2% patients have raised triglycerides in serum
(>150mg/dl).21 The values of serum TG in this study
are consistent with above mentioned study. The
reason for difference in serum cholesterol values may
be due to difference in the dietary habits of the people
at Multan and Lahore.
Earlier studies have shown that higher triglycerides
and low HDL-C in type 2 diabetes mellitus are
independent on the degree of obesity.(24) This is
inconsistent with this study, while laakso and
pyorala stated that obesity (BMI) effects on serum
lipids and lipoproteins were more in diabetics than
in non-diabetic subjects22 which is consistent with
present study Garg stated that the severity of
obesity is a determinant of lipoprotein abnormalities
in type 2 diabetes besides the degree of glycemic
control.23 There are studies which seem to suggest
that lipoprotein distribution in type 2 diabetes
mellitus is not significantly altered by the degree of
glycaemia.25,27
There was no significant difference between male
and female for raised TC, TG, and LDL-C but low
HDL-C was more in females than in males, which
was statistically significant (p < 0.05). Same results
were found in Malaysian and Iran study26 showed
no significant difference in HDL-C but drawback of
this study was inclusion of patients on hypolipidemic
Table-VI
Correlation of dyslipidemia with respect to glycemic control of diabetes
Variable Correlation with HbA1c Inference (direct or indirect)
Raised Total Cholesterol >200mg/dl r = -0.041; p = 0.753: (n = 62) Inverse but no significant correlation
Raised TG > 150mg/dl r = 0.101; p = 0.431: (n = 63) Direct but no significant correlation
Raised LDL-C > 100mg/dl r = 0.058: p = 0.620; (n = 76) Direct but no significant correlation
Low HDL-C < 40 mg/dl r = 0.005: p = 0.0967 (n = 68) Direct but no significant correlation
Raised TG, raised LDL-C and low HDL-C were directly correlated but raised TC was indirectly correlated with
HbA1C which were statistically not significant (Table-VI)
Role of Lipid Profile And Bmi In The Evaluation of Newly Diagnosed Type 2 Diabetes Mellitus S Saber et al 35
drugs. The prevalence of dyslipidemia was increased
with increasing BMI levels in both sexes, which is
consistent with study of Brown et al .27 The reported
prevalence of dyslipidemia varied from 25 to 60%.28 This wide variation could be attributed to the
studied population and the glycemic control as well
as to the variation in the definition of the “cut off”
values for lipid profile parameters.
Low HDL-C was a common associated finding with
raised serum TG, serum cholesterol, and LDL-C
.The findings of Kannel, et al. Jarrett et al. and
Barette et al.28 were also consistent with this study.
The most frequent dyslipidemia entity in newly
detected type 2 diabetics in this study was reduced
HDL-C (94%) which is similar to previous research
works.29 This same pattern was also observed in
African-American diabetics studied in USA using
ADA criteria.30 Life style, environment, occupation
and level of education may account for these
differences.31
The abnormal lipid profile observed in type 2 diabetes
mellitus is said to be related to insulin resistance
as reported in previous studies, which leads to
increased release of free fatty acids from fatty tissue,
impaired insulin dependent muscle uptake of free
fatty acids and increase fatty acid release to the
hepatic tissue which has been closely associated with
diabetic dyslipidemia, hypertension and enormous
risk to vascular diseases.31
In this study there was no significant difference of
dyslipidemia between good and poor glycemic
control, but one Indian study31 showed significant
difference.
The study has documented several lipid
abnormalities in newly detected type 2 diabetes
mellitus and has pointed to the significance of
diabetic management in the control of overweight
and obesity is of importance.
Conclusion
This study has revealed that BMI abnormalities,
dyslipidemia, uncontrolled glycemic status were
highly prevalent in newly diagnosed type 2 diabetes
mellitus. Most of our patients had dyslipidemia
irrespective of glycemic control. Female patients had
high frequency of low HDL-C, which is an important
risk factor for Coronary Heart Disease. It is therefore
recommended that every type 2 diabetic patients
should have a fasting lipid profile and BMI
measurement and treated appropriately to reduce
the risk of Coronary Heart Disease.
Limitations Of The Study
The present study did not represent the actual
scenario of the status of BMI and lipid profile in
newly diagnosed type 2 diabetic patients in
Bangladesh because the study was conducted in one
tertiary level hospital (Bangladesh Medical College
and Hospital (BMCH) in Dhaka city only.
1 Sample size and duration of the study was short.
2 Treatment outcome cannot be assessed because
of lack of follow up.
Acknowledgements
Department of Medicine and Endocrinology,
Bangladesh Medical College Hospital. I want to
express my deepest respect to all newly diagnosed
type 2 diabetic patients who were participated
spontaneously in this study.
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prevalence of diabetes: estimates for the year 2000 and
projections for 2030. Diabetes Care 2004;27(5):1047-53.
2. Aguilar-Salinas CA, Reyes Rodriguez E, Ordonez-
Sanchez ML, Torres MA, Ramirez-Jimenez S,
Dominguez-Lopez A, et al. Early onset type 2 diabetes:
metabolic and genetic characterization in the mexican
population. J Clin Endocrine 2001;86(1):220-6.
3. Mudaliar S. New frontiers in the management of type 2
diabetes. Indian J Med Res 2007;125(3):275-96.
4. Simon D. Epidemiological features of type 2 diabetes.
Rev Part 2010; 60(4):469-73.
5. Delavari A, Alikhani S, Nili S, Birjandi RH, Birjandi F.
Quality of care of diabetes mellitus type 2 patients in
Iran. Arch Iran Med 2009;12(5):492-5.
6. Turner RC, Millns H, Neil HA, Stratton IM, Manley SE,
Matthews DR, et al. Risk factor for coronary artery
disease in non insulin dependent diabetes
mellitus:United Kingdom Prospective Diabetes study.
BMJ 1998; 316(7134):823-8.
7. Tzoulaki I, Molokhia M, Curcin V, Little MP, Millett CJ,
Ng A, et al. Risk of cardiovascular disease and all cause
mortality among patients with type 2 diabetes
prescribed oral antidiabetes drugs: retrospective cohort
study using UK general practice research database.
BMJ 2009; 339:b4731.
8. Kraemer H, Berkowitz RL, Hammer LD.
Methodologicaldifficulties in studies of obesity, I:
measurement issue. Ann Behav Med 1990;12:112-118.
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9. Must A, Dallal GE, Dietz WH. Reference data for obesity:
85th and 95th percentiles of body mass index (wt/ht2)
and triceps skin fold thickness. Am J Clin Nutr
1991;53:839-846.
10. Willett WC. Nutritional Epidemiology. New York:
Oxford university press. 1996;217-244.
11. Mgonda YM, Ramaiya KL, Swai AB, McLarty DG, Alberti
KG. Insulin resistance and hypertension in non-obese
Africans sin Tanzania. Hypertension, 1998; 31(1):114-
18.
12. Hussain A, Vaaler S, Sayeed MA, et al. Type 2 diabetes
and impaired fasting blood glucose in rural Bangladesh:
a population based study. Eur J Public Health 2007; 17:
291-6.
13. Aliqaisblebil et al. Pattern of dyslipidemia in type 2
diabetic patients in the state of penang, Malaysia. Int J
Pharm Pharm Sci, 2012;4:305-08.
14. Tagoe DNA, Amo-Kodieh P; Type 2 diabetes mellitus
influences lipid profile of diabetic patients. Ann Biol
Res. 2013;4(6):88-92.
15. van Tilburg J, van Haeften TW, Pearson P, Wijmenga
C. Defining the genetic contribution of type 2 diabetes.
J Med Genet 2001;38(9):569-78.
16. El-Hazmi MAF, Al-Swailem AR, Warsy AS, Al-Meshari
AA, Sulaimani AA, Al- Swailem AM. Lipids and related
parameters in Saudi type II diabetes mellitus patients.
AnnSaudi Med 1999; 19:304-307.
17. Titty FK; Glycemic control, dyslipidemia and metabolic
syndrome among recently diagnosed diabetes mellitus
patients in Tamale Teaching Hospital, Ghana. West Afr
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patients attendind Igbinedion hospital and medical
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Characterization of lipid parameters in diabetes mellitus
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Sievert, D.A. Pollock, et al., 2008. NHSN annual update:
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J, Puukka P. Serum lipids, lipoproteins and
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1982. Plasma lipids and diabetes mellitus in an adult
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118.
Introduction
Coronary artery disease (CAD) is a major cause of
death and disability in both developed and developing
countries1. The burden of CVD, especially the CAD
is increasing at a greater rate in South Asia than
in any other region globally. Among the NCDs, CVD
is probably the most important cause of mortality
and morbidity in Bangladesh2. According to the
Health Bulletin 20173, CVDs have an age-
standardized mortality rate of 411 per 100,000
people. CVDs and hypertension have been showing
an increasing trend. Advancing age, male sex,
Association of Microalbuminuria with Severity of
Coronary Artery Disease in Non-diabetic
Myocardial Infarction Patients - A ReviewMd. Shafiqur Rahman Patwary1, Md. Daharul Islam2, Ranajit Sen Chowdhury3, Mohammad
Mamoon Islam4, Md. Abdul Kader Akanda5, Durba Halder6
Abstract:
Coronary artery disease (CAD) is a major cause of death and disability in both developed & now
in developing countries. CAD is a multifactorial disorder with several different risk factors.
Advancing age, male sex, hypertension, diabetes mellitus, cigarette smoking and dyslipidemia
are the major and independent well known risk factors for CAD.Atherosclerosis, chronic
inflammation and endothelial dysfunction are major driving force underlying the initiation of
atheromatous plaques, their unstable progression.Conditions which are accompanied with
impaired endothelial function (for example, hypertension, dyslipidaemia, vascular disease,
inflammation, etc) also may present as impaired glomerular endothelial function (changed
permeability), such that microalbuminuria (MAU) represents a state of vascular endothelial
dysfunction, with the kidney being a window to the vasculature in other tissue parts. So,
endothelial dysfunction due to chronic inflammation in atherosclerosis has been suggested as
association of microalbuminuria with myocardial infarction patients and it is considered
indicator of severity of vascular dysfunction. Studies have shown that microalbuminuria (MAU)
is an independent risk factor for cardiovascular diseases.
Key Words: Microalbuminuria, Coronary artery disease and Myocardial Infraction.
(Sir Salimullah Med Coll J 2018; 26: 37-40)
1. Associate Professor Cardiology, National Institute of
Cardiovascular Disease, Dhaka.
2. Associate Professor Medicine, Sir Salimullah Medical
College, Dhaka.
3. Associate Professor Medicine, Sir Salimullah Medical
College , Dhaka
4. Sir Salimullah Medical College, Dhaka.
5. Professor and Head of the department of Cardiology,Sir
Salimullah Medical College, Dhaka.
6. Associate Professor, Sir Salimullah Medical College,
Dhaka.
Address of Correspondence: Dr. Md. Shafiqur Rahman
Patwary, Associate Professor Cardiology ,National Institute
of Cardiovascular Disease, Dhaka
hypertension, diabetes mellitus, dyslipidemia and
cigarette smoking are the independent risk factors
for CAD4, but they do not entirely explain the
variation in cardiovascular disease incidence and
mortality. Therefore, additional risk factors have
been proposed to better identify patients potentially
at risk for CAD, and urinary albumin is a promising
candidate. Since the first description in 19745, the
presence of subclinical increases in urinary albumin
excretion has attracted attention, but much remains
to be understood about the role of microalbuminuria
(MAU) in non-diabetic individuals.
Myocardial infarction (MI)
Myocardial infarction (MI) is a major cause of
mortality and morbidity worldwide. Each year, an
estimated 785,000 persons will have a new MI in
the United States alone, and approximately every
minute an American will succumb to one. In
addition, MI has major psychological and legal
implications for patients and the society and is an
important outcome measure in research studies.
The prevalence of MI provides useful data regarding
the burden of coronary artery disease and offers
insight into health care planning, policy, and
resource allocation. The Third Universal Definition
of Myocardial Infarction (MI) expert consensus
document was published in October 2012 by the
global Myocardial Infarction Task Force15.
The detection of a rise and/or fall of cardiac
biomarkers, with at least one of the values being
elevated (>99th percentile upper reference limit, or
URL), is central to the third universal definition of
MI. The highly sensitive and specific cardiac
troponin (cTn) is the preferred biomarker of
myocardial necrosis. In addition, one of the five
following predefined criteria should be satisfied
before a diagnosis of MI is made: (1) symptoms of
myocardial ischemia; (2) new (or presumably new)
significant ST-segment/T-wave changes or left
bundle branch block; (3) development of pathological
Q waves on ECG; (4) new loss of viable myocardium
or regional wall motion abnormality by imaging;
(5) identification of intracoronary thrombus by
angiography or autopsy. The third global MI task
force maintains that the electrocardiogram (ECG)
is an integral part of the diagnostic work-up in
patients with suspected MI and should be obtained
and interpreted in a timely manner.
Clinical classification of myocardial infarction: For
the sake of immediate treatment strategies, such
as reperfusion therapy, it is usual practice to
designate MI in patients with chest discomfort, or
other ischemic symptoms that develop ST elevation
in two contiguous leads, as an ‘ST elevation MI’
(STEMI). In contrast, patients without ST elevation
at presentation are usually designated as having a
‘nonST elevation MI’ (NSTEMI). Many patients
with MI develop Q waves (Q wave MI), but others
do not (nonQ MI). Patients without elevated
biomarker values can be diagnosed as having
unstable angina15.
Albuminuria
In general, urinary albumin excretion is classified
as normoalbuminuria (<30 mg/day or ACR <30 mg/
g), microalbuminuria (30–300 mg/day or ACR 30–
300 mg/g), and macroalbuminuria (>300 mg/day or
ACR >300 mg/g)16.
Discussion
There is an extensive literature supporting the role
of inflammation in coronary artery disease (CAD).
Inflammatory cells, inflammatory proteins, and
inflammatory responses from vascular cells play a
pivotal role in the pathogenesis of various stages of
atherosclerosis, including the initiation and
progression of atheroma, plaque instability and
rupture. The vascular endothelium is subject to
injury from numerous potential insults, such as
hemodynamic forces, oxidative stress, and modified
lipoproteins. Because of the central role of
inflammation in atherogenesis, plaque stability and
restenosis after PCI, several clinical studies have
targeted inflammatory factors as potential markers
for cardiovascular risk assessment6. The myocardial
tissue-specific biomarker cardiac troponin, high-
sensitivity assays for cardiac troponin, and heart-
type fatty acid binding potential help diagnose
myocardial infarction (MI) in the early hours
following symptoms. Inflammatory markers such
as growth differentiation factor-15, high-sensitivity
C-reactive protein, fibrinogen, and uric acid predict
MI and death7. Recent study reported that there is
a strong relationship between the degree of
albuminuria and extent and complexity of CAD in
patients with type 2 DM or non DM and this
association is independent of traditional risk
factors8,9.
Normal urinary albumin excretion is <30 mg/day.
The term MAU is defined as urinary albumin levels
equal to 30 - 300 mg/24 h in 24-h urine collection or
albumin/creatinine ratio (ACR) of > 30 - 300 mg/g
creatinine in random spot urine sample16. It is a
surrogate marker for endothelial dysfunction and
is independently associated with atherosclerosis in
diabetic and in non diabetic patients9. Endothelial
dysfunction precedes morphological atherosclerotic
alterations and has a major action in lesion progress
and simultaneously affects the glomerular
endothelial dysfunction. Conditions which are
accompanied with impaired endothelial function (for
example, DM, hypertension, vascular disease,
inflammation, and insulin resistance) also may
present as impaired glomerular endothelial
function, such that micro albuminuria represents
a state of vascular endothelial dysfunction, with the
kidney being a window to the vasculature in other
tissue parts10. In summary patho-physiological
processes associated with MAU are manifold: Local
changes in the kidneys such as increased
intraglomerular capillary pressure, increased
shunting of albumin through glomerular membrane
pores and loss of glomerular membrane charge;
systemic changes include activation of inflammatory
38 Sir Salimullah Med Coll J Vol. 26, No. 1, January 2018
mediators, increased transcapillary escape rate of
albumin and vascular endothelial dysfunction9. So
microalbuminuria developed in MI patients and
albuminuria may be important factors determining
the occurrence and the severity of CAD.
In healthy individuals, the normal range for urinary
albumin excretion rate is less than 30 mg/day.
Urinary albumin excretion rate is known to increase
with exercise, oral protein intake, urinary tract
infection, and pregnancy. Albuminuria of 300 mg/
day or more indicates nephropathy9.Data from
several studies over the last two decades have
demonstrated that MAU is not only a predictor of
diabetic complications but also a powerful
independent risk factor for coronary artery disease
(CAD), moreover, MAU predicts development of
ischemic cardiovascular events related to the
development of atherosclerosis10. Micro-albuminuria
is prescient unrelated to conventional risk elements
of cardiovascular diseases and entire reasons of
death in diabetes or hypertension patient groups
and in the general population11. It is gaining
importance as a marker of atherogenic milieu and
indicates the target organ damage and can be a
valuable tool in screening and identification of
patients with cardiovascular disease12. In a study
reported that patients with MAU have more severe
angiographically detected CAD than those without
MAU, and MAU exhibits a significant association
with the presence and severity of CAD1.
Another study demonstrated that patients with
MAU had much greater atherosclerotic burden in
the form of multivessel CAD than patients without
it, and this was especially true in patients with overt
diabetes. The mechanism of accelerated
atherosclerosis in MAU is uncertain. Abnormal
vasodilation, endothelial dysfunction, inflammation,
insulin resistance, or abnormal coagulation may be
involved13. Another study reported that significant
Microalbuminuria was found in patients of
myocardial infarction who were non diabetic and
non-hypertensive. The mortality and morbidity in
short term outcome was also significantly increased
in patients having MAU, indicating the significance
of Microalbuminuria as powerful prognostic
biomarker14. So it is concluded that micro-
albuminuria may have an association with
myocardial infarction in absence of traditional risk
factors like Diabetes and Hypertension.
Conclusion
Multiple studies shows significantly high
microalbuminuria levels found in non diabetic MI
patients. The results of the various studies indicate
that non diabetic patients with microalbuminuria
have more extensive and complex angiographic CAD
compared to those without microalbuminuria. Since
the MAU is simple and relatively inexpensive
investigation, early identification of MAU may
influence the aggressiveness of management and
ultimately the outcome of disease.
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Microalbuminuria: Correlation With Prevalence and
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disease in diabetic patients. Mymensingh Med J 22: 353-
357.
11. Sharma S, Ghalaut V, Dixit R, Kumar S, George P
(2013) Microalbuminuria and C-reactive protein as a
predictor of coronary artery disease in patients of acute
chest pain. J Cardiovasc Dis Res 4: 37-39.
12. Sukhija R, Aronow W, Kakar P, Garza L, Sachdeva R,
Sinha A, et al. Relation of Microalbuminuria and
Coronary Artery Disease in Patients With and Without
Diabetes Mellitus. Am J Cardiol 2006;98: 279 –281
13. Memon AG, Kolachi M (2015) Relationship of
Microalbuminurea in Non-Diabetic and Non-
Hypertensive Patients with Acute Myocardial
Infarction. J ClinExpCardiolog 6:403. doi:10.4172/2155-
9880. 1000403
14. Thygesen et el (2012) Third universal definition of
myocardial infarction.
15. Tietz textbook of Clinical Chemistry and Molecular
Diagnostics-4th edition.
40 Sir Salimullah Med Coll J Vol. 26, No. 1, January 2018
Outpatient Laparoscopic Cholecystectomy: Five
Years Experience in Hepatobiliary & Pancreatic
Surgery Division in BSMMUMd. Nur-E-Elahi1, Bidhan C Das2, Md. Saief Uddin3, Sadia Imdad4, Md. Mohsen Chowdhury5,
Zulfiqur Rahman Khan6
Abstract
Background: Outpatient Laparoscopic Cholecystectomy (OLC) performed in Hepatobiliary &Pancreatic Surgery Division of Bangabandhu Sheikh Mujib Medical University (BSMMU),
indicated mainly for non-complicated gall stone disease and gall bladder polyps should
influence tertiary hospitals in the country to spread out this practice.
Method: During the five years period from July 2013 to June 2018, Laparoscopic Cholecystectomy(LC) was performed in the evening OT of Hepatobiliary & Pancreatic Surgery Division of
Department of Surgery of Bangabandhu Sheikh Mujib Medical University (BSMMU) on
Outpatient basis. Established inclusion criteria, the one that is followed worldwide for ‘Day
Case’ LC was followed for patient selection for Outpatient Laparoscopic Cholecystectomy (OLC)which includes: ASA (American Society of Anesthesiology) classes I and II; age: 18 – 60 years;
body mass index (BMI) < 30 kg/m2; patient acceptance and cooperation (informed consent).
Patients suffering from acute cholecystitis or who have/ ‘had-previous- history-of’ Jaundice
and preoperative abnormal LFTs were deemed not suitable for having the surgery in an outpatientsetting. All the OLC was performed by faculty members or under direct supervision by senior
residents. Peroperative details were noted and every resected sample was sent for
histopahotlogical examination. Discharge was aimed to be within 36 hours of performing the
surgery and 1st follow-up was advised on 7th post-operative day (POD) in the HepatobiliaryOutdoor and 2nd follow-up at 3 months after operation. There after follow-up schedule was
tailored according to the status of the patient. Evaluation was done about the success rates of
doing OLC and outcome of the procedure (readmissions, morbidity and mortality, further
treatment, overall satisfaction, safety etc.)
Results: A total of 124 patients underwent OLC with 116(93.5%) patients suffering from
symptomatic gallstone disease, 5(4.03%) from asymptomatic gallstone disease and 3(2.42%)
from gall bladder polyp. Male: Female ratio was 1: 2 with a mean age of 42±13.3. Pre anestheticcheckup showed 91(73.4%) patients were in ASA II class and 33(26.6%) were in ASA I. Conversion
rate was 0%. Post-Operative Nausea & Vomiting (PONV) was the most concerning issue in the
immediate post-operative period and 28(22.6) % cases experienced PONV. All cases got discharged
within 36 hours. In the 1st Follow-up at 7th POD 23 (18.5%) cases were found to have minorcomplications; port-site serous discharge in 9(7.25%) cases, Pain in the right upper quadrant of
abdomen referred to right shoulder tip in 12(9.7%) cases and abnormal LFTs in 2(1.61%) cases;
all of which resolved spontaneously. 1 case was readmitted due to retained stone in the CBD
which was later treated with ERCP stone extraction. 110(88.7%) cases were overall satisfied bythe treatment provided through OLC.
Conclusions: The study definitely speaks for OLC to be a clinically effective low-cost, low-
hazard treatment procedure for carefully selected patients between age 18-60 when performed
in a teaching hospital by or in presence of faculty surgeons.
Key Words: OLC, Outpatient Surgery, Laparoscopic Surgery.
(Sir Salimullah Med Coll J 2018; 26: 41-46)
1. Assistant Professor, Department of Hepatobiliary, Pancreatic & Liver transplant Surgery, Bangabandhu Sheikh Mujib
Medical University (BSMMU), Dhaka
2. Associate Professor, Department of Hepatobiliary, Pancreatic & Liver Transplant Surgery, Bangabandhu Sheikh Mujib
Medical University (BSMMU).
3. Assistant Professor, Department of Hepatobiliary, Pancreatic & Liver transplant Surgery, Bangabandhu Sheikh Mujib
Medical University (BSMMU)
4. Junior Consultant, Department of Surgery, Shaheed Suhrawardy Medical College Hospital, Dhaka.
5. Professor, Department of Hepatobiliary, Pancreatic & Liver transplant Surgery, Bangabandhu Sheikh Mujib Medical
University (BSMMU).
6. Chairman, Department of Hepatobiliary, Pancreatic & Liver transplant Surgery, Bangabandhu Sheikh Mujib Medical
University (BSMMU).
Correspondence: Dr. Md. Nur-E-Elahi, Assistant Professor, Department of Hepatobiliary, Pancreatic & Liver Transplant
Surgery, Room # 914, Block ‘C, Department of Hepatobiliary, Pancreatic & Liver Transplant Surgery, Bangabandhu Sheikh
Mujib Medical University (BSMMU), +8801713130501; nureelahi@outlook.com
Introduction
Laparoscopic cholecystectomy (LC) is the “Gold
Standard” surgical technique accepted worldwide
for managing gall stone disease and simple gall
bladder polyps.1,2 In recent years, advancement in
technical skills and anesthetic procedures have
rendered this procedure to be performed in an
outpatient basis, where proper patient selection and
judicial attempt at surgery can make it an safe and
acceptable approach, advocated by many authorities.3-8.
Key factors to be noted while thinking of performing
OLC are immediate post-operative complications
like postoperative nausea & vomiting (PONV) which
is found to be higher in many series and chance of
presence of some complications like bleeding and
bile duct injury. However, with careful case selection
and by adopting meticulous surgical techniques OLC
can be safely done.8-10 Besides clinical effectiveness
and cost saving, OLC also favors treatment in
resource scarce settings where limited number of
hospital beds are mostly occupied.9-14.
In Bangladesh, outpatient cholecystectomy is
gradually gaining acceptance from surgeons and
patients. Likewise, in our Hepatobiliary &
Pancreatic Surgery Division with limited bed facility
and a very long queue of patients to-be-admitted,
we opted to perform OLC with proper patient
selection and surgical technique. The aim of the
study is thus to evaluate the outcome of outpatient
LC (OLC) in a university hospital, confirming the
safety and effectiveness.
Materials and Methods
Hundred and Twenty-four patients who underwent
OLC for gall stone disease and gall balder polyp with
curative intent between July 2013 and June 2018
were carefully analyzed. [Patient Selection]
Patients with USG-documented Gall Stone Disease
or Gall Bladder Polyp were selected for OLC with
utmost care, following a strict inclusion criteria: i)
ASA (American Society of Anesthesiology) physical
status classification classes I and II. ii) Age between
18 and 60. iii) Body Mass Index (BMI) < 30 kg/m2
iv) Patient who accepted OLC and consented for
having OLC. Acute Cholecystitis and jaundice or
previous history of jaundice or previous history of
altered Liver Function Tests (LFTs) was the
exclusion criterion due to possible need of increased
hospital stay and also due to the increased chance
of conversion. Similarly patients with previous
abdominal surgery and dilated bile ducts at USG
were also excluded. [Patient Assessment &
Preparation] All patients were assessed uniformly
very carefully before surgery to check compliance
with the inclusion criteria and rechecked again
during preanesthetic checkup, the day before
surgery, by checking complete blood count, random
blood sugar, serum creatinine, LFTs ( total bilirubin,
alanine transaminase, alkaline phosphatase,
prothrombin time) chest x-ray, pulmonary function
test when required, ECG and echocardiogram. Oral
midazolam 7.5 mg was prescribed in the night before
surgery to reduce stress and patients were advised
to attend the hospital in the morning for rechecking
of the status. Patients were maintained nothing per
oral 6 hours prior to the procedure and was asked
to attend the evening OT. [Per-operative Care]
Broad Spectrum Antibiotic (as per Antibiotic
Guideline of Bangabandhu Sheikh Mujib Medical
University; from December 2015), single dose was
given detected induction. Standard 4-port
Laparoscopic Cholecystectomy was performed while
ensuring Critical View of Safety (CVS) to avoid
bleeding or bile duct injury; Calot’s identification
was documented taking picture in each cases.
Antegrade (Calot’s-first) dissection was approached
preferably. In cases where adhesiolysis, bile leakage
from gall bladder wall or bleeding dictated- an
appropriate sized silicon drain was kept
laparoscopically in the Morrison’s pouch. Analgesic
soln. (10 ml of 0.5% bupivacaine admixed with 10
ml Normal Saline) was infiltrated in the skin, fascia
and muscle layer of the trocar sites before closure.
Duration of operation was noted duly.
[Postoperative Care] Intravenous Broad
Spectrum Antibiotic (as per Antibiotic Guideline of
Bangabandhu Sheikh Mujib Medical University;
from December 2015) as per dosage schedule was
given in the night of operation and till patient is
allowed oral liquid when oral formulation was
prescribed in the postoperative period. Post-
Operative Nausea & Vomiting (PONV) was assessed
and noted; any further subjective complaints were
also duly noted in each cases; Postoperative Pain
was given due respect; Inj. Pethidine at 1-2mg/kg
body weight was given to each patient ,in the
recovery room,when the patients came around and
one single dose of diclofenac suppository was given
at night.
42 Sir Salimullah Med Coll J Vol. 26, No. 1, January 2018
All patients were ensured of general care in the
following morning of operation ( oral care, sips of
water, respiratory exercise, early mobilization) in
the post-operative ward. Awake, oriented, mobilized
patients who are well tolerating oral fluids; passing
adequate urine; having no pain (responsive to oral
analgesics), no nausea and vomiting and with stable
general condition seen in the evening of 1st POD
(after 24 hours of OLC) were given discharge with
advice to attend 1st Follow-up in the Hepatobiliary
Outdoor with CBC and LFTs after 7 days. Follow-up
was done by clinical examination and reported
investigations on an outpatient basis one week and 3
months after operation. Thorough Evaluation was
done about the success rates of OLC including
postoperative outcome and patient’s overall
satisfaction.
Results
Table-I
Demographic data n (%)
Age (years) 42±13.3
Female 83/(66.9)
Male 41/(33.1)
ASA Grade
ASA- I 33/(26.6)
ASA-II 91 /(73.4)
Indication for OLC
Symptomatic gallstones 116/(93.5)
Gallbladder polyp 3/(2.42)
Asymptomatic gallstone 5/(4.03)
Mean Operating time(Minute) 43±15.1
Conversion Rate 1.61%
Drains Used 17(13.7%)
Successful Discharge within 36 hours 115(92.7%)
Postoperative follow up till following morning
Nausea & vomiting 28(22.6%)
Postoperative Complications
Serosanguinous discharge 9(7.25%)
from umbilical trocar site
Shoulder tip pain 12(9.7%)
Abonormal LFT 2(1.61%)
Bile leakage 0(0%)
Readmission rate 1(0.81%)
Causes of readmission
Retained stone in CBD 1(0.81%)
Patients satisfaction at 110(88.7%)
1 week follow-up
Discussion
Newer anesthetic tools and techniques in
collaboration with skillful surgical techniques have
made OLC a popular practice in the advanced
countries. Many studies have shown that in proper
setting OLC can be both safe and cost-effective.15-
18 To ensure this proper setting implementation of
standard inclusion criteria for OLC is a must. In
our series attaching to the strict inclusion criteria
was associated with a 92.7% discharge rate in the
following morning.
A total of 124 patients underwent OLC during the
five years period while a total of 496 laparoscopic
cholecystectomies were performed, giving the
inclusion rate of OLC to be 25%. Female
preponderance prevails with 1:2 ratio, the mean age
of presentation 42±13.3 (range 24-58 years). The
findings correlates very well with other series.19-27
Mean operative time for OLC in our series is 43±15.1
minutes. The time taken for senior residents to
perform meticulously was higher than the cases
done by faculty surgeons. Though the operative time
correlates well with the reported studies yet with
experience this time can be lessened. 25-7
In our series, most of the patients i.e., 116(93.5%)
patients were suffering from symptomatic gallstone
disease, 5(4.03%) from asymptomatic gallstone
disease and 3(2.42%) from gall bladder polyp. The
finding is profoundly similar with reported studies;
the reason for this is that, in most of the studies
where OLC is evaluated the almost similar inclusion
criteria is followed.15-27
No conversion to open cholecystectomy was needed
and no mention worthy peroperative complications.
OLC’s were either performed by trained surgeons
or under direct supervision of trained senior
surgeons. Strictly following standard criteria for
selection during inclusion rendered this significantly
reduced conversion rate which is true for all sorts
of Laparoscopic Cholecystectomy.18
Post-Operative Nausea & Vomiting (PONV) was the
most concerning issue in the immediate post-
operative period and 28(22.6) % cases experienced
PONV. All cases got discharged within 36 hours.
In the 1st Follow-up at 7th POD 23 (18.5%) cases
were found to have minor complications; port-site
Outpatient Laparoscopic Cholecystectomy: Five Years Experience Md. Nur-E-Elahi et al 43
serous discharge in 9(7.25%) cases, Pain in the right.
Upper quadrant of abdomen referred to right.
Shoulder tip in 12(9.7%) cases and Abnormal LFTs
in 2(1.61%) cases; all of which resolved
spontaneously. 1 case was readmitted due to retained
stone in the CBD which was later treated with
ERCP stone extraction. 110(88.7%) cases were
overall satisfied by the treatment provided through
OLC.
124 patients were selected for OLC (Outpatient
laparoscopic cholecystectomy) during the period
when a total number of 496 laparoscopic
cholecystectomies were performed, giving a inclusion
rate of 25% for OLC. 66.9% patients were female.
Mean age of the sample was 42±13.3 (range 24–64)
years. Mean operative time for OLC was 43±15.1
minutes that correlates very well with other studies.19-27
Seventeen patients (13.7%) had drain inserted.
Moderate to severe peri-cholecystic adhesion was
present in 9 cases and accidental Gall Bladder injury
happened in 8 cases which demanded for drains as
per the judgment of the performing surgeons. In all
cases drain output was carefully measured in the
following morning when in all cases only minimal
collection was found and subsequently drains were
removed. Placement of drain in our case is higher
than published studies.21-26 The performing
surgeons mindset to-be-in-the-safe-side might be the
reason behind this higher rate of drain insertion.
Inadvertent or missed bleeding from the liver bed
or slipped cystic artery or bile duct injury are trivial
concerning complications after LC which is
suggested to be avoided by adopting proper dissection
technique; in our series standard dissection
technique was ensured and there was no
postoperative bleeding or bile duct injury.15
In the 1st Follow-up at 7th POD 23 (18.5%) cases
were found to have minor complications; port-site
serous discharge in 9(7.25%) cases, Pain in the right.
Upper quadrant of abdomen referred to right.
Shoulder tip in 12(9.7%) cases and Abnormal LFTs
in 2(1.61%) cases; all of which resolved
spontaneously, gradually within 3 weeks with
continued oral antibiotic and oral analgesics and
follow-up.
Readmission rate found in other series is around
2% in several studies, 14, 19, 20 while in our series
only one patient (0.81%) developed jaundice with
in 7th POD and in USG was found to have a retained
stone in the CBD. Her preoperative LFTs’ and
imaging did not show evidence of any ductal
dilatation. She was readmitted and underwent
ERCP stone extraction.
Post-Operative Nausea & Vomiting (PONV) is the
most concerning issue in the immediate post-
operative period after OLC.21-24 PONV associated
with ambulatory surgery accounts for 0.1 - 0.2%
of unanticipated admissions 25. In our series
somewhat high rate of PONV is noted; 28(22.6) %
cases experienced PONV and intravenous
ondansetron single dose was given to combat PONV.
Marinis et al21 , in their series of 110 cases of day
case laparoscopic surgery reported no case
suffering from PONV. Namely three protocols ; i)
propofol for induction ii) avoidance of NO iii)
prophylactic ondansetron ( 4 mg IV, at the end of
LC) and adequate hydration favored Marinis Et
al. to combat PONV.
Postoperative pain is a key influential factor for the
success of OLC, proper pain control is essential and
obligatory for patient satisfaction.26Various drug
regimen is proposed by many authors to combat
postoperative pain to ensure early mobilization and
satisfaction for the outpatient procedures.27-29 Like
many other studies, trocar site infiltration of local
anaesthetics was found quite effective to combat
port-site pain.16,6,10-12,30,31, Inj. Pethidine at 1-
2mg/kg body weight; given in the postoperative
ward when the patients came around and one single
dose of diclofenac supposirory given at night was
sufficient for post-operative pain management in
our series.
Hundred and fifteen patients (92.5%) were
discharged within 36 hours of performing OLC. 9
cases had a prolong stay at the post-operative ward
due to PONV and pain abdomen but none required
admission and all cases were discharged within 72
hours.
Patient satisfaction rate is the key variable for the
study and in our series overall patient satisfaction
rate was 88.7%. In reported series satisfaction rate
between 85%-90% is observed worldwide; 3-7 which
correlates very well with our study and is the most
significant components of success of OLC.
44 Sir Salimullah Med Coll J Vol. 26, No. 1, January 2018
Conclusion
Our study demonstrates outpatient Laparoscopic
Cholecystectomy (OLC) to be an admissible
procedure for treating gall stone disease and gall
bladder polyp in tertiary hospitals of the country.
The patient satisfaction can approach acceptable if
strict inclusion criteria, standard dissection
(operative) technique and judicial perioperative
measures are practiced.
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46 Sir Salimullah Med Coll J Vol. 26, No. 1, January 2018
Review Article
Procalcitonin: An Early Marker for Diagnosis of
Neonatal SepsisJesmin Akter1, Sunirmal Roy2, Rehena Akter3, Nasir Hossain4, Md. Moniruzzaman Bhuiyan5, Md. Zahir Uddin6,
Md. Abdul Mannan7
Abstract
Sepsis is the common cause of neonatal mortality. It is responsible for about 30-50% of the total
neonatal deaths in developing countries. It is estimated that up to 20% of neonates develop sepsis
and approximately 1% die of sepsis related causes. Sepsis related mortality is largely preventable
with timely recognition, rational use of antimicrobial therapy, aggressive supportive care and
preventive measure. Early diagnosis of neonatal sepsis is difficult solely on the basis of physical
finding because signs are not specific and may be absent when the infection is identified just after
delivery. Definitive diagnosis of neonatal sepsis is based on blood culture which takes at least 24-
48 hours and often falsely negative. Several serum biomarkers have been identified in recent years
with potential uses to help diagnose local and systemic infections; differentiate bacterial from
viral or fungal infection and guide antibiotic therapy. Currently, there are at least 178 serum
biomarkers that have potential role in the management of patients with infection and 34 have been
studied specifically for diagnosis of sepsis. The serum biomarker that has been most extensively
studied recently is procalcitonin, current literature suggest that it may prove to be most useful
biomarker for infection. This review provides an overview of different published studies that
assessed procalcitonin as an early marker of infection than more frequently used CRP.
Key Words: Sepsis, Procalcitonin, review
(Sir Salimullah Med Coll J 2018; 26: 47-51)
1. Assistant Professor (Neonatology), Sir Salimullah Medical College, Dhaka
2. Associate Professor (Neonatology), Sir Salimullah Medical College, Dhaka
3. Assistant Professor (Radiology & Imaging), Jessore Medical College, Dhaka
4. Associate Professor (Paediatric Nephrology), Sir Salimullah Medical College, Dhaka
5. Assistant Professor (Paediatrics), Sir Salimullah Medical College, Dhaka
6. Assistant Professor (Neonatology), Dhaka Medical College, Dhaka
7. Associate Professor (Paediatrics), Royal College of Medicine Perak, Universiti Kuala Lumpur
Address of correspondence: Dr Jesmin Akter, Assistant Professor (Neonatology), Sir Salimullah Medical College,
Dhaka, E-mail: doctor.jesmin@gmail.com
Introduction
Procalcitonin (PCT), a precursor of calcitonin is
a 116 amino acid protein secreted by C cells of thyroid
gland in normal situation and is the propeptide of
calcitonin hormone and has no hormonal activity.1Its level may increase during septicaemia,
meningitis, pneumonia and urinary tract infection.
Macrophage and monocytic cells of various organ
such as liver, lungs, kidney, adipocytes and muscle
cells are the potential sources of procalcitonin.2,3It
was initially described as a potential marker of
bacterial sepsis.4 It was shown in healthy volunteers
that PCT was detectable in the plasma two hours
after the injection of endotoxin, increasing to a
plateau in 6-8 hours and then decreasing to normal
after 24 hours.5,6Procalcitonin is degraded by specific
protease into three peptides namely kalacelcin,
calcitonin and aN- terminal fragment and half life
of procalcitonin is 25 and 30 hours. In severe
bacterial infection and sepsis, macrophage and
monocytic cells of various organs such as liver are
believed to be involved in the synthesis and release
of PCT in response to bacterial infections.7 There
are some evidence that procalcitonin is more specific
for bacterial infections with serum level rising and
falling more rapidly in bacterial infection. Serum
level of procalcitonin were recognized to be elevated
in patient with infection in early 1990 and since
that time numerous studies have investigated the
potential roles of procalcitonin for diagnosis and
management of local and systemic infection.8,9 Its
level may increase during septicemia, meningitis,
pneumonia and urinary tract infection. Macrophages
and monocytic cells of various organs, such as liver,
lungs, kidney, adipocytes and muscle cells are the
potential sources of PCT in severe bacterial infection
and sepsis.10,11 In bacterial infection, PCT increases
from concentrations in the picogram range. In
normal adult PCT level is 250 pg/ml and in normal
neonates up to 48 hours after birth it is 600 pg/ml.
But in local or systemic bacterial infection possible,
PCT value is ³ 250 to <500 pg/ml and progress to
sepsis it is > 500 to <2000 pg/ml and in sepsis the
value is ³ 2000 to < 10,000 pg/ ml and in septic
shock, PCT value is > 10,000. The increase levels
of PCT often correlates with the severity of disease
and mortality. Increases in PCT occur more rapidly
than increases in CRP. Procalcitonin can be
detected in the plasma 2 hours after the injection
of endotoxins. Within 6-8 hour PCT concentrations
rise and a plateau is reached after approximately
12 hour. 6
Compare of PCT with CRP
C- reactive protein (CRP) has been used for many
year as marker of infection but its specificity has
been challenged 12. Procalcitonin has been proposed
as a more specific and better prognostic marker than
CRP although its value has also been challenged13.
Compared to CRP, PCT has better diagnostic and
prognostic value and will clearly distinguish viral
and bacterial infection.C-reactive protein (CRP) is
a good marker for diagnosis of neonatal sepsis.
Estimation of CRP levels are potentially useful in
this respect. CRP is the most extensively used
and investigated acute phase reactant.14,15,16 and
synthesized by the liver. It can be considered as
a specific but late marker of neonatal infection .17
It cannot be used to differentiate between
bacterial and other infection. CRP level rises 12-
24 hours of infection and remain elevated for 3-7
days. It is a disadvantage that CRP increases
after 48 hours of infection.19 Elevated CRP levels
are seen in infection , in autoimmune disease , in
surgery, muconium aspiration syndrome and
recent vaccination.17,18
Procalcitonin has been proposed as a marker of
bacterial sepsis in critically ill patients.
Procalcitonin levels increase in severe sepsis and
its plasma concentration is related the patients
clinical condition. Serum procalcitonin levels
appeared to correlate with the severity of microbial
invasion.19
In localized bacterial infections, severe viral
infections and inflammatory reactions of
noninfectious origin do not or slighty increase
procalcitonin level.20The increase level of
procalcitonin (PCT) has been observed before the
rise in CRP.21 The unique feature that PCT is
increase in bacterial and fungal infections but
remain unchanged even in severe viral infections
and other inflammatory diseases, make PCT
attractive as a potential diagnostic variable for the
diagnosis of bacterial infection.22 The
measurement of procalcitonin is reliable and
so can be used for early and rapid diagnosis
of systemic infection in neonates in a short
period of time. This review provides an overview
of different studies published in different journal
that assessed PCT as a marker of bacterial
infection and seeks to answer the question whether
PCT is more reliable and an early marker for
bacterial infection than more frequently used CRP.
Related previous works
Procalcitonin as an early diagnostic marker of sepsis.
The evaluation of tests for neonatal sepsis is
important because the infection may present a very
serious threat to the baby. There is an urgent need
to know whether the baby has sepsis to initiate
treatment as quickly as possible. Confirmation of
the diagnosis may take time and diagnostic tests
are used to obtain a rapid identification of the
infectious status.
Extensive literatures exist on single laboratory test
or combination of tests as well as tests together with
risk factors and or clinical signs to diagnose neonatal
sepsis. There is no single reliable test for the early
diagnosis of neonatal sepsis,therefore there is a
continuing search for a new infection marker.
Early diagnosis of neonatal sepsis is complicated
because the first signs of the disease may be
minimal, and are similar to those of various
noninfectious processes. Furthermore, blood culture
results are not available until at least 48-72 hours
after the specimen reaches the laboratory. Definitive
diagnosis of sepsis is based on positive blood culture
or cerebro-spinal fluid (CSF) culture and both take
at least 24-48 hours and are often falsely negative.
Empirical antibiotic therapy is therefore started
immediately when neonatal infection is suspected.
Determination of leukocyte count , C-reactive
protein, elastase and cytokines have role to establish
or rule out neonatal infection.23
In 1993 ,Assicot and colleagues reported high
concentration of PCT (Procalcitonin) in sera of
children during septic conditions.7 PCT also seemed
to correlate with the severity of microbial invasion
and decreased rapidly during antibiotic therapy.4,24
Since 1993 ,many studies have assessed the use of
PCT as a marker of bacterial infection in adult,
children and neonates.24
48 Sir Salimullah Med Coll J Vol. 26, No. 1, January 2018
M I Aboud et al. conducted a prospective case control
study to evaluate PCT as a marker of neonatal sepsis
in intensive care unit. They found that serum level
of PCT was more reliable marker than serum level
of CRP.25
The usefulness of PCT was assessed by Lopez and
their colleagues as a marker of neonatal sepsis of
vertical transmission in neonates admitted to the
13 neonatology unit over one year. They conclude
that serum PCT concentration showed a moderate
diagnostic reliability for detection of neonatal
sepsis.26
In a study ,Koksal et al concluded that serum PCT
level was superior to serum CRP level in terms of
early diagnosis of neonatal sepsis, in detecting the
severity of the illness and in evaluation of the
response to antibiotic treatment.27
The role of serum PCT and CRP in the diagnosis of
neonatal sepsis was assessed by NaherBS and their
colleagues in Bangladesh.They found that PCT was
a sensitive, independent and useful biomarker of
neonatal sepsis and it correlated with the severity
of infection.28
CinziaAuriti et al. evaluated the utility of PCT as a
diagnostic marker for nosocomial neonatal sepsis
and compared the results of PCT with those of the
most widely used test for sepsis among 20 neonates
with sepsis and 20 controls aged 4-30 days. It was
found that for PCT sensitivity 85%, specificity 80%
and for CRP sensitivity 80%, specificity 95%. They
concluded that PCT could be a useful marker for
diagnosis of nosocomial neonatal sepsis.29
In another study done by Sucilathangam et al (2012)
compared PCT and CRP an early diagnostic
markers for neonatal infection. This study showed
that serum PCT was superior to serum CRP level
in terms of early diagnosis of neonatal sepsis.The
PCT concentration was elevated in culture positive
neonates.These findings supported the usefulness
of the PCT to establish the diagnosis of neonatal
sepsis.29
The study of Zahedpaspasha et al. (2009) in Iran
showed that PCT levels were remarkably high in
neonatal sepsis and the levels dropped dramatically
after treatment with antibiotics.30
In one study done by Daynia E Ballot et al. (2004)
showed that PCT was significantly related to the
category of infection and not sufficiently reliable to
be the sole marker of neonatal sepsis. PCT would
be useful as a part of neonatal sepsis evaluation.31
J Blommendahl et al. conducted a study for
comparison of PCT with CRP and differential white
blood count for diagnosis of culture proven sepsis.
They showed that serum PCT concentration, serum
CRP and blood immature to total neutrophil
leucocyte ratio all had reasonable sensitivity (58-
77%), reasonable specificity(62-84%), good negative
predictive value(94-97%) and poor positive predictive
value (16-24%) for diagnosis of sepsis.12
Pierrakos and Vincent reviewed 3370 studies
retrieved from PubMed database using the key
words “sepsis” and “biomarker” in sepsis. They found
that more than 170 different biomarkers had been
assessed for potential use in sepsis, more for
prognosis than diagnosis. None had sufficient
specificity or sensitivity to be routinely employed in
clinical practice.9,18
PCT has been intensively investigated for its
diagnostic role in neonatal sepsis. It has been
reported that high concentration of plasma PCT was
found in infants with severe infection, while PCT
levels were very low in those with no infections.Many
authors found that procalcitonin is a promising
marker for the diagnosis of neonatal sepsis.4,32,33
In a recent study Koksal et.al. concluded that serum
PCT level was superior to serum CRP level in terms
of early diagnosis of neonatal sepsis, in detecting
the severity of the illness and in evaluation of the
response to antibiotic treatment.27 The usefulness
of PCT was assessed by Lopez Sastre and their
colleagues as a marker of neonatal sepsis of admitted
to 13 neonatology unit in Spain over one year. They
concluded that serum PCT concentration showed a
moderate diagnostic reliability for detection of
neonatal sepsis from the time of infection.26
Sakha et al. investigated the role of PCT in the
diagnosis of neonatal sepsis and its correlation with
the CRP. The sensitivity, specificity, positive
predictive value and negative predictive value of PCT
(more than 2000 pg/ml) were 66.7%,50%,
28.6%,83.3% and those of CRP (more than 3.5mg/
L) were 70.4%, 72.2%, 43.2% and 89% respectively
in diagnosis of neonatal sepsis.34 Ballot et al. studied
52 neonates with possible infections. Only 13
neonates had a definite infection, in whom the
sensitivity and the negative predictive value of serum
Procalcitonin: An Early Marker for Diagnosis of Neonatal Sepsis Jesmin Akter et al 49
PCT was 89.5% and 95% respectively. But they
stated that although PCT was significantly related
to the category of the infection, it was not sufficiently
reliable to be the sole marker of neonatal sepsis.
PCT would be useful as a part of the full sepsis
evalution, but it is relatively expensive. A negative
PCT on presentation may rule out sepsis.35
Boo et al. showed in 18 neonates among 87 infants
with confirmed sepsis, based on the positive blood
culture results, at a PCT cut-off level of greater than
or equal to 2000 pg/ml. The sensitivity and
specificity, PPV and NPV were 88.9%, 65.2%, 40%
and 95.7% and that for CRP, they were 55.6%,
89.9%, 58.8% and 88.6% respectively.36
So, PCT can be used as a good tool for the diagnosis
of neonatal sepsis. PCT is highly specific for bacterial
infection and help differentiating it from viral
infection. It correlates well with the progression and
the severity of the infection. PCT helps in avoiding
antibiotic therapy where it is not required and
thereby reducing the cost and the occurrence of
bacterial resistance. PCT can also be employed for
the prognosis of sepsis.
Conclusion
This review summarizes the use of procalcitonin as
an early and more reliable marker of bacterial
infection in neonate results in better overall
sensitivity, specificity than CRP and is a valuable
additional tool for the diagnosis of bacterial disease
in this age group. The benefits of measuring serum
PCT routinely in the diagnosis and follow up of
neonatal sepsis is to reduce hospital cost. Such benefit
might support a wider acceptance of the test in
routine practice.
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Recommended