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

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Introduction, Materials and Methods, Results, and Discussion.

The authors should sign a covering letter mentioning that final

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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.

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Each table should be typed in on separate sheet. Table should have

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Results should be presented in logical sequence in the text, tables or

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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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President

Prof. Dr. Mani Lal Aich

Vice President

Prof. Dr. Sanya Tahmina Jhora

General Secretary

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Dr. Bebekananda Halder

Dr. Afsan Zareen

Dr. Ishrat Jahan

Sir Salimullah Medical

College Teachers’

Association

EXECUTIVE COMMITTEE

Published by

Dr. Sunirmal Roy

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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

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including implication for future research should be

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References

References should be numbered consecutively in the order

in which they are first mentioned in the text. Identify

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are based on the formats used by the US National Library

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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

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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

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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

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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.

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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.

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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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J, Puukka P. Serum lipids, lipoproteins and

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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.

References

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Microalbuminuria: Correlation With Prevalence and

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Association of Microalbuminuria with Severity of Coronary Artery Disease Md. Shafiqur Rahman Patwary et al 39

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microalbuminuria with complexity of coronary artery

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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