P4624Predictive performance of CRUSADE bleeding score in non ST elevation acute coronary syndrome patients treated with ticagrelor versus clopidogrel

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
L Graca Santos ◽  
F Montenegro Sa ◽  
C Ruivo ◽  
R Ribeiro Carvalho ◽  
J Correia ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
Predictive Performance ◽  
Roc Curves ◽  
National Registry ◽  
Red Blood Cell Transfusion ◽  
Coronary Syndrome ◽  
St Elevation ◽  
Group 2 ◽  
Risk Categories ◽  
Group 1

Abstract Introduction CRUSADE score is commonly used for bleeding risk stratification in the context of acute coronary syndrome (ACS). However, the study validating it was performed before ticagrelor was available. Purpose To compare the predictive performance of CRUSADE score in two groups of non-ST elevation ACS (NSTEACS) patients, one treated with ticagrelor and another with clopidogrel. Methods Retrospective study of 2077 NSTEACS patients admitted between January 2014 and September 2017 and included in a multicentre national registry. Group 1 was composed by patients medicated with ticagrelor, and Group 2 with clopidogrel. Patients with bleeding history were excluded. The primary endpoint (PE) results from a composite which includes: in-hospital major bleeding (MB) according to the Registry criteria, need for red blood cell transfusion (RBCT), or haemoglobin drop ≥2g/dL (HbD). The groups were compared according to their demographic, clinical and laboratory characteristics. The occurrence of the PE (and its components) across CRUSADE risk categories was assessed by Chi-square for linear trend. The performance of CRUSADE score for PE prediction in each cohort was assessed by Receiver Operator Characteristics (ROC) curves. Results Group 1 included 662 (31.9%) and Group 2 1415 (68.1%) patients. Mean CRUSADE score was higher in Group 2 (23.1±14.7 versus (vs) 26.7±16.3, p=0.001). No difference was observed regarding the PE (14.8% vs 17.0%, p=0.200) and its components. With the exception of MB in Group 1 (p-trend=0.425), the relative occurrence of the PE and its components increased across CRUSADE risk categories [Figure 1. panel A]. In-hospital mortality was numerically superior in Group 2, but did not reach statistical significance (1.1% vs 1.6%, p=0.368). In both groups, the performance of CRUSADE score in predicting the PE was modest (Group 1 AUC=0.59 and p=0.006, Group 2 AUC=0.62 and p<0.001), and no difference was observed when comparing the two groups (P value for ROC curves comparison = 0.899) [Figure 1. panel B and C respectively]. Figure 1 Conclusion In this study based on a national registry of NSTEACS patients, the use of ticagrelor did not influence the occurrence of bleeding related events and it did not change the predictive performance of the CRUSADE score. According to this analysis, CRUSADE score may be applied without limitation to NSTEACS patients managed with ticagrelor.

The meaning of early percutaneous coronary intervention in acute coronary syndrome with preserved ST elevation

Open Medicine ◽  
2009 ◽  
Vol 4 (3) ◽  
pp. 265-271 ◽  
Author(s):  
Magdalena Wierzbicka ◽  
Maciej Kośmider ◽  
Agata Bielecka-Dąbrowa ◽  
Jan Goch
Keyword(s):  
Acute Coronary Syndrome ◽  
Logistic Regression ◽  
Regression Analysis ◽  
Logistic Regression Analysis ◽  
Coronary Intervention ◽  
Risk Of Death ◽  
Coronary Syndrome ◽  
St Elevation ◽  
Group 2 ◽  
Group 1

AbstractTo determine if delaying the primary precutaneous coronary intervention (PCI) for >6 hours for acute coronary syndrome with preserved ST elevation (STE-ACS) affects the PCI angiography effectiveness and clinical prognosis. The PCI was performed: for 71% of patients <6h (group 1), for 29% of patients >6h from the beginning of pain (group 2). For 1% of patients from group 1 and 3.4% of patients from group 2, no passage has been opened in the artery after STE-ACS. In spite of opening the passage mechanically, the phenomenon of lack of tissue reflow occurred in 2.7% of patients from group 1 and 12% of patients from group 2. Dangerous ventricular arrhythmias occurred more frequently in patients from group 2, including VF, asystole, haemodynamic complications classed 4° according to the Killip-Kimball scale and death. In an univariate logistic regression analysis, the following risk factors for death during the hospital phase were identified: delayed PCI >6 hours, 4° haemodynamic complications according to the Killip-Kimball scale, LVEF <40%, FV, p-k III block, TIMI <3, and no-reflow. In a multivariate logistic regression analysis, 4° according to the Killip-Kimball scale turned out to be the only risk factor for death during the hospital phase. Delaying PCI during STE-ACS for >6 hours significantly lowers the statistical chance to recover both full permeability and effective tissue reflow in the artery responsible for STE-ACS, which is connected with a significantly higher risk of serious complications, as well as with 8.5% risk of death during the hospital phase. The most significant, independent factor determining the survival of patients with STE-ACS after PCI is lack of cardiogenic shock.

scholarly journals The Threshold of Admission Glycemia as a Predictor of Adverse Events in Diabetic and Non-Diabetic Patients with Acute Coronary Syndrome

2009 ◽  
Vol 3 ◽  
pp. CMC.S2289 ◽  
Author(s):  
Taysir S. Garadah ◽  
Salah Kassab ◽  
Qasim M. Al-Shboul ◽  
Abdulhai Alawadi
Keyword(s):  
Acute Coronary Syndrome ◽  
Adverse Events ◽  
Diabetic Patients ◽  
Stress Hyperglycemia ◽  
Coronary Syndrome ◽  
History Of ◽  
Group 3 ◽  
Group 2 ◽  
High Level ◽  
Group 1

Recent studies indicated a high prevalence of hyperglycemia in non-diabetic patients presenting with acute coronary syndrome (ACS). However, the threshold of admission glucose (AG) as a predictor of adverse events in ACS is unclear. Objective The aim of this study was to assess the threshold of admission glucose (AG) as a predictor of adverse events including Major Acute Cardiac Events (MACE) and mortality, during the first week of admitting patients presenting with ACS. Material and Methods The data of 551 patients with ACS were extracted and evaluated. Patients were stratified according to their blood glucose on admission into three groups: group 1: <7 mmol/L (n = 200, 36.3%) and group 2: >7 mmol/L and <15 mmol/L (n = 178, 32.3%) and group 3: ≥15 mmol/L (n = 173, 31.4%). Stress hyperglycemia was arbitrarily defined as AG levels > 7 mmol/L (group 2 and 3). Patients with ACS were sub-divided into two groups: patients with unstable angina (UA, n = 285) and those with ST segment elevation myocardial Infarction (STEMI, n = 266) and data were analyzed separately using multiple regression analysis. Results The mean age of patients was 59.7 ± 14.8 years and 63% were males. The overall mortality in the population was 8.5% (5.4% in STEMI and 3.1% in UA) patients. In STEMI patients, the odds ratio of stress hyperglycemia as predictor of mortality in group 3 compared with group 1 was 3.3 (CI 0.99-10.98, P < 0.05), while in group 2 compared with group 1 was 2.4 (CI: 0.75-8.07, P = 0.065) after adjustment for age and sex. Similarly, in UA patients, the odds ratio of stress hyperglycemia in group 3 compared with group 1 was 2.7 (CI 0.37-18.98, P < 0.05), while in group 2 compared with group 1 was 2.4 (CI: 0.4-15.2, P = 0.344) after adjustment for age and sex. The incidence of more than 2 MACE in both STEMI and UA patients was higher in group 3 compared with the other two groups. Regression analysis showed that history of DM, high level of LDL cholesterol, high level of HbA1c, and anterior infarction were significant predictors of adverse events while other risk factors such as BMI, history of hypertension and smoking were of no significance. Conclusion This study indicates that the stress hyperglycemia on admission is a powerful predictor of increased major adverse events and hospital mortality in patients with acute coronary syndrome.

scholarly journals P977 CT phenotype of high-risk atherosclerotic plaques causing an acute coronary syndrome compared to silent vulnerable plaques

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
R I Hodas ◽  
D Opincariu ◽  
N Rat ◽  
I Rodean ◽  
M Chitu ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
High Risk ◽  
Morphological Characteristics ◽  
Plaque Morphology ◽  
Atherosclerotic Plaques ◽  
Plaque Instability ◽  
Coronary Syndrome ◽  
Atheromatous Plaques ◽  
Group 2 ◽  
Group 1

Abstract Funding Acknowledgements PlaqueImage.- research grant no. 103544/2016, contract number 26/01.09.2016 - Background Previous studies demonstrated that plaque morphology has a crucial role in the development of an acute coronary syndrome (ACS). However, not all vulnerable coronary plaques produce an ACS and the prediction power of various vulnerability features to predict an acute coronary event in a close future, has not been elucidated so far. Objective We aimed to use multi-slice computed tomography angiography (CTA) for assessment of morphological characteristics of culprit lesions producing an ACS in the next several months after CT assessment, in comparison with morphological characteristics of unstable coronary atherosclerotic plaques which did not trigger an ACS. Material and methods We analyzed 40 patients in whom CTA revealed presence of unstable coronary lesions, exhibiting at least one marker of vulnerability: napkin ring sign (NRS), spotty calcium (SC), positive remodeling (PR) or presence of low attenuation plaque (LAP), divided in 2 groups: group 1 - 20 patients who developed an ACS in the next 6 months following CTA examination, and group 2 – 20 patients matched for age, gender and risk factors, who did not present any cardiovascular event 6 month after CTA assessment. Post-processing of multi-slice CTA images was performed in order to assess morphological characteristics and CT-derived markers of atherosclerotic plaque instability. Results Similar mean values of plaque length (17.1 +/- 5.9 mm vs 16.9 +/- 3.4 mm; p = 0.6) and total atheroma volume (188.1 +/- 104.7 mm3vs 186.4 +/- 90.7 mm3; p = 0.8) were obtained for both groups. The mean number of vulnerability markers was 1.6 in group 1 vs 1.2 in group 2 (p = 0.07). However, atherosclerotic lesions in patients from group 1 presented significantly higher values of lipid-rich atheroma (9.8 +/- 10.8 mm3vs 2.6 +/- 1.0 mm3; p = 0.01) and remodeling index (1.14 +/- 0.3 in group 1 vs 0.89 +/- 0.19 in group 2, p = 0.04). At the same time, atheromatous plaques in patients who developed an ACS during the 6-months follow-up showed in a significantly higher proportion LAP (45% in group vs 10% in group 2, p = 0.03) and PR (15%in group 1 versus 5% in group 2, p = 0.04), but not NRS (30% vs 25%, p = ns) or SC (65% vs 40%, p = 0.2). Conclusions Atherosclerotic plaques producing an ACS exhibit a different phenotype than unstable plaques that remain silent. The CTA profile of atheromatous plaques producing an ACS includes the presence of low attenuation, positive remodeling, higher RI and lipid-rich atheroma. Presence of these features in high-risk coronary plaques identifies very high risk patients, who can benefit from adapted therapeutic strategy in order to prevent the development of an ACS.

scholarly journals Association of Haemoglobin and C-Reactive Protein level with Different Risk Factors among Acute Coronary Syndrome Patients

2019 ◽  
Vol 5 (2) ◽  
pp. 156-160
Author(s):  
Md Mahboob Morshed ◽  
Md Joynul Islam ◽  
ATM Ashadullah ◽  
Khondker Shaheed Hussain ◽  
Mohammad Ahtashamul Haque
Keyword(s):  
Risk Factors ◽  
Acute Coronary Syndrome ◽  
Reactive Protein ◽  
Coronary Syndrome ◽  
Group 4 ◽  
History Of ◽  
Study Population ◽  
Group 3 ◽  
Group 2 ◽  
Group 1

Background: Different risk factors may be related with the haemoglobin and CRP level among the acute coronary syndrome patients. Objective: The purpose of the present study was to see the association of haemoglobin and CRP level with different type of risk factors among the acute coronary syndrome patients. Methodology: This cross-sectional study was conducted in the Department of Cardiology at Mymensingh Medical College, Mymensingh, Bangladesh from December 2010 to November 2011 for a period of two (02) years. Patients of ACS who were presented within 12 hours of chest pain were included as study population. Study population were categorized in four groups according to the level of hemoglobin and C-reactive protein. Age, cardiovascular risks factor, history, family history of cardiovascular disease, treatment history and ECG were taken during admission. Blood sample was collected for baseline laboratory investigations like Troponin-I, Random Blood Sugar (RBS), Blood urea, Serum creatinine, lipid profile, Hemoglobin & CRP level. Sample were then send to standard laboratory/Biochemistry department of MMCH. Result: The mean age of the population was 52.18±8.88 years. Smoking was the highest percentage in Group 1 which was 54(50.0%) cases (P=0.001). Hypertension was found most common in group 1 (47.6%), Group 2 (33.3%), Group 3 (10.7%) and Group 4 (8.3%). Smoking (p=0.001) and hypertension (p=0.016) was found statistically significant. Diabetes was found in Group 1 (37.7%), Group 2 (43.5%), Group 3 (11.6%) and Group 4 (7.2%). Group 1 (50%) and Group 2 (50%) patients were dyslipidaemic. Family history of IHD was present group-1 (36.8%), Group 2 (44.7%), Group 3 (73.2%) and Group 4 (53%). Among the smoker patient 65.6% cases had CRP level ˃12 mg/l; 39.8% cases had CRP level ˂12mg/L. Among the nonsmoker 34.4% cases had CRP level ˃12mg/l and 60.2% cases had CRP level ˂12mg/L. The finding was statistically significant. Conclusion: In conclusion haemoglobin and CRP level is associated with different type of risk factors among the acute coronary syndrome patients. Journal of National Institute of Neurosciences Bangladesh, 2019;5(2): 156-160

scholarly journals Glycemic variability in type 2 diabetes mellitus and acute coronary syndrome: liraglutide compared with insulin glargine: a pilot study

2020 ◽  
Vol 48 (6) ◽  
pp. 030006052092606
Author(s):  
Maria Isabel del Olmo-García ◽  
David Hervás Marín ◽  
Jana Caudet Esteban ◽  
Antonio Ballesteros Martin-Portugués ◽  
Alba Cerveró Rubio ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Type 2 Diabetes ◽  
Type 2 Diabetes Mellitus ◽  
Acute Coronary Syndrome ◽  
Hospital Setting ◽  
Glycemic Variability ◽  
Coronary Syndrome ◽  
Group 2 ◽  
Group 1

Objective To explore the glucagon-like peptide-1 analogue liraglutide in the hospital setting in patients with type 2 diabetes mellitus (T2DM) and acute coronary syndrome and to evaluate the safety and efficacy and its impact on hospitalization and short-term glycemic variability (GV). Methods A 12-week, open-label, prospective, randomized pilot clinical study with parallel groups that compared liraglutide (group 1) with glargine (group 2) and its impact on glycemic control and GV. Results Thirteen patients were included. During hospitalization, mean glucose was 164.75 mg/dL (standard deviation [SD] 19.94) in group 1 and 166.69 mg/dL (38.22) in group 2. GV determined by CV and SD was 20.98 (7.68) vs. 25.48 (7.19) and 34.37 (13.05) vs. 43.56 (19.53) in groups 1 and 2, respectively. Group 1 prandial insulin requirements during hospitalization were lower compared with group 2. Follow-up A1c in group 1 was 6.9% (−1.51%) and 6.5% in group 2 (−1.27). GV after discharge and hypoglycemia were lower in group 1 compared with group 2. Conclusions Liraglutide seems to reduce GV in the acute phase of acute coronary syndrome, and patients achieved optimal control with a low incidence of hypoglycemia. These results support the need to explore liraglutide in a larger multicenter trial. Trial registration: The study was approved by the National Medical Ethics Committee of Spain. The study was registered at European Clinical Trials Database (EudraCT): 2014003298-40.

scholarly journals Comparison of the efficacy of half ticagrelor loading doses and clopidogrel in elderly acute coronary syndrome patients in China

2020 ◽  
Vol 19 (3) ◽  
pp. 661-666
Author(s):  
Jian Xue ◽  
Mingming Li ◽  
Lijie Wang ◽  
Minjun Ma ◽  
Jin Zhang
Keyword(s):  
Acute Coronary Syndrome ◽  
Proportional Hazards ◽  
Cox Proportional Hazards ◽  
Cardiac Events ◽  
Coronary Syndrome ◽  
Therapeutic Benefits ◽  
Proportional Hazards Regression ◽  
Elder Patients ◽  
Group 2 ◽  
Group 1

Purpose: To evaluate the effects of half-load doses (HLD) of ticagrelor and clopidogrel on elderly acute coronary syndrome patients (ACS) over a period of 90 days. Methods: Seventy-four patients diagnosed as ACS were included in this trial. The patients were randomly distributed into group 1 (treated with HLD ticagrelor, 90 mg LD) and group 2 (treated with clopidogrel, 300 mg LD). The interaction of treatment effect was evaluated using Multivariate Cox proportional hazards regression models. Results: Within three months, a total of 12 patients (16.21 %) died of myocardial infarction or stroke. The endpoint of HLD ticagrelor-treated elderly ACS patients was 20 %, and the incidence of clopidogreltreated endpoints was 14.81 %. Conclusion: In the first 45 patients treated with HLD ticagrelor, their cumulative incidence of cardiac events was relatively high. However, there were no considerable changes in the therapeutic benefits of these two drugs in elderly ACS patients. Keywords: Elder patients, Acute coronary syndrome, Ticagrelor, Clopidogrel

scholarly journals Comparative Characteristics of The Effects of Drug and Mechanical Reperfusion in The Treatment of Acute Coronary Syndrome with ST Elevation in Patients Working in Environmentally Challenging Conditions

2020 ◽  
Vol 8 (6) ◽  
pp. 479-486
Author(s):  
Javadova Tarana Mamedgasanovna ◽  
Mammadgasan Mammadguseynovich Agayev
Keyword(s):  
Systolic Function ◽  
Left Ventricular Systolic Function ◽  
Left Ventricular ◽  
Coronary Syndrome ◽  
Combined Application ◽  
St Elevation ◽  
Group 2 ◽  
Comparison Of The Results ◽  
Group 1

Studied clinical and hemodynamic efficacy of complex use  heparin,Сyто-Mас,  propranolol (obzidan), fosinopril (monopril)  with and PCI; PCI conducted separately on hemodynamics on cardiohemodynamics on ekoendotoksikoz (AMP) and the clinical course of patients working in environmentally stressful conditions in the acute phase and follow-up of MI. Comparison of the results of complex mediakamentoz and mechanical revascularization with PCI conducted separately. Investigated  50 patients with   STMI in the age of 30 to 70 years (56,7 ± 1,20 years). Of the  50 patients 25 were treated Cyto-Mac, foznopril, propranolol with heparin and PCI (group 1); 25  patients were treated with PCI alone (group 2). In both groups, blood was determined by the degree ekoendotoksikoza (AMP) by EchoCG and Doppler EchoCG  studied  ESV, EDV,  EF, SI, CI , an  local contractility violation index of left ventricle (LCVI) , with the aid of restenosis koronorografii. A well established dynamics of systolic and diastolic blood pressure, clinical features of MI during follow-up. Patients treatedheparin,Cуто-мас, propranolol, foznopril  and PCIindicators of central hemodynamics stabilizis. The reduced  ЕSV,EDV, LCVI and decreased degree ofekoendotoksikoza (АMP), improves left ventricular systolic function of demand , increases PV. However, in this group, one patient on the third day was recorded AHF and one recurrent MI. İn The group spent only 2 PCI in relapse developed MI, 1 - restenosis,  2 -AHF and 1 patients died. The results show that the combined application of drug therapy with PCI provides a positive result in  comparsionwiththan separately conducted  PCI in ACS  with elevation ST.

scholarly journals In-hospital outcomes of treatment of patients with acute coronary syndrome using distal radial access

2021 ◽  
Vol 20 (7) ◽  
pp. 3070
Author(s):  
Yu. V. Mikheeva ◽  
D. S. Kurtasov ◽  
P. P. Ogurtsov ◽  
A. G. Koledinskii
Keyword(s):  
Acute Coronary Syndrome ◽  
Clinical Laboratory ◽  
Randomized Study ◽  
Study Groups ◽  
Cardiac Events ◽  
Hospital Outcomes ◽  
Coronary Syndrome ◽  
Transradial Access ◽  
Group 2 ◽  
Group 1

Endovascular methods are leading in the treatment of patients with acute coronary syndrome (ACS). Transradial access (TRA) is traditionally used, but there are some disadvantages. Distal transradial access (dTRA) is an alternative to conventional TRA, but its outcomes in patients with ACS are controversial.Aim. To evaluate the safety and efficacy of vascular accesses, as well as in-hospital outcomes of treatment of patients with ACS using conventional TRA versus dTRA.Material and methods. This single-center, prospective, randomized study included 264 patients with ACS, which were divided into 2 groups: group 1 (n=132) — dTRA, group 2 (n=132) — TRA. The groups were comparable in the initial clinical, laboratory and angiographic characteristics.Results. During percutaneous coronary intervention, 240 drug-eluting stents were implanted in 184 patients. In 10 patients, access was converted: from dTRA to TRA in 2,3% (n=3), from dTRA to femoral  — 3,0% (n=4), from dTRA to femoral in 2,3% (n=3). The mean puncture time was 125,1±11,9 s in group 1 and 58,8±8,2 s in group 2 (p<0,00005). There was no difference in the total intervention duration as follows: 30,5±7,1 min and 29,4±4,6 min (p=0,1428), respectively. The time to hemostasis was significantly higher in the TRA group: 354,2±28,1 vs 125,4±15,3 min in group 1 (p<0,00005). When using dTRA, a lower incidence of hematomas (0,8 (n=1) vs 7,0% (n=9) (p=0,019)), spasm (5,6 (n=7) vs 13,2% (n=17) (p=0,039)) and radial artery occlusion (0,8 (n=1) vs 6,2% (n=8) (p=0,036)). The number of major adverse cardiac events (MACE) in both groups was comparable: 10,4% (n=13) and 10,1% (n=13) in group 1 and 2, respectively (p=0,932).Conclusion. The use of dTRA does not increase the total procedure duration compared to conventional TRA. The complication rate was comparable in both study groups. When dTRA was used, the incidence of local complications was significantly lower compared to conventional TRA. Thus, dTRA can be an alternative to conventional TRA, but large randomized trials are required for final conclusions.

scholarly journals Prediction of major adverse cardiac events of patients with acute coronary syndrome by using TIMI risk index

2013 ◽  
Vol 18 (2) ◽  
pp. 52-57 ◽  
Author(s):  
Mohammad Abul Ehsan ◽  
Md Manzoor Mahmood ◽  
Laila Farzana Khan ◽  
Md Abu Salim
Keyword(s):  
Myocardial Infarction ◽  
Acute Coronary Syndrome ◽  
Risk Index ◽  
Major Adverse Cardiac Events ◽  
Cardiac Events ◽  
Coronary Syndrome ◽  
Adverse Cardiac Events ◽  
St Elevation ◽  
Group 1

Patient with acute coronary syndrome (ACS) has considerable variability in outcome and mortality risk. The Thrombolysis in Myocardial Infarction (TIMI) risk index (TRI) for unstable angina/non ST elevation myocardial infarction & ST elevation myocardial infarction were a convenient bedside clinical risk score for predicting 30 days mortality at presentation with ACS. This study was done to predict and validate major adverse cardiac events in patients of ACS thus it will help us to quantify risk, observe the prognostic value and to guide appropriate therapy by using TRI. This prospective study was carried out in the department of cardiology, BSMMU, Dhaka from April, 2011 to March, 2012. After considering all ethical issues, data were collected from 279 patients attending at cardiac emergency department with the presentation of ACS. History & physical examinations were done. TIMI risk index were calculated for each patient. The major adverse cardiac events (recurrent myocardial infarction, urgent revascularization, and all-cause mortality) were measured for next 30 days in hospital setting & outpatient department by follow up. After follow-up, Cox univariate and multivariate regression analysis were used to evaluate the influence of potential risk factors on duration of event-free survival, and likelihood ratio tests to assess the outcome. Major adverse events of TIMI risk index group 1, 2, 3, 4 & 5 were 0%, 0%, 3.7%, 12.9% & 19.2% respectively in UA/NSTEMI group. In STEMI group major adverse cardiac events of TIMI risk index group 1, 2, 3, 4 & 5 were 0%, 4.7%, 12.5%, 17.1% & 24.1% respectively. Increasing TRI were associated with increased risk of major adverse cardiac events. These score were a valid tool for risk assessment. DOI: http://dx.doi.org/10.3329/jdnmch.v18i2.16024 J. Dhaka National Med. Coll. Hos. 2012; 18 (02): 52-57

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