Malignancy in Clinically Non-toxic Multinodular Goiter

Objective: Goiter is a common form of thyroid swelling among population living in areas of iodine deficiency. Of the goiters, non-toxic multinodular goiter (MNG) is the most common and benign form of thyroid disease. However, studies have shown that long-standing MNGs may harbour malignancy. The present study was, therefore, undertaken to ascertain the prevalence of malignancy in clinically diagnosed non-toxic MNGs. Methods: This cross-sectional study was conducted in the Department of Surgery (all four-units) and ENT Department, Rajshahi Medical College Hospital, Rajshahi from July 2007 to June 2008 on 100 patients of clinically non-toxic MNG who underwent thyroid surgery. Biopsy materials were taken from the excised nodules and were sent for histopathological examination to see what proportion of them harboured malignancy. Result: The findings of the study showed that 40% of patients were 30-40 years old with mean age of the patients being 35.5 ± 10.1 (range: 14-75) years. Majority (87%) of the patients was female. Half of the patients with non-toxic MNGs had a history of thyroid swelling for 1-5 years and the rest half for > 5 years with median duration of illness being 5.5 years (range: 1-30 years). Of the 100 patients 4% had stridor and 6% dyspnoea; dysphagia and cervical lymphadenopathy each was 6%. Nearly 60% of the patients had goiter of size 15 sq-cm or below. Sub-total thyroidectomy was the most common operation performed (33%) followed by right hemi-thyroidectomy (24%), near total thyroidectomy (20%), left hemi-thyroidectomy (18%) and total thyroidectomy (5%). Histopathological examination of resected specimens revealed that 15% of the MNGs had malignancy with papillary to follicular carcinoma ratio being 4:1. Histopathological typing showed that 79% was simple MNGs, 4% follicular adenoma, 12% papillary carcinoma, 3% follicular carcinoma and 2% chronic thyroiditis. Neither age nor sex was found to be associated with presence of malignancies in MNGs (p = 0.865 and p = 0.647 respectively). The goiter-size was also not associated with presence of malignancies (p = 0.691). However, the mean duration of thyroid swelling in patients who had malignancy was much higher (8.5 years) than that in patients who did not haveany malignancy (5.7 years) (p = 0.024). Conclusion: The study concluded that a small proportion of long-standing non-toxic MNGs may turn into malignancy. Therefore, routine operative treatment without confirming that the cases are malignant does not seem to be justified. Ibrahim Card Med J 2020; 10 (1&2): 84-88

Awareness of Rural People about Prevention of Non-Communicable Diseases

Background & Objective: Non-communicable diseases, particularly diabetes, hypertension and ischemic heart diseases have created an epidemic situation worldwide. Bangladesh is also in the grip of the menace. The only way to get rid of the menace is prevention of these diseases which demands awareness against the diseases. This study was undertaken to assess the level of knowledge of adult people of Puthia Upazila regarding prevention of the seclected non-communicable diseases (NCDs). Methods: The study was carried out in the Department of Community Medicine Rajshahi Medical College, Rajshahi over a period of 2 months from April 2018 to May 2018. All adult people (18 years onwards) residing in the rural area of Puthia Upazila were the respondents (study population) in this study. The survey invited the adult individuals to participate in the study. A total of 1001 individuals voluntarily responded to participate in the study. Of them 648(64.7%) were free from the NCDs and were interviewed to assess their level of knowledge on prevention of selected NCDs. A self-administered questionnaire containing the variables of interest for evaluating knowledge was used. Result: Two-thirds (68.2%) of the respondents were 30–50 years old with mean age of the respondents being 44.3(range: 25-90) years. Males outnumbered females by 11:9. Over half (54%) informed that they had little knowledge and 10.7% were familiar with the NCDs. Around half held the view that diabetes, hypertension, ischemic heart diseases and stroke were NCDs/chronic diseases. Approximately 70% told that the NCDs were on a rising trend. Regarding causes of chronic diseases, the respondents told excess intake of fat and sedentary life-style (67.9%), intake of excess CHO (54.2%), indulgence in smoking (68.2%), less intake of vegetables and fruits (57.4%), excess or additional salt intake (50.5%) and family history of NCD (44.1%). Regarding prevention of NCDs, around 70% were in favor of adopting healthy dietary behaviour and avoiding too much fatty food, followed by regular exercise (71.2%), avoiding or giving up smoking (70.8%) and avoiding or giving up taking extra salt (57.9%). Conclusion: The study concluded that the people of Puthia Upazilla are aware more or less about the selected NCDs (diabetes, hypertension, ischemic heart diseases and stroke). They are also aware that these diseases are increasing. Around two-thirds of the people are aware about the risk factors of these non-communicable diseases and the ways to prevent them. Ibrahim Card Med J 2020; 10 (1&2): 27-32

COVID-19: Medical versus Religious Perspective

not available Ibrahim Card Med J 2020; 10 (1&2): 5-10

Perception and Practices of Nurses about Diabetic Foot Care

Background & objective: Diabetic-foot care or diabetic foot ulcer (DFU) care is a vital aspect of care for diabetic patients. It is conceived that nurses placed in a diabetic hospital are knowledgeable and efficient in the management of diabetic ulcer care. But how efficiently they are providing this service has not yet been formally evaluated. The present study was undertaken to evaluate the nurses’ “diabetic foot care behavior” at the BIRDEM (Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders), Dhaka. Methods: This study was carried out on nurses having at least one year of experience in “diabetic foot” care (preventive, curative and rehabilitative services) in BIRDEM General Hospital (the largest Diabetic Footcare Hospital in Bangladesh) between July 2019 to December 2019. A total of 207 Senior Staff nurses or nurses working in the surgical wards or in the outpatient departments (OPDs) were consecutively included in the study. A pre-structured questionnaire was used to assess the knowledge, attitude, and practices of nurses pertaining to diabetic foot care. The questionnaire, among others, included variables like age, gender, professional experience, and qualifications. The knowledge section comprised 15 items focusing on risk factors, descriptions, and the management of diabetic ulcers. The options provided for each question were “True,” or “False,”. A score of ‘1’ was given for each correct answer and ‘0’ for each wrong answers. All the 15 responses were then summed up to find the integrated score obtained by the respondents. The summed-up score was then converted into percentage of score obtained. The knowledge level of the respondents was evaluated in terms of Likert scale 0-4, where ‘0’ means poor knowledge (knowledge score ≤ 60%) and ‘4’ means highly satisfactory level of knowledge (knowledge score 91-100%) and ‘1’, ‘2’ and ‘3’ means fair (knowledge score 61-70%), average (knowledge score 71-80%) and satisfactory knowledge (knowledge score 81-90%) respectively. Results: About 50% of the respondents were 40 or > 40 years old with mean age of the respondents being 37.4±10.4 years. The respondents were predominantly female (80%) married (75.4%). Approximately 80% of the respondents had diploma (basic nursing degree) degree alone, 14.5% obtained graduate (BSc Nursing) degree as well. Over half (51.1%) of the respondents had > 10 years of professional experience with average years of experience being 14.6 ± 0.7 years, but two-thirds (68.1%) had < 5 years and only 13% had > 10 years of wound-care experience. Nearly 40% had specific training on wound care. One-third (34.3%) of the nurses were placed in Internal Medicine Unit, 33.8% in Surgery Unit, 14.4% in Emergency Unit. Over two-thirds (68.6%) of the nurses were service nurses, 18.4% were supervisor, 3.9% were intensive care nurses and 8.2% were polyclinic nurses. The respondents’ level of knowledge was evaluated in terms Likert scale 0 – 4 (as described in the Methods section). Accordingly 30% of the respondents had poor, 8% fair, 47.1% average 2.9% satisfactory and 12% highly satisfactory level of knowledge. Conclusion: The study concluded that nurses generally possess an inadequate level of knowledge pertaining to DFUs, despite a positive attitude towards learning or acquiring knowledge about DFU and its care. A comprehensive educational program focusing on evidence-based practice is deemed necessary to ensure better clinical practices by the nurses. Ibrahim Card Med J 2020; 10 (1&2): 57-65

Morphometric Study of Lateral Ventricles of Brain by MRI in Healthy Adults in Northern Zone of Bangladesh

Background & Objective: The present study was done to provide information about the morphometric measurement of lateral ventricles of human brain in relation to age and sex in northern Bangladeshi people. Methods: This cross-sectional study was conducted in the Department of Anatomy, Rajshahi Medical College, Rajshahi over a period one year from July 2014 to June 2015. All patients attending at Radiology & Imaging Department of Rajshahi Medical College Hospital and at different private hospitals and clinics of Rajshahi city and had normal MRI scan of brain were the study population. A total of 60 individuals of both sexes and age ranging between 18-50 years were included in the study. Having obtained ethical clearance from the Ethical Committee and verbal consent from the patients, the data collection was commenced. Patients were asked to lie on the MRI table in supine position with head fixed and coil placed around the head. MRI was done with MRI machine (Airis II Hitachi 0.3 Tesla) and images were taken by T1WI, T2WI, STAIR, FLAIR. Images were taken from axial, sagittal and coronal planes with sequence slice thickness being 7 mm. From the images of axial slices, six proper slices were selected. Result: Age distribution of the subjects with respect to sex shows that nearly two-thirds (63.3%) of the female subjects were 30 or younger than 30 years old, whereas 50% of the male subjects were early middle-aged (p = 0.110). The mean lengths of frontal horn of right and left lateral ventricles in male subjects were significantly greater than those in female subjects (p = 0.002 and p = 0.001 respectively). Likewise, the right and left ventricular bodies in male subjects were significantly longer than those of their female counterparts (p = 0.033 and p = 0.012 respectively). The length of frontal horn of the lateral ventricles was found to increase with age up to 40 years in both right and left ventricles and then it began to decrease. The mean lengths of frontal horn of right and left lateral ventricles at ages ≤ 30, 31-40 and > 40 years were 27.25, 28.74 and 26.0 mm and 27.57, 28.93 and 27.19 mm respectively. While the three measures of length of frontal horn of right lateral ventricles were significantly heterogeneous (p = 0.049), the three measures of length of frontal horn of left lateral ventricles were not significantly different (p = 0.141).The mean lengths of body of right and left lateral ventricles at different ages were 40.40, 43.98, 45.11 mm and 41.06, 44.52 and 45.21 mm respectively (p = 0.001 andp = 0.001 respectively). Conclusion: The present study concluded that the lateral ventricles vary in size within certain limit according to age, sex and laterality. All the parameters of lateral ventricles (lengths of frontal horn, length of ventricular body) were significantly larger in males than those in females. While the length of frontal horn of the lateral ventricles (of both sides) increases in size up to the age of 40 years and thereafter regresses, the length of ventricular body bears a linear relationship with age throughout life-span. Ibrahim Card Med J 2020; 10 (1&2): 45-50

Clinical Presentation and Severity Assessment of Community Acquired Pneumonia in Adults Admitted to a Teaching Hospital

Background & Objective: The purpose of the study was to evaluate the clinical presentation and severity of community acquired pneumonia in adults. Methods: The present cross-sectional study was conducted in Sir Salimullah Medical College & Mitford Hospital, Dhaka over a period of 1 year. Patients admitted with the symptoms and signs suspected of pneumonia and confirmed by clinical examination and necessary investigations were the study population. The baseline characteristics, patients’ behavioural factors, presenting complaints, co-morbidities, examination findings and investigations were recorded. Data were processed and analyzed using software SPSS (Statistical Package for Social Sciences), version 11.5. The test statistics used to analyze the data were descriptive statistics. Result: In the present study, a large proportion of patients were 50 years or more than 50 years with mean age of the patients being 46.4 ± 13.3 years. A male predominance (58%) was observed in the series. Over half (56%) of the patients was smoker and 8% were alcoholic. Fever (90%) and purulent sputum (70%) were the common complaints. The second most common complaints were chest pain and haemoptysis (each of 44%). Thirty eight percent of the patients had dyspnoea and a very few had other symptoms. Eighteen percent of the patients had COPD, another 18% had diabetes and 4% had cardiac insufficiency. About one-quarter (24%) of the patients had agitation stupor, 88% bronchial breathing and 68% crackles. Right lower lobe (31%) and right middle lobe (26%) were commonly affected by pneumonia of the patients detected with a chest X-ray. Assessment of severity pneumonia by CURB-65 score shows that 83% of the patients had mild (score 0 – 1) CAP, 12% had moderate (score 2) and 5% had severe CAP (score 3 or more).Over two-thirds (68.5%) of the patients exhibited positive sputum for Gram’s stain. Conclusion: The study concluded that CAP is more likely to occur in older males with preexisting comorbidities like diabetes and COPD. Fever and purulent cough are the predominant presentation of CAP followed by chest pain and haemoptysis. Pneumonic consolidation on chest X-ray and +ve gram stain are diagnostic of CAP, while raised total count of WBC with neutrophilic leucocytosis are supportive to it. Assessing pneumonia severity by CURB-65 scoring system revealed that severe pneumonia (score 3 or more) is now a rarity. Patient evaluation should focus on severity of illness, patient age, comorbidities, clinical presentation, epidemiologic setting, and previous exposure. The majority of patients with CAP are treated empirically based on the most common pathogen(s) associated with the condition. Ibrahim Card Med J 2020; 10 (1&2): 51-56

Routine VDRL Test in Pregnant Women: How Justified Is It?

Background & objective: The present study was undertaken to justify the role of routine antenatal screening for syphilis using the Venereal Disease Research Laboratory (VDRL) test in Bangladeshi pregnant women. Methods: The study was carried out in the Department of Gynecology & Obstetrics Inpatient and Outpatient, Dhaka Medical College Hospital (DMCH) and selected Private Clinics over a period of 6 months between January 2016 to June 2016. Pregnant women attending at the above-mentioned places during the study period were the study population. A total of 371 women attending at antenatal clinic at OPD or admitted in the Inpatient Department of DMCH were consecutively included. The outcome variable was outcome of VDRL test. Result: In the present study, the mean age of the pregnant women was 24.3 years. In terms of occupation, housewife comprised the main bulk (78.8%). About 64% were multigravida and 60% were primipara. Of the 371 pregnant women subjected to VDRL test, only 4(1.1%) exhibited reactive. About one-third of the women had history of past abortion. Of them two-thirds had experienced abortion once. Of the aborted cases 57% were spontaneous and 43% induced. Ten percent of the women gave the history of delivering dead baby. Three-quarters of the dead babies were fresh, 22.2% had skin lesion and only one was macerated. Half of the women had history of vaginal discharge, 27.2% itching in vagina and vulva and 17% dysuria. However, very few husbands had dysuria, pus discharge through urethra or ulcer in the genital region. About 10% of women gave the history opthalmia neonatrum in their children born in the past. History of dysuria was rare (0.8%), but pus discharged from urethra of their husbands was 12.1%. HbsAg was found positive in 5(1.3%) cases and pus-cell in urine in 41(11.1%) cases. Conclusion: The study concluded that pregnant women with VDRL test positivity in Bangladeshi population are low and, as such, the role of routine antenatal screening for syphilis with VDRL test should be re-considered. Ibrahim Card Med J 2020; 10 (1&2): 89-95

Role of Climatic Conditions on the Incidence of Varicella in an Out-patient Clinic of a Tertiary Care Pediatric Hospital at Dhaka

Background & objective : Chicken pox or varicella is a disease of both tropical and temperate zones bearing a complex-relationship with climatic variables, like temperature, rainfall and relative humidity, wind velocity and so on. As no study has, by far, been conducted to relate its occurrence with these climatic variables in Bangladesh, this study was intended to explore the effect of weather conditions on the incidence of varicella in Dhaka city of Bangladesh. Methods: The present cross-sectional study obtained data of 172 varicella cases from the records of the daily register of Out-patient Department of Dhaka Shisu Hospital, Dhaka between January 2018 to December 2019. According to the study protocol a child was diagnosed as having varicella or chicken pox who had a history of short febrile illness accompanied by a pruritic vesicular eruption (on the face and trunk)) of the skin and mucous membranes which ultimate weeps out and crusts. Total number of cases treated monthly at Out-patient Department (OPD) during the period was also recorded. Climatic data were provided by Bangladesh Meteorological Department, which among others, included monthly average temperature, relative humidity (RH) and amount of rainfall or precipitation. While the outcome variable was monthly number of varicella cases, the predictive variables were average temperature, humidity and rainfall during the study period. Result: Over 70% of children were 1-10 years old with median age of the children being 5.5 years (range: < 1 month -14 years). Boys were a bit higher (54%) than the girls (46%). A seasonal pattern of chicken pox was seen with clustering of cases between mid-February to mid-April (spring season) with two peaks – one in February and another in April, when monthly average temperature, total rainfall and humidity all were at their optimum. The peak incidences of chicken pox cases during the spring both in 2018 and 2019 as correlated with climatic data of the same period, it is seen that the prevailing weather then was optimum-average temperature was 23°C, average precipitation was 20-25% of the total annual precipitation and relative humidity was around 65%. Conclusion: The study concluded that majority of the varicella cases occur under ten years of age and boys are a little more susceptible to have the infection than the girls. A seasonal pattern of chicken pox is clearly seen with clustering of cases between mid-February to mid-April (spring season) with two peaks when monthly average temperature, total rainfall and humidity all are optimally favorable for the multiplication of varicella zoster virus. Ibrahim Card Med J 2020; 10 (1&2): 11-17

Pattern of diseases among Bangladeshi Hajj Pilgrimsin Mecca, Saudi Arabia

Background & objective: Each year millions of Muslims embark on a religious pilgrimage called the “Hajj” to Mecca in Saudi Arabia. The mass migration during the Hajj is unparalleled in scale, and pilgrims face numerous health hazards. Performing the tasks of pilgrimage is stressful and laborious and as such requires immense mental and physical fitness on the part of the pilgrims. But a substantial proportion of the pilgrims lack it. Besides, the hot and dry environment and untold overcrowding predispose them to the risk of many communicable diseases. The present study, was therefore, intended to find the pattern of diseases among Bangladeshi Hajj pilgrims at Mecca, Saudi Arabia. Methods: This descriptive cross-sectional study was carried out on Bangladeshi Hazz pilgrims in Mecca Saudi Arabia over a period of 1 month from mid-September to mid-October, 2015. A total of 710 pilgrims (18 or > 18 years) attending at Bangladeshi Hazz Medical Center (BHMC) in Mecca, Saudi Arabia during the period were consecutively included in the study after having voluntary verbal consent obtained from them. Diseases were diagnosed mainly on the basis of clinical signs and symptoms with provision of only random and fasting blood sugar estimation and ECG. The diagnosed diseases were grouped into major and minor problems or conditions and were treated as out-patient basis. Result: In the present study upper middle-aged (50 – 60 years) and elderly (≥ 60 years) pilgrims together formed nearly 73% of the patients with mean age of the patients being 56 years. Males were a bit higher than the females with male-female ratio being roughly 11:9. The study demonstrated that the commonest cause of out-patient visit was respiratory illness (41.2%) followed by diabetes (17.2%), peptic ulcer disease (PUD) (11.7%) and cardiovascular diseases (10.7%)(which included hypertension, new onset ischemia or exacerbation of preexisting ischemic heart diseases). A few (3.2%) of the patients presented with diarrhoeal diseases (loose motion or dysentery). Other minor ailments were allergy or dermatitis, insomnia, paronychia, anxiety, UTI, hemorrhoids, epistaxis, glossitis, oral ulcer, earache, conjunctivitis, worm infestation, spot bleeding etc., accounting for 4.8% of the patients. Conclusion: The study concluded that respiratory illness is the most common health problems among pilgrims visiting to Mecca, Saudi Arabia followed by diabetes, PUD and cardio-vascular diseases. The pilgrims should be educated in their home country before starting for pilgrimage as how to maintain their health in their new and challenging environment and Bangladesh Hazz Mission in Mecca should ensure enough medical support to them. Ibrahim Card Med J 2020; 10 (1&2): 96-101

Outcome of Elderly Population Undergoing Primary PCI in a Tertiary Hospital in Bangladesh

Objective: To evaluate in-hospital and 1-year outcomes of primary percutaneous coronary intervention (PPCI) in elderly patients with ST-elevation myocardial infarction (STEMI). Methods: All patients aged ≥ 65 years presenting with STEMI and undergoing PPCI at Ibrahim Cardiac Hospital & Research Institute, Bangladesh from January 2015 to August 2017 were consecutively included in the study based on predefined eligibility criteria. Data pertaining to angiographic characteristics, procedural variables, in-hospital and 1-year outcome variables were recorded and analyzed with the help of descriptive statistics and Chi-square Test. Results: The mean age of the patients was 69.2 ± 5.2 (range: 65-85) years with male to female ratio being 4:1. The patients were predominantly diabetic (78%) followed by hypertensive (74%) and dyslipidaemic (70%) smoker (54%). Half of the patients presented with anterior myocardial infarction (MI), 30% had inferior MI, 12% with right ventricular (RV) extension and 8% with inferolateral extension. About one-quarter (24%) had arrhythmia with complete heart block (CHB). The culprit arteries were LAD (50%), followed by RCA (42%) and LCx (8%). Nearly half (46%) had single vessel disease, 34% double and 20% triple vessel disease. Majority (80%) received a single stent and 20% required two stents with mean diameter and length of the stents were 2.9 ± 0.4 mm and 27.3 ± 7.9 mm respectively. Intracoronary eptifibatide was used in 20% cases. In terms of left ventricular ejection fraction (LVEF), 58% and 28% had mild and moderate LV systolic dysfunction respectively. The mean duration of hospital stay was 4.0 ± 1.9 days. About 18% required repeat hospitalization. Overall, 7(14%) patients died (4 during their stay in the hospital due to cardiac cause and 3 during follow up due to non-cardiac causes). At 1 year follow up, in-stent restenosis was seen in 1 case followed by target vessel revascularization (TVR). The Association between age and outcome revealed that advanced age (age ≥ 75 years) was an important predictor of in-hospital and one-year outcome with Relative Risk (RR) of having unfavorable outcome was > 5-fold (95% CI: 1.6-19.5) in patients of advanced age than that in patients of age < 75 years (p = 0.008). Conclusion: Primary PCI is a feasible treatment option for elderly Bangladeshi patients presenting with STEMI with fewer in-hospital and 1-year follow up deaths. Adverse cardiovascular events are even less. Advanced age (age ≥75 years) is an important determinant of adverse cardiovascular events including mortality, probably because of more medical co-morbidities associated with advanced age. Ibrahim Card Med J 2020; 10 (1&2): 18-26