Health-care-seeking behaviour in patients with hypertension: experience from a dedicated hypertension centre in Bangladesh

Objective: The study aimed to assess health-seeking behaviour (HSB) and associated factors among hypertensive patients in Bangladesh.Methods: This cross-sectional study was conducted in the Hypertension & Research Centre, Rangpur, Bangladesh, between January 2022 and June 2022. A total of 497 hypertensive adults were recruited consecutively. A pre-tested structured questionnaire was deployed by the research team for data collection. Multivariable logistic regression analysis was used to explore the predictors of HSB.Results: The mean age of the hypertensive patients was 52 ± 11 (SD) years. Most of them were aged between 51 and 60 years (33%), female (55%), came from rural areas (57%), and belonged to middle socioeconomic class (68%). One-fourth of the patients (27%) had chosen informal healthcare providers for their first consultation. Fear of stroke (244, 45%), headache (170, 36%), and neck pain (81, 17%) were the three most common compelling causes of their visit to the hypertension centre. Age (aOR 0.78, 95% CI 0.68 - 0.89), male sex (aOR: 1.79, 95% CI 1.05 - 3.10), living in semi-urban (aOR 4.68, 95% CI 1.45 - 15.10) and rural area (aOR 1.68, 95% CI 1.01 - 2.80), farmers as occupation (aOR: 3.24, 95%CI: 1.31 - 8.06) and belonging to lower social economic class (aOR 4.24, 95% CI 1.68 - 10.69) were predictors of visiting informal providers of hypertensive patient. One-fourth of the hypertensive patients received consultation from informal healthcare providers.Conclusions: Raising awareness among patients and proper referral to specialised hypertension centres could promulgate the patients towards appropriate behaviour.

The 2023 Dengue Outbreak in Bangladesh: Exploring the Epidemiology in Hospitalized Patients

For the past two decades, Bangladesh has faced recurrent dengue outbreaks, with the most recent occurring in 2023. We investigated the socioeconomic, clinical, and laboratory aspects of patients diagnosed with dengue during this outbreak. This observational study was conducted from July to September 2023 at Dhaka Medical College Hospital and Chittagong Medical College Hospital, and included 450 confirmed cases of dengue. Sociodemographic information was collected via face-to-face interviews, clinical examinations, and laboratory testing, which was done within 24 hours of admission. Dengue severity was classified according to the 2009 WHO dengue guidelines. Notably, 17% of patients experienced severe dengue, and 89% of those with nonsevere cases exhibited at least one warning sign. Most patients were young adults (mean age, 33 years), with a nearly equal male-to-female ratio. Common clinical presentations included fever (95%), myalgia (62%), and headache (58%), whereas warning signs such as vomiting (54%) and abdominal pain (39%) were prevalent. Plasma leakage indicators, including ascites, pleural effusion, and edema, were found predominantly in severe cases. Laboratory findings revealed leukopenia, thrombocytopenia, and elevated hepatic enzymes (alanine aminotransferase and aspartate aminotransferase) in nearly half the patients. An elevated hematocrit level was associated with severe dengue. We report that a substantial number of patients developed severe dengue during the epidemic in 2023, and provide detailed clinical-epidemiological profiles of the patients, offering valuable insight into management of dengue cases.

Status of lipid control in Bangladeshi subjects with type 2 diabetes mellitus on lipid-lowering drugs: a multicenter, facility-based, cross-sectional study

BACKGROUND

Achievement of lipid targets is crucial in patients with type 2 diabetes mellitus (T2DM) to mitigate the risk of cardiovascular diseases (CVD). Data on lipid-control status among patients with T2DM in Bangladesh are scarce. This study was conducted to determine the lipid-control status among patients with T2DM who were on lipid-lowering drugs in the country.

METHODS

This cross-sectional study was conducted in the diabetes outpatient departments of several tertiary hospitals in Bangladesh from January 2022 to December 2022. Adults of both sexes diagnosed with T2DM for at least one year and were on the lipid-lowering drug(s) for a minimum of 3 months were included in the study by consecutive sampling. Patients' data were collected by face-to-face interviews, and blood samples were collected for fasting lipid profile. The lipid target was set at < 200 mg/dL for total cholesterol (TC), < 150 mg/dL for triglyceride (TG), < 100 mg/dL for low-density lipoprotein cholesterol (LDL-C), > 40 mg/dL for high-density lipoprotein cholesterol (HDL-C), and < 160 mg/dL for non-HDL cholesterol (non-HDL-C).

RESULT

Three thousand sixty patients (age 44.7 ± 13.3 years, female 57%) with T2DM were evaluated. Overall, almost 81% of the study subjects achieved the LDL-C target. Besides, TC, TG, HDL-C, and non-HDL-C targets were achieved by 40.8, 21.6, 66.3, and 44.1% of patients, respectively. However, all the lipid parameters were under control in only 8.8% of patients. Almost 77.6% of the patients with ischemic heart disease, 81.5% of patients with stroke, and 65% of patients with CKD had LDL levels < 70 mg/dL. Only 10.03% achieved the HbA1c target of < 7%. 7.4% of patients achieved both HbA1c < 7% and LDL < 100 mg/dL and 5% achieved both HbA1c < 7% and LDL < 70 mg/dL. Advanced age (aOR 0.97, 95% CI 0.96, 0.98, p < 0.001), longstanding T2DM (aOR 0.53, 95% CI 0.39, 0.72, p < 0.001), and non-statin therapy (aOR 0.25, 95% CI 0.16, 0.37, p < 0.001) were negatively associated with lipid control (LDL < 100 mg/dL) while using oral hypoglycemic drugs or insulin (aOR 2.01, 95% CI 1.45, 2.77, p < 0.001) and having cardiovascular comorbidity (aOR 3.92, 95% CI 3.00, 5.12, p < 0.001) were positively associated with lipid control.

CONCLUSION

Though most patients with T2DM achieved their target LDL level, the prevalence of both glycemic and overall lipid control was low in our study despite lipid-lowering therapy.

Two level logistic regression analysis of factors influencing skilled birth attendant during delivery among Bangladeshi mothers: A nationally representative sample

BACKGROUND

In order to minimize the maternal and child mortality rate, the presence of skilled birth attendants (SBA) during delivery is essential. By 2022, 4th health, population and nutrition sector programme in Bangladesh aims to increase the percentage of deliveries performed by SBA to 65 percent. The objective of the present study was to determine the rate and associated factors of usage SBA among Bangladeshi mothers during their delivery.

METHODS

This study utilized secondary data that was collected by Bangladesh Demographic and Health Survey (BDHS) 2017-18. The usage of SBA was measured by a question to respondent, who assisted during your delivery? It was classified into two classes; (i) skilled birth attendant (qualified doctors, nurses, midwives, or paramedics; family welfare visitors, community skilled birth attendants, and sub-assistant community medical officers) (code 1), and (ii) unskilled birth attendant (untrained traditional birth attendants, trained traditional birth attendants, relatives, friends, or others) (code 0). Two logistic regression model was used to determine the associated factors of SBA after removing the cluster effect of the outcome variable.

RESULTS

This study found 53.2% mothers were delivered by SBA in Bangladesh, among them 56.33% and 42.24% mothers were delivered by nurse/midwife/paramedic and doctor respectively. The two level logistic model demonstrated that geographical location (division), type of residence, religion, wealth index, mothers' body mass index, mothers' education level, mothers' occupation, total ever born children, mothers' age at first birth (year), number of ANC visits, husbands' education level and husbands' occupation were significant (p<0.01) predictors of SBA. Mothers' education and wealth index were the most important contributory factors for SBA in Bangladesh.

CONCLUSIONS

This study revealed that still 46.8% mothers are delivered by unskilled birth attendant, this might be treated of Bangladesh Government to achieve SDGs indicator 3.1.2 by 2030. Counseling could be integrated during ANC to increase awareness, and should ensure for every Bangladeshi mothers visit ANC service during their pregnancy at least 4 times.

Comparison of fasting and random lipid profiles among subjects with type 2 diabetes mellitus: an outpatient-based cross-sectional study in Bangladesh

BACKGROUND

Despite the wide acceptability of fasting lipid profiles in practice, emerging evidence suggests that random lipid profiles might be a convenient alternative for lipid measurement. The objective of the present study was to compare the fasting and random lipid profile among subjects with type 2 diabetes mellitus (T2DM).

METHODS

The present cross-sectional study included 1543 subjects with T2DM visiting several endocrinology outpatient clinics throughout Bangladesh from January to December 2021. The fasting lipid profile was measured in the morning following 8-10 h of overnight fasting, and the random lipid profile was measured at any time of the day, irrespective of the last meal. The values of fasting and random lipids were compared using the Wilcoxon signed-rank test and Spearman rank correlation coefficients.

RESULTS

In this study, a good level of correlation was observed between fasting and random lipid levels [r = 0.793, p < 0.001 for triglyceride (TG); r = 0.873, p < 0.001 for low-density lipoprotein cholesterol (LDL-C); r = 0.609, p < 0.001 for high-density lipoprotein cholesterol (HDL-C); and r = 0.780, p < 0.001 for total cholesterol (TC)]. In addition, TG and TC levels increased by 14% and 0.51%, respectively, in the random state compared to the fasting state (p- <0.05), while LDL-C levels decreased by 0.71% (p-value 0.42). No change was noticed in the HDL-C level. The difference between fasting and random lipid profiles was similar irrespective of patients' age, sex, BMI, glucose-lowering drug(s), and lipid-lowering therapy.

CONCLUSIONS

Random lipid profile correlates significantly with fasting lipid profile with little difference. Hence, it might be a reliable alternative for fasting lipid profile in patients with T2DM.

Clinical Profile of Pediatric Cases of Dengue during the 2019 Epidemic in Bangladesh: A Multicenter Cross-Sectional Study

Bangladesh experienced the largest dengue epidemic during 2019, with more than 100,000 confirmed cases and 164 deaths. Almost one-third of these cases were children. The present study aimed to investigate the clinical and hematological manifestations of pediatric dengue cases during the epidemic. This was a multicenter cross-sectional study conducted in Dhaka Medical College Hospital, Dhaka, Dr. Sirajul Islam Medical College Hospital and Tangail Sadar Hospital, Tangail, Bangladesh between the period of June 2019 and September 2019. The study included 208 pediatric patients (age <18 years) with confirmed dengue fever. Patient's demographics, clinical and laboratory features of dengue were collected through patients' interview, clinical examination and laboratory investigations. Descriptive statistics were used to represent the patients' socio-demographic information, clinical presentations and hematological parameters. The majority of the patients were aged between 6 and 17 years with male predominance. The most commonly presented clinical manifestations were fever (100.0%), headache (59.0%), myalgia (42.0%), rash (36.0%), retro-orbital pain (28.0%) and diarrhea (24.0%). Warning signs abdominal pain (40.0%) and persistent vomiting (29.0%), bleeding manifestations such as melena (17.0%), gum bleeding (7.0%) and epistaxis (6.0%) and evidence of plasma leakage such as oliguria (3.4%), ascites (2.4%), pleural effusion (1.4%), and shock (1.0%) were also present in the patients. Raised HCT levels, leucopenia and thrombocytopenia were present in almost 23.0%, 43.0% and 28.0% of children, respectively. Warning signs and plasma leakage were present in a substantial number of patients indicating potential risk of severe dengue. Prompt diagnosis and management based on best clinical judgment might prevent severe dengue at an early stage.

Adverse events following immunization with ChAdOx1 nCoV-19 and BBIBP-CorV vaccine: A comparative study among healthcare professionals of Nepal

Background

Adverse events following immunization (AEFI) against SARS-CoV-2 are common as reported by clinical trials and contemporary evidence. The objective of the present study was to evaluate the local and systemic adverse events following vaccination with ChAdOx1 nCoV-19 and BBIBP-CorV among the healthcare professionals (HCPs) of Nepal.

Methods

This cross-sectional study was conducted among 606 vaccinated HCPs of Kathmandu, Nepal. Data was collected from June 15 to 30, 2021 using a self-administered online survey tool. Multiple binary logistic regression models were used to predict the adverse events according to the vaccine types and doses after adjusting for age, sex, comorbidity and previous SARS-CoV-2 infection.

Results

The mean (SD) age of the participants was 35.6 (13.2) years and 52% of them were female. Almost 59% of participants were vaccinated with two doses and around 54% of total of them took the ChAdOx1 nCoV-19 vaccine. At least one local and systemic adverse event was reported by 54% and 62% of participants after the first dose and 37% and 49% after the second dose of ChAdOx1 nCoV-19 and by 37% and 43% after the first dose and 42% and 36% after the second dose of BBIBP-CorV vaccine respectively. Injection site pain, swelling and tenderness at the injection site were the most frequently reported local AEFI while, fatigue, headache, fever and myalgia were the most frequently reported systemic AEFI. The logistic model demonstrated that the risk of both local and systemic adverse events was higher among the ChAdOx1 nCoV-19 vaccine recipients compared to the BBIBP-CorV vaccine. Almost 10% of individuals reported a post-vaccination SARS-CoV-2 infection and most of them occurred after taking the first dose of vaccine.

Conclusions

Recipients of both the ChAdOx1 nCoV-19 and BBIBP-CorV vaccine among the HCPs of Nepal reported only mild and constitutional symptoms including injection site pain and tenderness, headache, fever, fatigue, etc. after vaccination.

A Survey on Depressive Symptoms and Its Correlates Amongst Physicians in Bangladesh During the COVID-19 Pandemic

Aim

The aim of this study was to determine the presence of depressive symptoms and understand the potential factors associated with these symptoms among physicians in Bangladesh during the COVID-19 pandemic.

Methods

A cross-sectional study using an online survey was conducted in between April 21 and May 10, 2020, among physicians living in Bangladesh. Participants completed a series of demographic questions, COVID-19-related questions, and the Patient Health Questionnaire-9 (PHQ-9). Descriptive statistics (frequency, percentage, mean and standard deviation), test statistics (chi-squared test and logistic regression) were performed to explore the association between physicians’ experience of depression symptoms and other study variables. Stepwise binary logistic regression was followed while conducting the multivariable analysis.

Result

A total of 390 physicians completed the survey. Of them, 283 (72.6%) were found to be experiencing depressive symptoms. Predictors which were significantly associated with depressive symptoms were gender (with females more likely to experience depression than males), the presence of sleep disturbance, being highly exposed to media coverage about the pandemic, and fear around (a) COVID-19 infection, (b) being assaulted/humiliated by regulatory forces and (c) by the general public, while traveling to and from the hospital and treating patients during the countrywide lockdown.

Conclusion

The findings of this study demonstrate that there is a high prevalence of depressive symptom among physicians especially among female physicians in Bangladesh during the COVID-19 pandemic. Immediate, adequate and effective interventions addressing gender specific needs are required amid this ongoing crisis and beyond.

Anxiety and depressive symptoms among physicians during the COVID-19 pandemic in Bangladesh: a cross-sectional study

Objectives

In addition to risking their physical well-being, frontline physicians are enduring significant emotional burden both at work and home during the coronavirus disease 2019 (COVID-19) pandemic. This study aims to investigate the levels of anxiety and depressive symptoms and to identify associated factors among Bangladeshi physicians during the COVID-19 outbreak.

Methods and design

A cross-sectional study using an online survey following a convenience sampling technique was conducted between April 21 and May 10, 2020. Outcomes assessed included demographic questions, COVID-19 related questions, and the Hospital Anxiety and Depression Scale (HADS).

Results

The survey was completed by 412 Bangladeshi physicians. The findings revealed that, in terms of standardized HADS cut-off points, the prevalence of anxiety and depressive symptoms among physicians was 67.72% and 48.5% respectively. Risk factors for higher rates of anxiety or depressive symptoms were: being female, physicians who had experienced COVID-19 like symptoms during the pandemic, those who had not received incentives, those who used self-funded personal protective equipment (PPE), not received adequate training, lacking perceived self-efficacy to manage COVID-19 positive patients, greater perceived stress of being infected, fear of getting assaulted/humiliated, being more connected with social media, having lower income levels to support the family, feeling more agitated, less than 2 h of leisure activity per day and short sleep duration. All these factors were found to be positively associated with anxiety and depression in unadjusted and adjusted statistical models.

Conclusions

This study identifies a real concern about the prevalence of anxiety and depressive symptoms among Bangladeshi physicians and identifies several associated factors during the COVID-19 pandemic. Given the vulnerability of the physicians in this extraordinary period whilst they are putting their own lives at risk to help people infected by COVID-19, health authorities should address the psychological needs of medical staff and formulate effective strategies to support vital frontline health workers.

Association Between Hair Diseases and COVID-19 Pandemic-Related Stress: A Cross-Sectional Study Analysis

Introduction:

Psychological stress from the ongoing coronavirus disease 2019 (COVID-19) pandemic can potentially aggravate the course of several stress-sensitive skin and hair diseases. This study aimed to determine the potential association of COVID-19 stress with hair diseases, such as telogen effluvium (TE), alopecia areata (AA), and seborrheic dermatitis (SD), among medical students in Bangladesh.

Methods

This online-based cross-sectional study was conducted among 404 medical students of Bangladesh using a self-administered questionnaire, including sociodemographic information, status of hair diseases (i.e., TE, AA, and SD), COVID-19 fear scale, impact of event scale specific for COVID-19 (IES-COVID-19), and COVID-19 student stress questionnaire (CSSQ) scale, to determine pandemic-related stress. The logistic regression model was used to analyze the association.

Results

Overall prevalence of TE, AA, and SD was 61.1, 24.7, and 57.7%, respectively, with female predominance in case of TE and male predominance in case of AA and SD. More than half of the participants had COVID-19-related fear and traumatic stress symptoms. In the multiple logistic regression model, smoking [adjusted odds ratio (aOR) 2.93, 95% CI 1.29–6.65 for AA and aOR 4.19, 95% CI 1.83–9.56 for TE], COVID-19-related fear (aOR 1.70, 95% CI 1.01–2.89 for AA and aOR 2.620, 95% CI 1.25–5.48 for TE), and COVID-19-related traumatic stress symptoms (aOR 1.84, 95% CI 1.08–3.13 for AA, aOR 2.61, 95% CI 1.19–5.68 for TE, and aOR 1.92, 95% CI 1.14–3.25 for SD) were the risk factors of hair fall disorders.

Conclusion

Our study showed that a large number of medical students experienced TE, AA, and SD during the pandemic era. COVID-19-related stress and fear potentially have an association with these diseases.

The Prevalence and Associated Factors of Depressive Symptoms Among Medical Students in Bangladesh During the COVID-19 Pandemic: A Cross-Sectional Pilot Study

Background

Whilst very limited studies have demonstrated a correlation between the COVID-19 pandemic and depressive symptoms amongst Bangladeshi medical students, the prevalence and associated factors of depressive symptoms as measured by the Patient Health Questionnaire (PHQ-9) remains widely unknown.

Objective

The study aimed to investigate the prevalence and factors associated with depression symptoms among Bangladeshi medical students during the COVID-19 pandemic lockdown period.

Method

In this web-based cross-sectional pilot study, medical students' data was collected using the Google Forms web survey platform after obtaining electronic informed consent. A total of 425 medical students were selected using a systematic sampling technique to accumulate depression symptoms and demographic and pandemic-related information. Depression was measured by a self-administered, validated English version of the Patient Health Questionnaire (PHQ-9) tool. The descriptive analysis utilized frequency and percentages, while the stepwise binary logistic regression analysis was performed to investigate the factors associated with depressive symptoms.

Result

Among 425 medical students, 62.3% were female, 97.4% unmarried. Almost 80.2% of medical students had mild to severe levels of depressive symptoms as characterized by PHQ-9. A significantly higher probability of depression was found amongst female students (adjusted OR = 1.8), those who struggled to stay away from social media (adjusted OR = 1.8), those who tried to be optimistic for maintaining better psychology (adjusted OR = 11.1), and those who always had a sleeping difficulty in the last 4 weeks (adjusted OR = 8.9).

Conclusion

A very high prevalence of depression symptoms among Bangladeshi medical students was found across the majority of socio-demographic variables. The alarming prevalence and associated factors of depression suggests the need for follow-intensity psychosocial interventions designed for medical students during the COVID-19 pandemic.

Chikungunya outbreak in Bangladesh (2017): sociodemographic and clinical characteristics of patients from three hotspots

BACKGROUND

Chikungunya is a severely debilitating disease. Bangladesh witnessed one of the largest outbreaks in 2017. Here, we described the clinical profile of the chikungunya outbreak in Bangladesh and its heterogeneity across three hotspots.

METHODS

This was a descriptive cross-sectional study of 432 individuals interviewed from the outpatient department of three study sites (Dhaka, Chittagong, and Sitakundu Upazilla of Bangladesh) after confirmation by the study physicians. Both laboratory-confirmed cases and probable cases were recruited between July and October 2017.

RESULTS

Of all, 18% (79) were laboratory confirmed, and 353 82% (335) were probable cases. The male:female ratio was almost equal (1.09:1), and the predominant age group was 18-59 years. The mean age of the presentation was 36.07 ± 13.62 (SD) years. Fever and arthralgia were the most common presentations and were present in > 95% of cases. Other frequent symptoms were fatigue, myalgia, headache, nausea, and vomiting. Approximately half of the patients had arthritis and erythematous rash. Arthritis was predominant in Chittagong city, while maculopapular rash was not observed in Sitakunda city. However, fatigue, nausea, and vomiting are more common among patients in Dhaka city. Significant heterogeneity of clinical manifestations was present across the three hotspots (p < 0.05 for all). Both confirmed and probable cases shared similar characteristics except muscle ache (p = 0.22) and rash (p = 0.37).

CONCLUSION

The clinical profile of chikungunya virus-induced disease displays significant location-related heterogeneity in Bangladesh during a large outbreak. Although the causes of such differences are unclear, improved public and medical personnel education on this condition may lead to earlier diagnosis and treatment.

Survey on Knowledge, Attitude, Perception and Practice among University Students during the COVID-19 Pandemic

Background: The numbers of infections and death by COVID-19 have continued to rise worldwide and preventive practice has remained to be one of the most effective ways to prevent it. We conducted this study to survey the knowledge, attitude, perception and practice of university students during the early stage of the pandemic in Bangladesh. Methods: This was a cross-sectional study with 305 students from Rajshahi University, conducted between March 11 and March 19, 2020. We developed a questionnaire for collecting information regarding COVID-19 following the instructions and guidelines of WHO and used frequency distribution, Kolmogorov-Smirnov test and Mann-Whitney and Kruskal-Wallis (non-parametric) tests for data analysis. Statistical significance was accepted at p < 0.05. Results: The knowledge of the students on COVID-19 was of average level; however, more than one-third of them were unwilling to avoid public transport and travel public places with friends and family. Their practice of preventive measures was not at a satisfactory level. More than one-third of them were not keen to stay home and not hesitant to visit crowded places. About half of the students thought the pandemic would not affect their daily activities, and most of them felt it would not affect their study, financial status, fieldwork of their course, or meeting with their friends and relatives. Female students were found more knowledgeable than male ones. Conclusions: The general knowledge of students had an average level on COVID-19, but their attitude, perception and preventive practices were not consistent with their level of education. The authorities should consider the findings while promulgating policies and implementing measures for the prevention of COVID-19. Doi: 10.28991/SciMedJ-2021-03-SI-9 Full Text: PDF

Microwave resonator array with liquid metal selection for narrow band material sensing

A microwave resonator array is integrated with liquid metal to select an individual resonator response within a resonator array, enabling simple and accurate analysis for dielectric sensing. Galinstan, a liquid metal, acts as a multiplexer by inducing a capacitive load to the nearby resonator, lowering its resonant frequency, and thereby isolating its resonant response from other resonators in the array. The liquid metal could be positioned within a fluidic channel to be above any of the resonators, which tuned the resonant frequency from 3.9 to 3.3 GHz where it can be analyzed individually. The resonators showed a consistent response to liquid metal tuning, with tuning error measured below 30 MHz (5%). The sensor also exhibited stable sensitivity to test materials placed on the selected resonator, with a maximum resonant frequency shift of 300 MHz for a dielectric test material (ε = 10.2) and almost no variation in resonant amplitude. The selected resonant response was only sensitive to materials on the selected resonator, and was unaffected by test materials, even when placed on other resonators. The presented design enabled robust and accurate detection of materials using planar microwave resonators that can be controlled at a user’s convenience, specifically for use in systems where multiple parameters or system settings may need to be individually determined.

Immediate psychological responses during the initial period of the COVID-19 pandemic among Bangladeshi medical students

BACKGROUND

The most recent global pandemic of COVID-19 has been creating multidimensional damages, including a detrimental impact on the mental health status of individuals. Medical students, a vulnerable cross-section of the population, may have perceived a myriad of psychological stressors during this crisis in the background of their prevailing stressful academic pressure and preexisting higher psychological and mental health issue.

OBJECTIVE

To determine the prevalence of anxiety and depressive symptoms and to elucidate the psychological impact of COVID-19 pandemic on Bangladeshi medical students.

METHOD

A cross-sectional study design was utilized to conduct this survey. The online survey including demographic questions, COVID-19 related questions, and the Hospital Anxiety and Depression Scale (HADS; higher scores on the subscales indicate higher levels of depressive and anxiety symptoms), was completed by 425 Bangladeshi medical students. Collected data were statistically analyzed by using SPSS (version 25.0) software.

RESULT

The HADS anxiety subscale revealed that 65.9% of the medical students had different levels of anxiety, ranging from mild (27.3%), moderate (26.8%), and severe (11.8%). As per HADS depression subscale, 49.9% of the medical students had varying degrees of depressive symptoms, with 3.3% of the participants had suffered from severe depressive symptoms. Female students had a relatively more anxiety and depressive symptoms when compared with males. The students, who were severely tensed of getting infected by the virus, were at higher risk of suffering from anxiety (3.5-fold) and depressive (2.7-fold) symptoms, when compared with no/minimally stressed students. Besides, fear of getting assaulted or humiliated on the way to hospital or home, not to be able to give maximum concentration on study after COVID-19 pandemic, students' present emotional status (agitation), had statistically significant higher risk of anxiety.

CONCLUSION

A substantial proportion of Bangladeshi medical students are experiencing pandemic-related adverse psychological impact. Poor mental health conditions of these vulnerable medical students pose important threat to their potential contribution in future health care. Thus, medical colleges and health authorities should focus on addressing their psychological needs and formulate effective strategies to ameliorate medical students' mental health status, particularly during any infectious disease outbreak.

Willingness to work during initial lockdown due to COVID-19 pandemic: Study based on an online survey among physicians of Bangladesh

BACKGROUND

During the catastrophic situation of the COVID-19 pandemic, the role of the health care workers (HCWs) is the most crucial, and their absenteeism, whether due to inability or unwillingness, becomes a major concern for the national health system. Hence, the present study aimed to determine the willingness and its associated factors to work during the COVID-19 pandemic among the physicians of Bangladesh.

METHODS

This was a cross-sectional study conducted from April 21 to May 10, 2020, using an online survey among the Bangladeshi physicians living in the country. Both univariate and multivariable binary logistic regression models were used to determine the predictors of the willingness of the physicians to work during the COVID-19 pandemic.

RESULTS

More than 69% physicians reported that they were willing to work during the COVID-19 pandemic, 8.9% reported that they were not willing, while 21.4% of participants were not sure about their willingness. Younger age, having experience of treating patients during previous pandemics, working in the emergency departments and high self-reported compliance to the recommended PPE were important predictors of being willing to work during COVID-19 pandemic. Concern for family and risk of transmitting the infection to family members were most commonly reported as major barriers of working during the pandemic (30%) followed by having comorbidities (25%), lack of adequate safety measures (25%), fear of being infected (12.2%), not involved in clinical practice (12.5%) etc.

CONCLUSIONS

Though the majority of the physicians were willing to work during the COVID-19 pandemic, sufficient supply of PPE, support to maintain recommended quarantine and isolation policy after risky hospital duty along with adequate and effective training can increase their willingness to continue their sacred duty during this crucial pandemic.

Prevalence of anxiety and depressive symptoms among physicians during the COVID-19 pandemic in Bangladesh: a cross-sectional study

OBJECTIVES

In addition to risking their physical well-being, frontline physicians are enduring significant emotional burden both at work and home during the COVID-19 pandemic. This study aims to investigate the levels of anxiety and depressive symptoms and to identify associated factors among Bangladeshi physicians during the COVID-19 outbreak.

METHODS AND DESIGN

A cross-sectional study using an online survey was conducted between April 21 and May 10, 2020. Outcomes assessed included demographic questions, COVID-19 related questions, and the Hospital Anxiety and Depression Scale (HADS).

RESULTS

The survey was completed by 412 Bangladeshi physicians. The findings revealed that, in terms of standardized HADS cut-off points, the prevalence of anxiety and depressive symptoms among physicians was 67.72% and 48.5% respectively. Risk factors for higher rates of anxiety or depressive symptoms were: being female, physicians who had experienced COVID-19 like symptoms during the pandemic, those who had not received incentives, those who used self-funded PPE, not received adequate training, lacking perceived self-efficacy to manage COVID -19 positive patients, greater perceived stress of being infected, fear of getting assaulted/humiliated, being more connected with social media, having lower income levels to support the family, feeling more agitated, less than 2 hours of leisure activity per day and short sleep duration. All these factors were found to be positively associated with anxiety and depression in unadjusted and adjusted statistical models.

CONCLUSIONS

This study identifies a real concern about the prevalence of anxiety and depressive symptoms among Bangladeshi physicians and identifies several associated factors during the COVID-19 pandemic. Given the vulnerability of the physicians in this extraordinary period whilst they are putting their own lives at risk to help people infected by COVID-19, health authorities should address the psychological needs of medical staff and formulate effective strategies to support vital frontline health workers.

STHRENGHTS & LIMITATIONS OF THE STUDY

This study reports a novel and concerning findings on the prevalence of anxiety and depression symptoms with identification of several important associated factors among Bangladeshi physicians during the COVID-19 pandemic.The cross-sectional nature of the study design could not establish causal relationship between the dependent and independent variables.This study was carried out by conducting a web-based survey, which might generate sampling bias by excluding the physicians who do not have access to internet or inactive in social medias, and thus limit the generalizability of the findings.

Risk factors and etiology of neonatal sepsis after hospital delivery: A case-control study in a tertiary care hospital of Rajshahi, Bangladesh

BACKGROUND

Sepsis is one of the major causes of neonatal death worldwide as well as in Bangladesh. The objective of the present study was to identify the risk factors and causative organisms of neonatal sepsis after delivery in a tertiary care hospital, Bangladesh.

METHODS

This was a case-control study conducted in the neonatal ward of Rajshahi Medical College Hospital (RMCH), a 1000-bed tertiary hospital situated in Rajshahi, Bangladesh. Neonates diagnosed as neonatal sepsis by clinical and laboratory parameters were included as cases in this study. Admitted neonates unsuspected or undiagnosed for sepsis were considered as controls. Maternal and neonatal information and their laboratory reports were collected and analyzed. Both bivariate and multiple logistic regression models were used to identify the risk factors of neonatal sepsis.

RESULTS

A total of 91 cases and 193 controls were included in the study. Maternal history of urinary tract infection (UTI) during the third trimester of pregnancy (aOR 2.75, 95% CI: 1.04-7.23, p <0.05), premature birth (aOR 2.77, 95% CI: 1.08-7.13, p <0.05) and APGAR score <7 at five minutes (aOR 2.58, 95% CI: 1.04-6.39, p <0.05) were associated with onset of neonatal sepsis in multiple logistic regression model. All these factors were also associated with developing early-onset neonatal sepsis, while maternal UTI and male sex of neonates were associated with developing late-onset neonatal sepsis. Escherichia coli (40.7%), Staphylococcus aureus (27.5%), and Klebsiella pneumoniae (18.7%) were the commonly isolated organisms causing neonatal sepsis. All these organisms were highly resistant to common antibiotics like amoxicillin, cephalosporins, aminoglycosides and quinolones. Carbapenemase group of drugs along with amikacin, nitrofurantoin and linezolid were the most sensitive drugs.

CONCLUSIONS

Strengthening the existing facility for antenatal screening for early diagnosis and treatment of maternal infection during pregnancy as well as identifying high-risk pregnancy for adequate perinatal management is necessary to prevent neonatal sepsis-related morbidity and mortality. Rational use of antibiotics according to local epidemiology and culture and sensitivity reports may minimize the increasing hazards of antibiotic resistance.

High prevalence of multidrug resistant uropathogens: A recent audit of antimicrobial susceptibility testing from a tertiary care hospital in Bangladesh

Objectives:

Urinary tract infections due to multi drug resistant bacteria have been on the rise globally with serious implications for public health. The objective of this study was to explore the prevalence of multi drug resistant uropathogens and to correlate the urinary tract infections with some demographic and clinical characteristics of patients admitted in a tertiary care hospital in Bangladesh.

Methods:

A cross sectional prospective study was conducted at Shaheed Ziaur Rahman Medical College Hospital, Bogura, Bangladesh among clinically suspected urinary tract infection patients from January to December, 2018. Clean-catch midstream or catheter-catch urine samples were subjected to bacteriological culture using chromogenic agar media. Antimicrobial susceptibility testing of the isolates was done by Kirby-Bauer disk diffusion method following Clinical and Laboratory Standards Institute guidelines. Descriptive statistical methods were used for data analysis.

Results:

Culture yielded a total of 537 (42.8%) significant bacterial growths including 420 (78.2%) multi drug resistant uropathogens from 1255 urine samples. Escherichia coli was the most common isolate (61.6%) followed by Klebsiella spp. (22.5%), Pseudomonas spp. (7.8%), Staphylococcus aureus (5.4%) and Enterobacter spp. (2.6%) with multi drug resistance frequency of 77.6%, 71.9%, 90.5%, 86.2% and 92.9% respectively. There was female preponderance (M:F; 1:1.97; P=0.007) but insignificant differences between paediatric and adult population (43.65% vs. 42.57%) and also among different age groups. Diabetes, chronic renal failure, fever and supra-pubic pain had significant association as co-morbidities and presentations of urinary tract infections (P<0.05). Multi drug resistance ranged from 3.7 to 88.1% including moderate to high resistance found against commonly used antibiotics like ciprofloxacin, cephalosporin, azithromycin, aztreonam, cotrimoxazole and nalidixic acid (28.6 to 92.9%). Isolates showed 2.4 to 32.2% resistance to nitrofurantoin, amikacin, netilmicin and carbapenems except Pseudomonas spp. (66.7% resistance to nitrofurantoin) and Enterobacter spp. (28.6 to 42.9% resistance to carbapenems).

Conclusion:

There is very high prevalence of multi drug resistant uropathogens among hospitalized patients and emergence of carbapenem resistance is an alarming situation. Antibiotic stewardship program is highly recommended for hospitals to combat antimicrobial resistance.

A hospital-based study on complementary and alternative medicine use among diabetes patients in Rajshahi, Bangladesh

Background

The use of complementary and alternative medicine (CAM) among type 2 diabetes mellitus (T2DM) patients is increasing worldwide. It can affect optimum glycemic management. This study was to determine the rate and influencing factors of CAM use among diabetes patients as well as their effect on glycemic control.

Methods

This cross-sectional study was conducted among T2DM patients attending the outpatient department of Rajshahi Medical College Hospital. It is a tertiary hospital in the northern part of Bangladesh. A face-to-face interview with a pretested structured questionnaire was used for data collection. Chi-square (χ²) test and multivariate logistic regression model were used in this study for data analysis.

Results

Out of 244 T2DM patients, 86 (35.2%) used CAM. Multivariate logistic regression model showed that lower family income group (AOR = 8.7, 95% CI: 2.15–35.22, p-value 0.002), having no institutional education (AOR = 3.4, 95% CI: 1.17–9.87, p-value 0.025) and having diabetes for more than five years (AOR = 2.821, 95% CI: 1.34–5.94, p-value 0.006) were the most influential predictors of CAM use. The most commonly used CAMs were herbal products (67.4%) and homeopathic medicine (37.2%). Most of the CAM users (72%) were influenced by friends, neighbors, and family members. The most common reasons behind CAM use were reported to be the belief that CAM helped control diabetes better (44.2%) and easy availability and lower cost (27.9%). More than half of the users reported the efficacy of CAM as ‘nothing significant’, while others reported as somewhat good. 14% of CAM users experienced side-effects, especially gastrointestinal upset. It was observed that using CAM was associated with poor glycemic control (AOR = 2.25, 95% CI: 1.14–4.44, p-value 0.018).

Conclusion

Our study demonstrated that some modifiable factors are associated with the use of CAM, and it cannot maintain good glycemic control. So, patients should be made aware of the ineffectiveness and bad effects of CAM by enhancing educational and poverty-alleviating programs.

Psychological Implications of Unemployment Among Bangladesh Civil Service Job Seekers: A Pilot Study

Background: Recent trends suggest that university graduates seeking jobs are more susceptible to common mental disorders, such as depression, anxiety, or stress. However, the mental health issues among unemployed graduates has not been explored in Bangladesh yet. Aims: This study aimed to assess for the first time the prevalence and associated risk factors of depression, anxiety, and stress among Bangladesh Civil Service (BCS) job seekers. Three hundred four graduates residing in Rajshahi, Bangladesh, who were preparing to attend the 40^th BCS examination, the most sought-after employment opportunity in the country, were surveyed. Methods: Measures included socio-demographics, field of study, and career-related variables, and the Bangla Depression Anxiety Stress Scale (DASS-21). Chi-square test, Fisher exact test, and binary logistic regression with "depression," "anxiety," and "stress" as the dependent variables were carried out to identify the factors associated with these. Results: Overall, the prevalence of moderate to extremely severe depression, anxiety, and stress was 49.3%, 53.6%, and 28.3%, respectively, with no detectable differences between genders. Insecurity related to a BCS job (OR = 0.41; CI = 0.26-0.65, p < 0.001; ref: job insecurity), family and social pressure to obtain a BCS job (OR = 4.58; CI = 1.67-12.56, p < 0.001), and stress (OR = 8.33; CI = 4.47-15.51, p < 0.001) emerged as independent predictors for depression. In addition, having part-time job was associated with anxiety (OR = 2.38; CI = 1.34-4.23, p = 0.003), and security in a BCS job and serving the nation through this job were negatively associated with stress (OR = 0.59; CI = 0.35-0.98, p = 0.042 vs. OR = 0.59; CI = 0.36-1.00, p = 0.05). Conclusion: The relatively high rates of depression, anxiety, and stress among graduate job seekers should prompt implementation of market force initiatives that incorporate interventions related to the major risk factors uncovered herein.

Conversion of regional to general anaesthesia at caesarean section: increasing the use of regional anaesthesia through continuous prospective audit

BACKGROUND

Anaesthetic-related maternal deaths have largely been attributed to complications of general anaesthesia. In our unit a retrospective audit conducted between 1997 and 2002 showed a 9.4% conversion rate to general anaesthesia for caesarean sections amongst women with epidural catheters in-situ. The Royal College of Anaesthetists has stated that <3% of cases should need conversion to general anaesthesia. To improve our figures, from 2004 to 2007 we prospectively audited all caesarean sections requiring general anaesthesia.

METHODS

Data were collected on the number of caesarean sections, initial anaesthetic technique used, need for conversion either pre- or intra-operatively and the use of labour epidural analgesia, where an epidural had been in-situ.

RESULTS

There were 2273 caesarean sections during the audit period. Neuraxial anaesthesia rates were for elective cases 95.3% (2004), 96.3% (2005), 98.3% (2006) and 98.2% (2007) and for emergency cases 82.3% (2004), 88.6% (2005), 87.0% (2006) and 85.7% (2007). Common reasons given for not using a regional technique were urgency of delivery (category 1) or anticipated large blood loss. Conversion rates from regional to general anaesthesia for elective cases were 0.8% (2004), 2.5% (2005), 0.5% (2006) and 0% (2007), and for emergencies 7.8% (2004), 2.7% (2005), 3.7% (2006) and 5.4% (2007). Improvements were seen in all but category-1 caesarean sections.

CONCLUSIONS

Prospective audit has been associated with improved rates for neuraxial anaesthesia and reduced need for conversion to general anaesthesia in all but category-1 caesarean sections. The Royal College of Anaesthetists standards may need to be reviewed to become category-specific.

Peripheral neuropathy with hypomyelinating features in adult-onset Krabbe's disease

We describe three brothers suffering from Krabbe's disease with onset in the fifth decade. The proband showed a complete deficiency of leukocyte enzyme galactocerebrosidase and was found to be heterozygous for two previously described mutations: G > A809 and 502T/del consisting of a 30 kb deletion. In all three brothers the neurological examination showed features of asymmetrical peripheral neuropathy associated with pyramidal signs and the electrophysiological examination showed a generalized slowing of nerve conduction velocities. Two patients died at 59 and 61 years of age due to respiratory failure. Both the proband and his brother underwent a sural nerve biopsy. In the former the most striking finding was the presence of uniformly thin myelin sheaths without evidence of demyelination; a complete absence of fibers was found in the latter. Our findings confirm that peripheral neuropathy may be the presenting feature of late-onset Krabbe's disease. Hypomyelination rather than demyelination may represent the distinguishing pathological finding of this condition.

Retrovirus-mediated gene transfer and galactocerebrosidase uptake into twitcher glial cells results in appropriate localization and phenotype correction

Galactocerebrosidase (GALC) is deficient in all tissues from human patients and animal models with globoid cell leukodystrophy (GLD) or Krabbe disease. The deficiency results in decreased lysosomal catabolism of certain galactolipids including galactosylceramide and psychosine that are synthesized maximally during myelination. According to current theories, the accumulation of psychosine in humans and animals with GLD induces oligodendrocyte degeneration and myelination ceases. Transduction of oligodendrocytes from twitcher mice with a retroviral vector containing the GALC cDNA can correct the enzyme deficiency in these cells. Our data show that twitcher astrocytes and oligodendrocytes can internalize exogenous GALC, as well as donate the enzyme to the mutant glial cells. Antibodies against human GALC localized the GALC antigen in retrovirally transduced cells and cells receiving enzyme via cell to cell secretion and uptake to the lysosomal fraction. In fact immunocytochemical studies in transduced oligodendrocytes revealed that the GALC colocalizes in vesicles lysosomal-associated membrane protein-2 (LAMP2) (+). Moreover, labeling cells with anti-GALC and a marker for oligodendrocytes demonstrated that, upon differentiation, transduced, twitcher oligodendrocytes attained the normal branched process configuration, while untransduced cells show only abnormal morphology. Phenotype correction in mutant oligodendrocytes has also been observed after enzyme transfer. These studies indicate that GALC activity supplied to cultured oligodendrocytes from twitcher mice by different methods can correct the pathological phenotype of these cells.

Generation of a mouse with low galactocerebrosidase activity by gene targeting: a new model of globoid cell leukodystrophy (Krabbe disease)

Globoid cell leukodystrophy (Krabbe disease) is a severe leukodystrophy caused by mutations in the galactocerebrosidase (GALC) gene leading to extremely low (less than 5% of normal activity) GALC activity. Human patients include primarily severely affected infants as well as patients with a later onset of symptoms. The infants usually die before 2 years of age, but it is difficult to predict the clinical course in older patients. In addition to these patients, additional individuals identified in this laboratory have 10--20% of normal GALC activity measured in accessible tissues. These individuals have a wide range of clinical presentations involving neurological degeneration. On molecular analysis of the GALC gene they all have three or more mutations considered to be normal polymorphisms resulting in amino acid changes in the two copies of the GALC gene. In order to investigate the role these amino acid changes may play on clinical, biochemical, and pathological findings, a new transgenic mouse was generated by homologous recombination. After preliminary studies determined what effect each amino acid change had on mouse GALC activity in transient transfection experiments, mice containing a cysteine residue at codon 168 instead of histidine (H168C) were produced. These mice developed symptoms, but they were delayed by 10--15 days from the well-characterized twitcher (twi) mouse. They accumulated psychosine slightly slower than twi mice, showed pathological changes less severe than twi mice in the central and peripheral nervous systems, and live about 15 days longer than twi mice. They have large litters and will play a role in therapy trials using new procedures currently under development.

Molecular genetics of Krabbe disease (globoid cell leukodystrophy): diagnostic and clinical implications

Galactocerebrosidase (GALC) is a lysosomal beta-galactosidase responsible for the hydrolysis of the galactosyl moiety from several galactolipids, including galactosylceramide and psychosine. The deficiency of this enzyme results in the autosomal recessive disorder called Krabbe disease. It is also called globoid cell leukodystrophy (GLD), because of the characteristic storage cells found around cerebral blood vessels in the white matter of affected human patients and animal models. Although most patients present with clinical symptoms before 6 months of age, older patients, including adults, have been diagnosed by their severe deficiency of GALC activity. More than 40 mutations have been identified in patients with all clinical types of GLD. While some mutations clearly result in the infantile type if found homozygous or with another severe mutation, it is difficult to predict the phenotype of novel mutations or when mutations are found in the heterozygous state. A high incidence of polymorphic changes on apparent disease-causing alleles also complicates the interpretation of the effects of mutations. The detection of mutations has greatly improved carrier identification among family members and will permit preimplantation diagnosis for some families. The molecular characterization of the naturally occurring mouse, dog, and monkey models will permit their use in trials to evaluate different modes of therapy.

Krabbe disease: genetic aspects and progress toward therapy

Krabbe disease or globoid cell leukodystrophy is a disorder involving the white matter of the peripheral and central nervous systems. Mutations in the gene for the lysosomal enzyme galactocerebrosidase (GALC) result in low enzymatic activity and decreased ability to degrade galactolipids found almost exclusively in myelin. The pathological changes observed, including the presence of globoid cells and decreased myelin, appear to result from the toxic nature of psychosine and accumulation of galactosylceramide that cannot be degraded due to the GALC deficiency. Over 60 mutations have been identified in this gene. The great majority are disease-causing; however, a few are considered polymorphisms. While most patients present with symptoms within the first 6 months of life, others present later in life including adulthood. Even patients with the same genotype can have very different clinical presentations and course. The reason for this is not known. Treatment at this time is limited to hematopoietic stem cell transplantation that appears to slow the progression of the disease and improve the magnetic resonance images. Studies using stem cells and viral vectors to transduce transplantable cells are under way in model systems. In culture, oligodendrocytes from the twitcher mouse model can assume a normal appearance after differentiation if GALC activity is provided via viral transduction or uptake from donor cells. Therefore continued myelination and/or remyelination in patients will require supplying GALC activity by transplanted cells or viral vectors to still functional endogenous oligodendrocytes or transplantation of normal oligodendrocytes or stem cells that can differentiate into oligodendrocytes. Using the animal models these options can be explored.

Protracted course of Krabbe disease in an adult patient bearing a novel mutation

BACKGROUND

Krabbe disease, or globoid cell leukodystrophy, is an autosomal recessive disorder caused by the deficiency of galactocerebrosidase (GALC) activity. Although most cases are diagnosed in infancy and show a fatal outcome in childhood, adult patients have been identified, showing progressive spastic hemiparesis to tetraparesis, followed by optic atrophy, dementia, and neuropathy. The disease can be diagnosed by detecting the deficiency of GALC activity (less than 5% of normal) in any available tissue sample. The cloning of the human GALC gene allowed the molecular characterization of newly diagnosed patients. More than 75 disease-causing mutations and polymorphisms in this gene have been identified.

OBJECTIVE

To describe a 28-year-old woman with Krabbe disease, correlating clinical and biochemical abnormalities to a novel mutation on the GALC gene.

METHODS

Clinical investigation was enriched by neurophysiological and neuroimaging data. The activity of GALC was assayed in white blood cells using radiolabeled natural substrate. Genomic DNA was isolated from peripheral blood, and the GALC gene was sequenced. The mutated gene was expressed and GALC activity was measured in transfected COS-1 cells.

RESULTS

The patient had progressive and bilateral amaurosis starting at 8 years of age. Although she was experiencing weakness in all her extremities, her intellect remained intact. She was found to be homozygous for a previously unreported missense mutation (T1886G), which leads to low, but not totally deficient, GALC activity.

CONCLUSIONS

Expression of this mutation in COS-1 cells using the pcDNA3 expression vector (Invitrogen, Carlsbad, Calif) resulted in low, although not null, GALC activity, which can explain the protracted clinical course in this patient. Patients carrying the mutation described herein might be potential candidates for therapeutic trials, such as bone marrow transplantation or gene therapy.

Transduction of cultured oligodendrocytes from normal and twitcher mice by a retroviral vector containing human galactocerebrosidase (GALC) cDNA

Krabbe disease or globoid cell leukodystropy is a lysosomal disorder caused by a deficiency of galactocerebrosidase (GALC) activity. This results in defects in myelin that lead to severe symptoms and early death in most human patients and animals with this disease. With the cloning of the GALC gene and the availability of the mouse model, called twitcher, it was important to evaluate the effects of providing GALC via a retroviral vector to oligodendrocytes in culture. After differentiation, the untransduced cells from normal mice extended highly branched processes while those from the twitcher mice did not. Oligodendrocytes in culture can be readily transduced to produce much higher than normal levels of GALC activity. Transduced normal and twitcher cells formed clusters when plated at high density. Transduction of twitcher oligodendrocytes plated at lower density, followed by differentiation, resulted in some cells having a completely normal appearance with highly branched processes. Other cells showed retraction and fragmentation. Perhaps over expression of GALC activity may be detrimental to oligodendrocytes. These studies demonstrate that the phenotype of twitcher oligodendrocytes can be corrected by providing GALC via gene transfer, and this could lead the way to future studies to treat this disease.

Globoid cell leukodystrophy in cairn and West Highland white terriers

Krabbe disease or globoid cell leukodystrophy (GLD) is an autosomal recessive disorder resulting from the defective lysosomal hydrolysis of specific galactolipids found primarily in myelin. This leads to severe neurological symptoms including seizures, hypotonia, blindness, and death, usually before 2 years of age in human patients. In addition to human patients, several animals, including dog, mouse, and monkey, have the same disease caused by a deficiency of galactocerebrosidase (GALC) activity. In this article we describe studies in cairn and West Highland white terriers (WHWT) affected with GLD. Through a screening test based on the molecular defect found in these breeds, over 50 cairn terrier carriers have been identified and a colony of five carrier dogs has been established. Affected dogs from this colony plus an affected WHWT were available for study. An affected WHWT was evaluated by magnetic resonance imaging at 6 and 11 months of age and pronounced changes in the T-2 weighted fast spin-echo images were found. Biochemical and pathological evaluation of the same dog after euthanasia at 12 months of age showed a large accumulation of psychosine in the brain and white matter filled with globoid cells. Some comparisons were made to younger affected and carrier dogs. Studies have shown successful transduction of cultured skin fibroblasts from an affected dog and normal canine bone marrow using a retroviral vector containing the human GALC cDNA. Successful treatment of this canine model will lead to studies in some humans with GLD.

Genetic galactocerebrosidase deficiency (globoid cell leukodystrophy, Krabbe disease) in rhesus monkeys (Macaca mulatta)

Globoid cell leukodystrophy, or Krabbe disease, is a severe disorder of the peripheral and central nervous system myelin caused by deficient galactocerebrosidase (GALC) activity. This autosomal recessive disease affects humans and animals including dogs, mice, and rhesus monkeys. Cloning of the human and animal GALC genes opened opportunities for therapeutic trials using animal models. We describe the clinical, pathologic, and biochemical features of the affected rhesus monkey. Affected monkeys had very low GALC activity and a two base pair deletion in both copies of the GALC gene. Clinical signs of tremors, hypertonia, and incoordination led to humane euthanasia by 5 months of age. At necropsy, peripheral nerves were enlarged. Microscopically, the cerebral, cerebellar, and spinal cord white matter was infiltrated with periodic acid-Schiff-positive multinucleated globoid cells, and there was a striking lack of myelin. Peripheral nerve fibers were decreased in number and separated by Alcian blue- and safranin O-positive material. Myelin sheaths were greatly diminished. Lipid analysis of brains of 12-day-old and 158-day-old affected monkeys revealed a great excess of psychosine in white matter. The rhesus monkey model will be especially useful for exploring treatment options, including prenatal bone marrow transplantation and various approaches to gene therapy.

Analysis of the 5' flanking region of the human galactocerebrosidase (GALC) gene

Galactocerebrosidase (GALC) is the lysosomal enzyme deficient in human and certain animal species with globoid cell leukodystrophy (GLD) or Krabbe disease. It catalyzes the hydrolysis of specific galactolipids including galactosylceramide and psychosine. The GALC protein is found in very low amounts in all tissues, which delayed its purification and the subsequent cloning of its cDNA and gene. We previously published the exon-intron organization of the human gene, but did not functionally analyze the 5' flanking region. We now provide a description of this GC-rich region which includes one potential YY1 element and one potential SP1 binding site. There are 13 GGC trinucleotides within the first 150 bp preceding the initiation codon. The 5' end of intron 1 contains six potential Sp1 binding sites, one AP1 binding site, and eight AP2 binding sites. A construct containing nucleotides -176 to -24 had the strongest promoter activity using a vector containing the chloramphenicol acetyltransferase reporter gene. We also provide evidence for the presence of inhibitory sequences located immediately upstream of the promoter region, and within the first 234 nucleotides of intron 1. These elements together with a suboptimal nucleotide at position +4 may explain the low level of GALC protein in all cell types.

Prevalent mutations in the GALC gene of patients with Krabbe disease of Dutch and other European origin

Sixty-four unrelated patients with infantile Krabbe disease (globoid cell leukodystrophy, GLD) of Dutch (n = 41) or other European origin (n = 23) were screened for the presence of a large 30 kb deletion starting in intron 10 (IVS10del30 kb), a base substitution 1538T(T513M) and a polymorphism, 502T. The deletion and the T513M mutation were present in 52% and 8.5%, respectively, of the 82 GALC alleles of the Dutch patients. The 502T polymorphism, which had an allele frequency of 5.3% in a Dutch control panel, occurred in 65% of the GLD alleles. Analysis of patients and both parents in 26 of the families showed that del30 kb was invariably associated with 502T. However, 502T was also present on 40% of the GLD alleles with an as yet unidentified mutation, which is 7.5 times higher than its frequency in controls. This suggests that besides del30 kb at least one other relatively frequent mutation has arisen on the 502T GALC allele. A relatively high incidence of del30 kb was also found in 23 other European (non-Dutch) patients (allele frequency 35%), but T513M did not occur in this group. Practical examples described in this report illustrate the potential usefulness of mutation analysis in many families with Krabbe disease for heterozygote detection and prenatal diagnosis.

Characterization of the rhesus monkey galactocerebrosidase (GALC) cDNA and gene and identification of the mutation causing globoid cell leukodystrophy (Krabbe disease) in this primate

Krabbe disease or globoid cell leukodystrophy (GLD) is a severe lysosomal disorder resulting from the deficiency of galactocerebrosidase (GALC) activity. This deficiency results in the insufficient catabolism of several galactolipids that are important in the production of normal myelin. Since the cloning of the human GALC cDNA and gene many disease-causing and polymorphic changes have been identified. This autosomal recessive disease has been reported to occur in several animal species, and recently the murine and canine GALC genes have been cloned. We now describe the cloning of the GALC cDNA and gene from the rhesus monkey and the identification of the mutation causing GLD in this species. The nucleotide sequence of the coding region and the gene organization were nearly identical to human. The deduced amino acid sequence of the monkey GALC was compared to the human, dog, and mouse, and it was found to be 97, 87, and 83% identical, respectively. The mutation causing GLD in the rhesus monkey is a deletion of AC corresponding to cDNA positions 387 and 388 in exon 4. This results in a frame shift and a stop codon after 46 nucleotides. A rapid method to detect this mutation was developed, and when 45 monkeys from this colony were tested, 22 were found to be carriers. The availability of this nonhuman primate model of GLD will provide unique opportunities to evaluate treatment for this severe disease.

Retroviral vector-mediated transfer of the galactocerebrosidase (GALC) cDNA leads to overexpression and transfer of GALC activity to neighboring cells

Galactocerebrosidase (GALC) is responsible for the lysosomal catabolism of certain galactolipids, including galactosylceramide and psychosine. Patients with GALC deficiency have an autosomal recessive disorder known as globoid cell leukodystrophy (GLD) or Krabbe disease. Storage of undegraded glycolipids results in defective myelin and the characteristic globoid cells observed on pathological examination of the central and peripheral nervous systems. Most patients have the infantile form of GLD, although older individuals are also diagnosed. Recently the human, mouse, and canine GALC genes were cloned, and mutations causing GLD have been identified. We now describe the construction of a vector containing human GALC cDNA (MFG-GALC), and the transduction of cultured skin fibroblasts from molecularly characterized Krabbe disease patients, as well as rat brain astrocytes and human CD34(+) hematopoietic cells, using retrovirus produced by the psi-CRIP amphotropic packaging cell line. The transduced fibroblasts showed extremely high GALC activity (up to 20,000 times pretreatment levels, about 100 times normal). GALC was secreted into the media and was taken up by untransduced fibroblasts from the same or a different patient. Mannose-6-phosphate receptor-mediated uptake was only partially responsible for the efficient transfer of GALC to neighboring cells. Additional studies confirmed the presence of normal GALC cDNA and mRNA in the transduced cells. The GALC produced by the transduced cells and donated to neighboring untransduced cells was localized to lysosomes as demonstrated by the normal metabolism of [14C]stearic acid-labeled galactosylceramide produced from endocytosed [14C]sulfatide.

Multiple mutations in the GALC gene in a patient with adult-onset Krabbe disease

A 53-year-old man was diagnosed 8 years earlier with globoid cell leukodystrophy (GLD, Krabbe disease) by his severe deficiency of galactocerebrosidase (GALC) activity. He was found to have eight nucleotide changes on the two copies of his GALC gene, including two in the leader sequence, four considered polymorphisms, and two unique mutations.

Cloning of the canine GALC cDNA and identification of the mutation causing globoid cell leukodystrophy in West Highland White and Cairn terriers

Globoid cell leukodystrophy, or Krabbe disease, is a severe, autosomal recessive disorder resulting from a deficiency of galactocerebrosidase (GALC) activity. GALC is responsible for the lysosomal catabolism of certain galactolipids, including galactosylceramide and psychosine. In addition to the human patients, there are several naturally occurring animal models for this disease, including the twitcher mouse, West Highland White terriers (WHWT), and Cairn terriers. All species have deficient GALC activity and have the characteristic pathological findings in the nervous system. We now describe the cloning of the canine GALC cDNA and the identification of the disease-causing mutation in both terrier breeds. The 2007-bp open reading frame is 88% identical to that in human, and the deduced amino acid sequence is about 90% identical. However, the 3'-untranslated region is about 1 kb shorter than that in the human. Two nucleotide changes were found in affected dogs, an A to C transversion at cDNA position 473 (Y158S) and a C to T transition at position 1915 (P639S). Expression studies in COS-1 cells demonstrated that the A to C change at 473 is the disease-causing mutation. A rapid test for the identification of the genotype at that position has been developed, and over 100 WHWT and Cairn terriers have been screened. This will allow breeders to mate their dogs selectively and will permit the establishment of a colony of dogs for use in therapy trials.

Two different mutations are responsible for Krabbe disease in the Druze and Moslem Arab populations in Israel

Infantile Krabbe disease is a severe, fatal autosomal recessive disorder resulting from the deficiency of galactocerebrosidase (GALC) activity. It is relatively common in two separate inbred communities in Israel. In the Druze community in Northern Israel and two Moslem Arab villages located near Jerusalem the incidence of Krabbe disease is about 1 in 100-150 live births. With our cloning of the GALC gene, mutation analysis of these populations was undertaken. The Moslem Arabs were homozygous for two mutations in the GALC gene; a T-to-C transition at CDNA position 1637 (counting from the A of the initiation codon), which is considered a polymorphism and a G-to-A transition at position 1582, which changes the codon for aspartic acid to one for asparagine. The Druze patients are homozygous for a T-to-G transversion at position 1748, which changes the codon for isoleucine to one for serine. Expression studies confirmed the deleterious nature of these mutations. The development of a simple polymerase chain reaction (PCR) amplification and restriction enzyme digestion method to identify these alleles will lead to accurate carrier testing and improved genetic counseling for interested individuals in these communities.

Characterization of the large deletion in the GALC gene found in patients with Krabbe disease

Globoid cell leukodystrophy (GLD) of Krabbe disease results from mutations in the galactocerebrosidase (GALC) gene. Previously, we had identified a large deletion in the GALC gene together with a C to T polymorphism at cDNA position 502 in a significant number of cases of infantile Krabbe disease; however, the deletion breakpoint had not been found. In this paper we show that the deletion is approximately 30 kb starting near the middle of the 12 kb intron 10, and includes all of the coding region through exon 17 plus an additional 9 kb. The deletion junction contains a 4 bp direct repeat and is preceded by sequence identified as belonging to the Alu family of interspersed repetitive elements. Using genomic DNA and a PCR-based test to detect normal and deleted sequences at that location, a large number of patients with all clinical types of GLD were analyzed. Of 21 infantile patients found to be heterozygous for the 502T polymorphism reported previously, 15 had the deletion, one could not tested and five, including a Hmong child, did not have the deletion. Sixteen other infantile patients previously tested were found to be either homozygous (10) or heterozygous (6) for the deletion. In addition, five patients with juvenile and adult GLD were found to be heterozygous for the deletion. In every case tested, the deletion was always found on the same allele as the 502T polymorphism. However, other disease-causing mutations have been found on the 502T allele. With careful genotype analysis these families can receive improved genetic information including patient and carrier identification and preimplantation diagnosis.

A large deletion together with a point mutation in the GALC gene is a common mutant allele in patients with infantile Krabbe disease

Galactocerebrosidase (GALC) activity is deficient in all patients with globoid cell leukodystrophy (GLD). While most patients have the severe infantile form of this autosomal recessive disorder (Krabbe disease), patients up to 50 years of age have been diagnosed in this laboratory. With the cloning of the GALC cDNA and availability of information regarding the gene organization, patients can be evaluated for their disease-causing mutations. We now report that a large deletion, together with a polymorphic C to T transition at position 502 of cDNA (counting from the A of the initiation codon), is responsible for a large number of disease-causing alleles in patients with Krabbe disease. Of 48 patients evaluated, 10 were found to be homozygous for the 502/del allele, five patients were heterozygous for this allele, 21 patients were heterozygous for the 502 mutation (presence of the deletion could not be confirmed), and one infantile patient was homozygous for the 502 mutation but at least one allele was not deleted. No patient was found to have the deletion without the 502 polymorphism. The delineation of mutations causing infantile Krabbe disease will provide new information regarding structure-function relationships in this multi-subunit enzyme and will improve the identification of patients and carriers in some families.

Structure and organization of the human galactocerebrosidase (GALC) gene

The deficiency of galactocerebrosidase (GALC; EC 3.2.1.46) is responsible for globoid cell leukodystrophy (GLD, Krabbe disease) in humans and certain animals. This enzyme catalyzes the lysosomal hydrolysis of specific galactolipids including galactosylceramide (galactocerebroside) and galactosylsphingosine (psychosine), among others. Recently we cloned the full-length human GALC cDNA using amino acid sequence information obtained from GALC purified from human urine and brain. In this communication we describe the organization of the human GALC gene. The gene, of nearly 60 kb, consists of 17 exons, which, aside from the first and last, are relatively small, ranging from 39 to 181 nucleotides. The 16 introns range from 247 nucleotides to nearly 12 kb. The 5' untranslated region is GC-rich, containing no perfect CAAT or TATA sequences, similar to genes for other lysosomal proteins. This information will be useful for studies to identify mutations causing low GALC activity in all patients with GLD and to identify the homologous gene in the important animal models.

Metachromatic leukodystrophy among southern Alaskan Eskimos: molecular and genetic studies

Metachromatic leukodystrophy (MLD) is an autosomal recessive disorder resulting from the inability to metabolize sulphatide, an important component of myelin. Although there is significant clinical variability between patients, most have the late-infantile form. It is one of the most common lysosomal disorders involving mental deterioration and is found throughout the world. The great majority of the cases have a deficiency of arylsulphatase A activity. Accurate diagnosis of MLD is complicated by the presence of so-called pseudodeficiency alleles and the need to receive specimens for biochemical testing within 24-48 h of collection. We report the identification of the mutation (a g-to-a transition in the first nucleotide of intron 4) in the arylsulphatase A gene causing late-infantile MLD among the Eskimo population of southern Alaska. As all patients and family members from living and deceased patients had the same mutation, a mutation-based test was developed to identify patients and carriers that can be done on dried blood spots sent via regular mail service. A possible genetic link between this population and the Navajo Indians of the southwestern United States is proposed.

Mutations in the lysosomal beta-galactosidase gene that cause the adult form of GM1 gangliosidosis

Three adult patients with acid beta-galactosidase deficiency/GM1 gangliosidosis who were from two unrelated families of Scandinavian descent were found to share a common point mutation in the coding region of the corresponding gene. The patients share common clinical features, including early dysarthria, mild ataxia, and bone abnormalities. When cDNA from the two patients in family 1 was PCR amplified and sequenced, most (39/41) of the clones showed a C-to-T transition (C-->T) at nucleotide 245 (counting from the initiation codon). This mutation changes the codon for Thr(ACG) to Met(ATG). Mutant and normal sequences were also found in that position in genomic DNA, indicating the presence of another mutant allele. Genomic DNA from the patient in family 2 revealed the same point mutation in one allele. It was determined that in each family only the father carried the C-->T mutation. Expression studies showed that this mutation produced 3%-4% of beta-galactosidase activity, confirming its deleterious effects. The cDNA clones from the patients in family 1 that did not contain the C-->T revealed a 20-bp insertion of intronic sequence between nucleotides 75 and 76, the location of the first intron. Further analysis showed the insertion of a T near the 5' splice donor site which led to the use of a cryptic splice site. It appears that the C-->T mutation results in enough functional enzyme to produce a mild adult form of the disease, even in the presence of a second mutation that likely produces nonfunctional enzyme.

Metachromatic leukodystrophy in the Navajo Indian population: a splice site mutation in intron 4 of the arylsulfatase A gene

Metachromatic leukodystrophy (MLD) is an autosomal recessive disorder of myelin metabolism, resulting from the inability to properly degrade 3-sulfogalactosylceramide (sulfatide). This metabolic block is often due to defective functioning of the lysosomal enzyme arylsulfatase A (ARSA). Unmetabolized sulfatide accumulates in the white matter of the CNS and in the peripheral nerves, leading to progressive demyelination and death. Late infantile, juvenile and adult clinical variants of MLD have been described. A Navajo Indian child was diagnosed with late infantile MLD (LIMLD), and his ARSA gene was amplified in three overlapping regions by the PCR and sequenced. A single mutation was found: a G-->A transition in the first nucleotide of intron 4 (IVS4nt1), which abolishes the 5' splice site consensus sequence. Negligible amounts of ARSA mRNA were observed in Northern blots. However, PCR amplification and sequencing of the ARSA cDNA showed that all of the mRNA species from the patient have exon 4 deleted. A new reading frame is thus established which results in a premature stop codon within exon 5. A minority of transcripts had additional splicing errors. Both parents carry this mutation, and the father also carries the pseudodeficiency (PD) allele. Three additional unrelated Navajo LIMLD patients were found to be homozygous for the same MLD-causing mutation by allele-specific oligonucleotide (ASO) hybridization. This method could be used for carrier and patient identification in this population.

Regional mapping of the human galactocerebrosidase gene (GALC) to 14q31 by in situ hybridization

The cDNA for human galactocerebrosidase (GALC) has recently been cloned and expressed. A portion of this cDNA was used for in situ hybridization, and the region of strongest signal corresponded to human chromosome region 14q31. This agrees with recent linkage studies that localized Krabbe disease (globoid cell leukodystrophy) to the same region. This information will be useful in future studies for mapping this gene in animal models of GALC deficiency.

Cloning and expression of cDNA encoding human galactocerebrosidase, the enzyme deficient in globoid cell leukodystrophy

Globoid cell leukodystrophy (Krabbe disease) is an autosomal recessive disorder resulting from the deficiency of galactocerebrosidase (GALC) activity. GALC is responsible for the lysosomal catabolism of galactosylceramide, a major lipid in myelin, kidney and epithelial cells of small intestine and colon. We describe the molecular cloning of human GALC cDNA and its expression in COS-1 cells. Degenerate PCR primers, derived from N-terminal amino acid sequence from the 51 kDa band from human brain, were used to amplify cat testes RNA, and the resulting product was used to screen human testes and brain libraries. Two overlapping clones contained the total protein coding region, while additional clones and PCR amplification were needed to obtain the complete 3' end of the cDNA. The 3795 bp obtained include 47 bp 5' to the initiation start site, 2007 bp of open reading frame (coding for 669 amino acids), and 1741 bp of 3' untranslated sequence. Modification of the sequence surrounding the initiation codon to one more favorable for expression, resulted in a 6-fold increase in GALC activity in transfected COS-1 cells. The isolation of this clone will permit investigations into the causes for GALC deficiency in humans and available animal models, development of more accurate tests for patient and carrier identification, and evaluation of methods for effectively treating GALC deficiency, initially using the animal models.

Mutational analysis in a patient with a variant form of Gaucher disease caused by SAP-2 deficiency

It is now clear that the lysosomal hydrolysis of sphingolipids requires both lysosomal enzymes and so-called sphingolipid activator proteins (SAPs). One gene, called prosaposin, codes for a precursor protein that is proteolytically cut into four putative SAPs. These four SAPs, of about 80 amino acids, share some structural features but differ somewhat in their specificity. Domain 3 of prosaposin mRNA contains the coding region for SAP-2, an activator of glucocerebrosidase. While most patients with Gaucher disease store glucosylceramide due to defects in glucocerebrosidase, a few patients store this lipid in the presence of normal enzyme levels. In this paper we describe the identification of a point mutation in domain 3 of a patient who died with this variant form of Gaucher disease. Polymerase chain reaction amplification was performed in the small amount of genomic DNA available using primers generated from the intronic sequence surrounding domain 3. The patient was found to have a T-to-G substitution at position 1144 (counting from the A of ATG initiation codon) in half of the M13 recombinant clones. This changes the codon for cysteine382 to glycine. His father and unaffected brother also had this mutation, but his mother did not. She was found to have half of the normal amount of mRNA for prosaposin in her cultured skin fibroblasts. Therefore, this child inherited a point mutation in domain 3 from his father and a deficiency of all four SAPs coded for by prosaposin from his mother.