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.

Patient self-referral patterns in a developing country: characteristics, prevalence, and predictors

BACKGROUND

Efficient healthcare delivery and access to specialized care rely heavily on a well-established healthcare sector referral system. However, the referral system faces significant challenges in developing nations like Bangladesh. This study aimed to assess self-referral prevalence among patients attending tertiary care hospitals in Bangladesh and identify the associated factors.

METHODS

This cross-sectional study was conducted at two tertiary care hospital, involving 822 patients visiting their outpatient or inpatient departments. A semi-structured questionnaire was used for data collection. The patients' mode of referral (self-referral or institutional referral) was considered the outcome variable.

RESULTS

Approximately 58% of the participants were unaware of the referral system. Of all, 59% (485 out of 822) of patients visiting tertiary care hospitals were self-referred, while 41% were referred by other healthcare facilities. The primary reasons for self-referral were inadequate treatment (28%), inadequate facilities (23%), critical cases (14%), and lack of expert physicians (8%). In contrast, institutional referrals were mainly attributed to inadequate facilities to treat the patient (53%), inadequate treatment (47%), difficult-to-treat cases (44%), and lack of expert physicians (31%) at the time of referral. The private facilities received a higher proportion of self-referred patients compared to government hospitals (68% vs. 56%, p < 0.001). Among patients attending the study sites through institutional referral, approximately 10% were referred from community clinics, 6% from union sub-centers, 25% from upazila health complexes, 22% from district hospitals, 22% from other tertiary care hospitals, and 42% from private clinics. Patients visiting the outpatient department (adjusted odds ratio [aOR] 3.3, 95% confidence interval [CI] 2.28-4.82, p < 0.001), residing in urban areas (aOR 1.29, 95% CI 1.04-1.64, p = 0.007), belonging to middle- and high-income families (aOR 1.34, 95% CI 1.03-1.62, p = 0.014, and aOR 1.98, 95% CI 1.54-2.46, p = 0.005, respectively), and living within 20 km of healthcare facilities (aOR 3.15, 95% CI 2.24-4.44, p-value < 0.001) exhibited a higher tendency for self-referral to tertiary care facilities.

CONCLUSIONS

A considerable number of patients in Bangladesh, particularly those from affluent urban areas and proximity to healthcare facilities, tend to self-refer to tertiary care centers. Inadequacy of facilities in primary care centers significantly influences patients to opt for self-referral.

Transporter Associated With Antigen Processing (TAP) 1 Gene Polymorphisms and Risks of Urothelial Cell Carcinoma Among the Japanese Population

Urothelial cell carcinoma is one of the costliest types of cancer because of its recurrence, lengthy course of therapy, and tendency to lead to further complications. Gene polymorphisms are one of many factors that are thought to cause the carcinogenesis of urothelial cell carcinoma. Two single-nucleotide polymorphisms (SNPs) of the transporter associated with antigen processing (TAP) 1 gene and their relationship with the risks of urothelial cell carcinoma in the Japanese population were examined in this study by using polymerase chain reaction (PCR), restriction fragment length polymorphism (RFLP) for genotyping and statistical analysis. The adjusted odd ratios with 95% confidence interval (CI) of the mutant types (A/G+G/G) in females for the I333V and D637G polymorphisms are 2.28 (1.11-4.66) and 2.50 (1.21-5.17), respectively. The findings showed that females with the (A/G+G/G) genotype are more likely to develop urothelial cell carcinoma than those with the A/A genotype. Any correlation between smoking and gene polymorphism was absent. Results indicate that TAP1 gene polymorphisms and the risk of urothelial cell carcinoma are related in females.

Implementation of Health Policies in the COVID-19 Pandemic Phases of Myanmar and How the Population Approach Influenced Their Success Rate

The impact of the COVID-19 pandemic is continuing in developing countries, and post-pandemic individuals are still suffering mentally and physically. Many researchers have tried to find the causes and risks that can impact the spread of disease. Among the causes and risks identified, socioeconomic factors and health policies played an important role in determining the transmission of the disease. However, the significance of these factors for the spread of infection is different depending on the country. In this editorial, we discuss the implementation of health policies in Myanmar and their effect on infection transmission.

Serum Albumin and C-reactive protein in Hospital Admitted Patients with Chronic Kidney Disease

Adequate knowledge about the causes of chronic kidney disease and their potential prevention can improve poor clinical outcome in chronic kidney disease (CKD) patients. The study was designed to evaluate the serum albumin and C-reactive protein (CRP) levels in hospitalized patients with Chronic Kidney Disease. This cross-sectional study was carried out in the Department of Biochemistry, Mymensingh Medical College, Mymensingh, Bangladesh with the collaboration of the Department of Nephrology, Mymensingh Medical College Hospital, Mymensingh, from January 2021 to December 2021. The subjects were selected on the basis of inclusion and exclusion criteria by purposive and convenient sampling method. A total of 110 subjects were included in this study. Among them, 55 were diagnosed CKD patients denoted as Group I and 55 were normal healthy individuals denoted as Group II. In this study, serum albumin and CRP levels were measured. All values were expressed as Mean±SD. All statistical analysis was done by using SPSS (statistical package for social science) windows package version 21.0. Statistical significance of difference between Group I and Group II were evaluated by using student's unpaired 't'-test and the significance was defined as p<0.05. Correlation was done by using Pearson's correlation coefficient test. Mean age of Group I was 52.65±4.93 and Group II was 51.15±6.32 (p=0.165). The mean±SD of BMI was 24.46±1.84 for Group I and 24.50±1.05 for Group II (p=0.886). The mean±SD values of serum albumin were 3.62±0.26g/dl and 4.16±0.69g/dl in Group I and Group II respectively. We found highly significant (p<0.001) decrease in serum albumin. The mean±SD values of CRP were 24.00±16.73mg/L and <6.0±0.00mg/L in Group I and Group II respectively. So, we found significant (p<0.05) increase in CRP levels. There was negative correlation between serum albumin and CRP. Analyzing the findings of this study, significant decrease in serum albumin and significant increase in CRP levels were observed in CKD patients.

Glasgow Coma Score Predicting the Poor Outcome of the Patients Presenting Fever with Altered Sensorium

To assess the role of the Glasgow Comma Score (GCS) for predicting the outcome of the patient with fever and altered sensorium was the objective of the study. This prospective observational study was conducted for six months following ethical approval. Informed consent was obtained prior enrollment. A total of 50 patients with complaints of fever for <2 weeks duration with altered sensorium with or without seizure were included in the study. GCS was calculated for all patients just after admission and before starting interventions. All patients were investigated and managed according to the hospital protocol. The outcome of the patients (living or dead within the hospital) was evaluated against the admission GCS score. The study was performed in accordance with the current Declaration of Helsinki. Of all, 42.0% (n=21) of the patients had bacterial meningitis, followed by viral encephalitis, cerebral malaria and coma vigil. Complete recovery occurred in 60.0% of cases, while recovery with disability occurred in 28.0% of cases. Death occurred in 12.0% of cases (n=6) due to cerebral malaria, viral encephalitis and bacterial meningitis (n=2 each cause). A higher number of deaths occurred in the lower GCS group (n=5 in GCS group 3-5) and this difference was statistically significant (p<0.05). Moreover, considering death as an outcome, multivariate logistic regression showed that GCS (OR 70.598, 95% CI-1.243-4009.41; p=0.039) was an independent predictor of the outcome. GCS seemed to be a predictor of the short-term outcome of the patient presenting with fever and altered sensorium in our setting. However, further exploration in larger setting with appropriate study design is recommended.

Use of cefepime, meropenem, or piperacillin/tazobactam as initial treatment for febrile neutropenia in patients with hematological malignancy — a real-life experience

Background

Antimicrobials like fourth-generation cephalosporins, carbapenems, or β-lactams are widely used in treatment of febrile neutropenia (FN). The present study aimed to compare the efficacy of cefepime, meropenem, and piperacillin/tazobactam as initial treatment for chemo-induced FN in patients with hematological malignancy.

Methods

This was an observational study conducted in the Department of Hematology of Dhaka Medical College Hospital from July 2020 to June 2021 including 99 adult FN patients with hematological malignancy who were randomized equally to three treatment arms to receive cefepime, meropenem, or piperacillin/tazobactam as an empirical antibiotic. Response to therapy was defined as improvement in symptoms (e.g., defervescence) or in laboratory values including neutrophil counts on day 3 and day 7 after the initiation of the therapy. Chi-square test and Fisher’s exact test were used to compare the efficacy of the treatment regimens.

Results

Response rate to initial treatment with different antibiotic regimens was similar without any statistically significant difference (60.6%, 63.6%, and 51.5% on day 3 and 63.6%, 75.8%, and 66.7% on day 7 for cefepime, meropenem, and piperacillin/tazobactam, respectively, p-value > 0.05) irrespective of underlying diagnosis, the severity of neutropenia, and cause of fever.

Conclusion

Initial therapy with cefepime, meropenem, or piperacillin/tazobactam is safe and equally effective in chemo-induced FN in patients with hematological malignancy. This finding may be considered in clinical practice for optimum therapeutic outcomes.

Sketch of 2018 dengue outbreak in a megacity, Bangladesh

Background

Dengue has become a major public health threat in Bangladesh since 2000, when the first outbreak was reported. Each outbreak has distinct characteristics, and thus, the report of the outbreak helps to understand the disease process and subsequent clinical management of these patients. On that ground, the study was designed to sketch the clinico-epidemiological characteristics of the 2018 dengue outbreak in Bangladesh.

Methods

This hospital-based cross-sectional study was conducted in one of the largest public medical college hospitals and a single private hospital located in the southern and northern parts of the megacity of the country. A total of 297 confirmed dengue cases were assessed with a preformed pretested questionnaire. Clinico-epidemiological and laboratory parameters were reported along with sociodemographic details. Statistical analysis was performed with SPSS 20.

Results

Male patients were predominantly affected by dengue infection. The mean age of the patients was 31.24 ± 13.99 (SD) years, with a range from 2 to 85 years. Eighty-two percent of patients reported from the Dhaka metropolitan city. The highest percentage of cases (37.1%) was isolated from Bansree, Dhaka city, followed by Rampura (21.4%) and Khilgaon (6.2%). In addition to common symptoms, e.g., fever (90.6%), headache (90.6%), chills (81.8%), anorexia and vomiting (76.4%), backache, and redness of the eyes were two prominent symptoms that affected more than two-thirds of the study population. On the other hand, less common symptoms, such as cough, abdominal pain, and respiratory distress, were present in 39.7%, 33.7%, and 15.5% of patients, respectively. Overall, 17.6% of patients were hypotensive during admission, with a mean systolic blood pressure of 107.65 ± 18.17 (SD) mmHg. Other prominent signs were dehydration (80.5%) and rash (33%).

Conclusion

This outbreak was especially characterized by gastrointestinal symptoms, which were predominant along with other typical features.

Thwarted belongingness, perceived burdensomeness, and acquired capability for suicide among university students of Bangladesh: Scales validation and status assessment

BACKGROUND

Identification of prior mental events of suicide attempts has immense importance in suicide prevention. However, it has not been studied in Bangladesh as there was no available psychometrically valid instrument measuring it.

OBJECTIVES

We aimed to test the psychometric properties of the interpersonal needs questionnaire (INQ-15) and acquired capability for suicide scale-fearlessness about death (ACSS-FAD) in Bangla along with the determination of the level of thwarted belongingness, perceived burdensomeness, and acquired capability for suicide.

MATERIALS AND METHODS

We collected data between 29 March and 14 April 2022 from 1,207 students of medical colleges and universities in Bangladesh by Google form. We assessed the psychometric properties of Bangla INQ and ACSS-FAD scales and examined factors associated with thwarted belongingness, perceived burdensomeness, and acquired capability for suicide.

RESULTS

The mean age of the participants was 22.82 ± 1.68 (range 18-29) years, 51% were females, 84% were graduate students, and 92% were unmarried. Both of the scales revealed acceptable levels of reliability. Confirmatory factor analysis revealed a two-factor structure of Bangla INQ after dropping three items from thwarted belongingness domain (item 9, 11, and 12) and a single factor structure for Bangla ACSS-FAD after dropping three items (item 1, 4, and 6). Perceived burdensomeness was significantly higher in females, students with a history of mental illness, family history of suicide, and the history of suicidal attempts. Fearlessness about death was significantly higher among females, non-Muslim participants, and history of suicidal attempts.

CONCLUSION

The current study revealed psychometric properties of two suicide scales (INQ and ACSS-FAD) in Bangla that can be used in subsequent studies. Prevention strategies targeting to females, persons with psychiatric disorder, history of previous attempt(s) should be prioritized specially among the young age group.

Comparison of clinical manifestation of dengue fever in Bangladesh: an observation over a decade

BACKGROUND

The clinical presentation of dengue fever had been observed to change with time since its first outbreak in 2000 in Bangladesh. This report showed the clinical presentation of the 2019 outbreak in Bangladesh along with its comparison to previous outbreaks witnessed in this region.

METHODS

This hospital-based cross-sectional study was conducted in one of the largest tertiary care hospitals in Dhaka city. A total of 553 laboratory-confirmed and 194 probable dengue cases were interviewed. The clinical manifestation of the confirmed cases of the current outbreak was compared with three of the outbreak reports retrieved from the databases. R version 3.6.3 was used for data analysis.

RESULTS

Among the confirmed cases, two-thirds were male (63.2%) and the average age was 27(± 11) years. Positive tests for NS1 and IgM were present in 99.6% (n = 525/527) and 82.6% (n = 38/46) of the cases, respectively. Thrombocytopenia was present in 66.1% of cases. Fever (100%) was common for all. Gastrointestinal (GIT) features, including abdominal pain (86.5%), anorexia and/or vomiting (69.6%), and Diarrhea (> 3 motions/day) (26.2%) were more frequent than typical rash and other pain symptoms. Hypotension was present in approximately a quarter of patients (25%). GIT features (anorexia, nausea, and/or vomiting) and hypotension were more common among adult participants while bleeding manifestation (melena and vaginal bleeding, p = 0.009 & 0.032) was more frequent in pediatric patients. Compared to outbreaks of 2008, 2016, and 2018, increasing trends in GIT symptoms e.g. anorexia, abdominal pain, and diarrhea were observed. While a negative trend in hemorrhagic manifestations (skin rash, melena, and conjunctival hemorrhage/hemorrhagic sclera) and arthralgia/joint pain were found.

CONCLUSION

The present outbreak was noticeably characterized by GIT symptoms and hypotension in addition to the typical clinical features like rash and pain symptoms. An increasing trend in GIT features and decreasing trend in hemorrhagic manifestations was noted over the last decade of dengue outbreaks.

Clinico-epidemiologic characteristics of the 2019 dengue outbreak in Bangladesh

BACKGROUND

Dengue fever shows a broad range of clinical presentations worldwide. Here we report on our clinical findings during the 2019 dengue outbreak in one of the largest tertiary care hospitals in Dhaka, the capital of Bangladesh.

METHODS

A total of 747 suspected dengue cases (553 confirmed and 194 probable) were interviewed with a pro forma case record form. Statistical analyses were conducted using SPSS 20.0. Ethical clearance was obtained from the Dhaka Medical College.

RESULTS

The mean age of the dengue cases was 27 y and approximately two-thirds were male. Positive tests for NS1 and anti-dengue immunoglobulin M antibody were present in 91.9% and 59.4% of the cases, respectively. Thrombocytopenia was present in 69% of cases and fever was present in 99.1% of cases. Gastrointestinal (GI) features, including anorexia and/or vomiting (69.4%), abdominal pain (39.8%) and diarrhoea (25.6%), were more prevalent than typical rash and pain symptoms. Hypotension was present in approximately one-quarter of patients (25.4%). Probable and confirmed dengue cases have shown similar clinical characteristics and laboratory findings.

CONCLUSIONS

The 2019 outbreak of dengue fever in Bangladesh was characterized by increased presentation with GI features. Recognition of this trend would permit early diagnosis and proper management of patients.

Pattern of Neonatal Danger Signs and its Related Factors in a Tertiary Level Hospital

Considering very limited information in the pattern of neonatal danger signs with associated risk factors in our perspective, the aim of the study was to understand the country-context pattern of neonatal danger signs and its related factors in a tertiary level hospital. This cross-sectional study was conducted among 259 mothers and their neonates in Dhaka Medical College Hospital, Dhaka, Bangladesh from 01 January 2015 to 31 December 2015. Data were collected by face to face interview from mother by pre-tested semi structure questionnaire which was adopted from WHO-UNICEF list of newborn danger signs. Measurement of weight was taken from hospital record. Observation of danger signs were done by following check list. Data analysis was done by SPSS 20.0. Of all, majority (41.6%) was in the age group of 20-24 years & was educated up to secondary level (42.47%). More than half of the participants (54.1%) had family income >10,000 BDT. Sixty percentage of mother took ANC visit <3 times during their pregnancy period. About 42.1% had ≥1 co-morbidities. Hospital was the predominate place of birth with 48.3% caesarean delivery. At least one neonatal danger sign was present in 20.1% while 39.4% had at least 2 danger signs. Rest of the child had ≥2 danger signs at a time. The distribution of danger signs were not feeding since birth or stop feeding 206(79.5%), severe chest in drawing 145(56.1%) respiratory rates 60 or more 126(48.6%), convulsion 72(27.8%), yellow soles 68(26.3%). Factors like 'fail to identify with an expert health assistant', trial of delivery at home, delivery at home, older neonatal age (8-28 days), presence of injury at birth, and cutting of umbilical cord by blade during delivery were associated with higher number of danger signs (p<0.05 in all cases). About 80% neonate in our setting had ≥1 sign and had association with fail to identify with an expert health assistant', trial of delivery at home, delivery at home, older neonatal age, presence of injury at birth, and cutting of umbilical cord by blade during delivery.

Mental health of young people amidst COVID-19 pandemic in Bangladesh

BACKGROUND

The psychological burden of the coronavirus disease 2019 (COVID-19) outbreak and lockdown strategy among young people not diagnosed with COVID-19 in the general population remains unknown and often have been overlooked. The objective of the study was to assess the prevalence and predictors of anxiety, depression and stress among young people diagnosed with COVID-19 of Bangladesh amidst the pandemic.

METHODS

A cross-sectional online survey was conducted from 1 May to 30 May 2020 using an online Google form-based questionnaire posted on Facebook. A snowball sampling approach was used for data collection. A total of 974 self-declared healthy individuals not diagnosed with COVID-19 participated here. Anxiety, depression and stress were measured using Bangla validated Generalized Anxiety Disorder Scale-7 (GAD-7), Patient Health Questionnaire (PHQ-9) scale, and Perceived Stress Scale (PSS), respectively. Statistical software SPSS 20 was used for analysis.

RESULT

Average age of the population was 25.86 ± 6.26 (SD) years with nearly half (48.6%) of them being young people (15 to ≤24 years). Most of the participants were male (76.3%). The overall prevalence of anxiety, depression and stress was found to be 64.1%, 73.3% and 69.4%, respectively. Young people had significantly higher proportion of anxiety (67.2% vs 61.1%), and depression (78.2% vs 68.7%) compared to adults (p = 0.045 and p < 0.001, respectively). However, most of the participants had mild depression (30.3%), minimal anxiety (31.4%), and moderate stress (67.5%), and severity of depression and anxiety was higher in the young participants. The mean GAD-7, PHQ-9 and PSS scores were 7.57 ± 5.61, 9.19 ± 6.15 and 16.02 ± 5.55 (SD), respectively. On multivariable logistic analysis, unemployment (Adjusted Odds Ratio [AOR] 3.642; Confidence Interval [CI]: 1.005-13.200; p < 0.05) was the single most important predictor of depression. For stress, unemployment (AOR 1.399; CI: 1.055-1.855), and female sex (AOR 1.638; CI: 1.158-2.317) were significant predictors.

CONCLUSION

Anxiety, depression and stress were highly prevalent among young people (≤24 years) not diagnosed with COVID-19 in Bangladesh amidst the pandemic. Unemployment is the most common underlying determinant. Authorities should address the issue on a priority basis.

Leishmaniasis in Dhaka Medical College-experience of three years

The People's Republic of Bangladesh has been working to eliminate visceral leishmaniasis or Kala-azar cases since there was a memorandum of understanding signed between neighboring countries in 2005. As a part of the elimination activity, 44 cases of Kala-azar were diagnosed and treated in the regional referral center Dhaka Medical College Hospital (DMCH) during the last three years, which is reported here. Confirmed leishmaniasis cases were included. Patients attending this specialized center with different demographic characteristics and varied presentations with laboratory findings were reviewed and recorded in a structured case record form. Ethical clearance was obtained prior to starting the study. A total of 44 patients with leishmaniasis were reviewed. Approximately 89% (n = 39) were New Kala-azar (NKA), 7% (n = 3) were Relapse Kala-azar (Relapse KA), only one case (2%) was Kala-azar Treatment Failure (KATF) and Post Kala-azar Dermal Leishmaniasis (PKDL) for both. The mean age of presentation was 32 years. Forty percent of patients had houses made by mud, 26% by tin shed, and the rest lived in buildings and semi-buildings. The predominant clinical features were fever (90.9%), pallor (88.6%), splenomegaly (81.8%) and hepatomegaly (68.2%). rK39 was positive in 90.7% of cases, and 94.4% of cases were positive for LD bodies on splenic aspirate. Of all, 90.90% were treated with Inj. Liposomal amphotericin B and 9.10% with the combination of Inj. Liposomal Amphotericin B and Inj. Miltefosine. Moving forward to the elimination of leishmaniasis from Bangladesh, the study highlights the status, characteristics and treatment of the disease in the country.