Common Risk Factors Responsible for Acute Kidney Injury among Children: Experience at Medical University in Bangladesh

Background: Acute kidney injury can occur among the younger children due to different reasons. Objective: The purpose of the present study was to find out the risk factors and primary disease responsible for acute kidney injury among younger children. Methodology: This cross-sectional study was conducted in the Department of Paediatric Nephrology with the collaboration of Paediatric Gastroenterology, Paediatric Neurology, Paediatric Neonatology and Microbiology and Immunology at Bangabandhu Sheikh Mujib University, Dhaka, Bangladesh from May 2018 to July 2019 for a period of one year. Patients with the age group of 1 month to 17 years who were at risk of AKI, and admitted in the inpatient department of Pediatrics and allied at Bangabandhu Sheikh Mujib University, Dhaka, Bangladesh in both sexes were selected as study population. To detect AKI, serum creatinine was measured at 0 h (baseline), 48 h and 5th day respectively. Result: A total number of 42 patients, who fulfilled the inclusion criteria were enrolled in this study. The risk factors of AKI was mainly pre renal in 60% (n=9) cases, mostly due to nephrotoxic drugs followed by hypovolemia. Renal causes were in 40% (n=6) cases. Among these 50% cases due to amikacin and 50% cases due to use of radiocontrast agent. Most patients were with renal disease which was 30(58%) cases. Among them 28(93.0%) cases were nephrotic syndrome and 2(7.0%) cases were hydronephrosis. However, 7(13%) cases were cardiac disease presented with congenital heart disease who used radiocontrast agent. Conclusion: In conclusion most common risk factors of acute kidney injury among younger children is pre-renal causes which are due to nephrotoxic drugs. Journal of National Institute of Neurosciences Bangladesh, January 2021, Vol. 7, No. 1, pp. 42-46

Multimorbidity Patterns Among Hospitalized Geriatric Patients in Medicine Wards of a Tertiary Care Hospital in Dhaka City

Background: Elderly people are posing a significant health burden in our country for their multi morbidity as economic growth has increased our life expectancy. Pattern of multi morbidity of this older people varies according to geography, ethnicity, culture and life style. Aim: The aim of this study was to identify the prevalence and pattern of multi morbidity of elderly patients admitted in a tertiary care hospital. Method: 50 random cases of elderly patients aged more than 60 years admitted in medicine and allied wards of Dhaka medical college hospital were observed at this cross-sectional study from January 2017 to June 2017(total 6 months period). Data were reviewed and analyzed using simple frequency and percentage. Protocol was reviewed by institutional ethical board (IRB) of Dhaka medical college hospital. Result: A total number of 50 elderly patients with age ranging from 60 to 95 years were observed with male and female ratio 1.3:1 having multi morbidity among 92.0% patients and female is more affected than male. Hypertension, ischemic heart disease, diabetes mellitus and stroke were found most common diseases as individual. Hypertension and diabetes mellitus was found as the most common multi morbidity pattern followed by hypertension and IHD, stroke & diabetes mellitus. Conclusion: This study sheds light on priority needs of elderly patients in terms of medical facility in tertiary care hospital of Bangladesh. Journal of National Institute of Neurosciences Bangladesh, January 2021, Vol. 7, No. 1, pp. 56-59

Genetics of Adult Onset Stroke Subtypes: A Review of Current Knowldege and Future Prospects

The genetic contribution in stroke onset depends on the stroke subtypes. Understanding the genetic mechanism may influence the future direction in stroke management. There is complex interplay of genetic and environmental factors for any stroke event. Very small proportion of stroke is attributable to mendelian disorders. Stroke may also manifest as part of a syndromic disease in the form of single gene multisystem disorder. But there is no direct contribution of genetic polymorphism in conventional stroke subtypes. Specific genetic loci increase the suspectibility to development of hypertension, diabetes, dyslipideamia or influence the coagulation pathway or chance of atheroma formation and embolism. While chr9p21 locus or PITX2 and ZFHX3 are related to cardioemetabolic, HDAC9, TSPAN2 and 9p21 locus are responsible for the large vessel occlusion. On the otherhand, genome-wide significant locus on chromosome 1q22 the APOE locus are found to have significant association with intracerebral hemorrhage. But the direct pathophysiologic relationship of genetic plymorphirsm may be linked to onset of sub arachnoid hemorrhage. MMP-3, endothelial nitric oxide synthase (eNOS), tumor necrosis factor (TNF)-α, VCAM-1 etc have been found to be responsible for intracranial aneurysm formation, growth and risk of rupture. Journal of National Institute of Neurosciences Bangladesh, January 2021, Vol. 7, No. 1, pp. 75-86

Effect of Clinical and Subclinical Hypothyroidism on Fetal Outcomes among Pregnant Women: A Sub-Specialty Department Experience

Background: Hypothyroidism can effect on the fetal outcomes during pregnancy. Objective: The purpose of the present study was to compare the effects of clical and subclinical hypothyroidism on fetal outcomes among pregnant women. Methodology: This cohort study was conducted in the Feto-Maternal Department of Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from a period of 6 months dated from September 2019 to February 2020. All cases of the clinical and sub-clinical hypothyroid pregnant women admitted in this department. Fetal outcomes of clinical and sub-clinical hypothyroid pregnant women during delivery were recorded. Findings of the cases recorded carefully. Result: A total number of 75 patients were recruited for this study who were divided in to two group designated as group I or sub clinical hypothyroidism and group II or clinical hypothyroidism. Fetal distress was 22(51.1%) cases in group I and 9(33.3%) cases in group II. The fetal outcome of the study patients had observed that 8(27.6%) and 12(80.0%) of the baby had low (<2.5 kg) birth weight in group I and group II' respectively. In group I most (62.1%) of the baby APGAR score was >7 and 11(73.3%) cases had < 6 APGAR score at 1st minute. Majority of the study patients had >7 APGAR score at 5 min in both groups which was 25(86.2%) and 12(80.0%) in group I and group II respectively. Conclusion: In conclusion there is a significant difference found in overt and sub-clinical hypothyroidism considering fetal stress, IUD and prematurity. Journal of National Institute of Neurosciences Bangladesh, January 2021, Vol. 7, No. 1, pp. 29-32

Neonatal COVID-19 with Rare Presentation in COVID Dedicated Hospital of Bangladesh: A Case Report

Although Coronavirus disease (COVID-19) can affect all age groups, severity of clinical presentation among children and newborns are milder than in adults. Along with classical symptoms, atypical presentation could be noted in the neonate. We report here a case of neonatal COVID-19 where a newborn infant presented with fever, lethargy, respiratory distress and recurrent seizure. Early detection and prompt management is the prerequisite for limiting transmission and reducing neonatal death rate. Journal of National Institute of Neurosciences Bangladesh, January 2021, Vol. 7, No. 1, pp. 87-89

Comparing of Fine Needle Aspiration Cytology (FNAC) and Tru-cut biopsy for the Diagnosis of Breast Pathology

Background: Diagnosis of breast pathology is very important for the management of the patients. Objective: The purpose of the present study was to compare the fine needle aspiration cytology (FNAC) and trucut biopsy for the diagnosis of breast pathology. Methodology: This analytical cross-sectional study was conducted in the Department of Surgery at Bangabandhu Shiekh Mujib Medical University, Dhaka, Bangladesh from 1 April to 31 October 2020 for a period of six months. All the women who were attended at the OPD of the Department of Surgery with the different complaints of breast at any age were selected as study population. The different disease profiles were recorded in the data sheet. Result: A total number of 200 patients were recruited for this study. The mean age with standard deviation was 33.85±7.969 years. The male and female ratio was 1:19. Breast pathology was found in equal in left and right side which was 100(50.0%) cases in each. The central zone was the most common area which was 90(45.0%) cases. Most of the breast pathology was firm which was 170(85.0%) cases. The comparison of FNAC and tru-cut biopsy was done. Fibroadenoma was found in 50(100.0%) cases in FNAC; but in tru-cut biopsy 10(20.0%) case was fibroadenoma; invasive ductal carcinoma was in 30(60.0%) cases and the rest of 10(20.0%) case was Phylloides tumor. In FNAC 1 case was diagnosed as gynaecomatia which was diagnosed as intradermal papilloma in tru-cut biopsy. The difference between the FNAC and tru-cut biopsy for the detection of different pathology of breast was statistically significant (p=0.000). Conclusion: In conclusion there is a significant difference between FNAC and tru-cut biopsy for the detection of breast pathology. Journal of National Institute of Neurosciences Bangladesh, January 2021, Vol. 7, No. 1, pp. 33-37

Pattern of Stroke and Short Term Outcome of COVID-19 Patients admitted in a Dedicated Stroke Unit at Referral Neurology Hospital of Bangladesh

Background: COVID-19 was declared as a pandemic by WHO on March 11, 2020. Though the most common and important presentation is with respiratory disease, reports of neurological features are increasing. Objective: In this study it was described the pattern of stroke in COVID-19 patients admitted in a dedicated stroke unit and their short term outcome. Methodology: This single arm, single centreprospective cohortstudy was conducted in the Stroke Unit of National Institute of Neurosciences and Hospital, Dhaka, Bangladesh from April to August, 2020 and wasincluded acute stroke patients irrespective of age and sex who were found RT-PCR positive for SARS CoV-2. The patientswere evaluated clinically, biochemically and by imaging. After diagnosis patients were referred to a COVIDdedicated hospital and were followed up over phone for 4 weeks from the day of admission in stroke unit to assess short term outcome. Results: Among the 41 patients, 21 were male and 20 female with an age range of 26 to 90 years where 58.5% patients were aged 60 and above. Majority (58.5%) of them came from different urban areas. Common co-morbidities were Hypertension (68.3%) and Diabetes mellitus (39%). Most common presenting features were hemiplegia (48.8%) and altered level of consciousness (39%). More than seventy percent (70.7%) patients had GCS of 10 or less and 56.1% patients had oxygen saturation 90% or less in room air. CT brain imaging revealed infarct in 39% and hemorrhage in 51.2%. Chest radiography revealed abnormality in 14.6% cases. Regarding the short term outcome, total 20 (48.8%) patients died where 7 died before referral to COVID-19 dedicated hospital. Death was higher in hemorrhagic stroke but there was no significant association between outcome and the type of stroke (p value>0.05). Conclusions: Hemorrhagic stroke is the most commonly occurring stroke among the COVID-19 patients and associated with p oor outcome. Journal of National Institute of Neurosciences Bangladesh, January 2021, Vol. 7, No. 1, pp. 25-28

Predictors of Outcome in Intracerebral Hemorrhage and Performance of Hemphill ICH Score and GVS Score

Background: The outcome of intracerebral hemorrhage (ICH) is gloomy. There are several scoring systems for predicting its outcome. Objective: The purpose of the present study was to observe the predictors of outcome in ICH patients and to assess the performance of ‘Hemphill ICH score’ and ‘GVS score’. Methodology: This cohort study involved patients of ICH admitted within 72 hours of acute event in July to December 2017 in the Department of Neurology at National Institute of Neurosciences (NINS) & Hospital, Dhaka, Bangladesh. Clinical and radiological data at admission and in-hospital events were obtained from medical records. Patients who were discharged from the hospital were interviewed at 30th day after event by face to face interview or over telephone. Follow up data was not found for 4 patients. Results: This study involved 115 patients of ICH [median age 60 years (interquartile range, IQR 50-70); 46% (53/115) female]. In-hospital and 30-day mortality of the ICH patients was 22% (25/115: 95% CI 15-30%) and 38% (42/111; 95% CI 29–48%) respectively. There was almost perfect agreement between Hemphill ICH score and GVS score (p<0.001 and κ=0.862). Kaplan-Meier survival curves of patients with different Hemphill ICH scores revealed significant difference among them; which was also true for patients with different GVS scores (by log-rank test, p<0.001 for both). The area under the curve (AUC) for the Hemphill ICH score to predict mortality was 0.70 (95% CI, 0.60–0.80) and for the GVS score 0.74 (95% CI, 0.64–0.83). In bivariate logistic regression, NIHSS score, GCS score, blood glucose at admission, nosocomial pneumonia, ICH volume, midline shift along with both Hemphill ICH and GVS score were observed to predict mortality at 30 days (p<0.05 for all). In two separate models adjusting for blood glucose and nosocomial pneumonia, every 1-point increase in the Hemphill ICH score and GVS score increases the mortality risk by 2.35 fold (adjusted OR: 2.35; 95% CI 1.33-4.16; p=0.003) and 2.99 fold (adjusted OR: 2.99; 95% CI 1.57-5.72; p=0.001) respectively. Conclusions: Both Hemphill ICH and GVS score have comparable predicting ability of outcome in ICH. In addition to components of scoring systems, occurrence of nosocomial pneumonia and blood glucose seems important. Journal of National Institute of Neurosciences Bangladesh, January 2021, Vol. 7, No. 1, pp. 3-9

Comparison of Laboratory Profiles of Cerebrospinal Fluid among Bacterial and Viral Meningitis Patients

Background: Laboratory profiles are important markers for the detection of meningitis. Objective: The purpose of the present study was to compare of laboratory profiles of cerebrospinal fluid among bacterial and viral meningitis patients. Methodology: This cross sectional study was carried out in the Department of Microbiology at Mymensingh Medical College, Mymensingh, Bangladesh from July 2010 to January 2012 for around 2 years. Clinically suspected patients with meningitis from paediatrics wards of MMCH, Mymensingh, Bangladesh were included in this study. On the basis of cytological tests and biochemical tests of CSF the study subjects were categorized into three groups, which were identified as bacterial meningitis, viral meningitis and normal CSF. After collection of CSF, physical examination, routine bed side culture and appropriate biochemical tests were performed. Tests for protein and glucose of CSF specimens were performed. Result: A total 115 clinically and laboratory confirmed meningitis patients were enrolled in this study. The most of the cases of study population were in the age group 1 month to 5 years 97(84.3%) cases. Regarding the physical findings of CSF, purulent was found 21(60.0%) cases in bacterial meningitis and 14 (40.0%) cases were slightly turbid. The mean with SD of total count of WBC was higher in bacterial meningitis (1623.1±1708.06/mm3) than viral meningitis (56.0±73.83/mm3) (p=<0.001). Again the mean with SD of glucose was lowest in bacterial meningitis which was 21.0±9.77 mg/dL followed by viral meningitis which was 63.6±20.22 mg/dL. (p<0.001). Considering protein of CSF the mean with SD was highest in bacterial meningitis which was 242.8±188.09 mg/dL followed by viral meningitis which was 69.6±84.67mg/dL (p<0.001). Conclusion: In conclusion the WBC count, CSF glucose and protein are significantly differ in bacterial and viral meningitis. Journal of National Institute of Neurosciences Bangladesh, January 2021, Vol. 7, No. 1, pp. 69-74

Predictors Modifying the Outcome of Tuberculous Meningitis (TBM) in Adults: A Hospital Based Study in Bangladesh

Background: Outcome of TBM can be modified by several predictors. Objective: This study was undertaken to evaluate the predictors of outcome of tuberculous meningitis (TBM) at 6 and 9 months. Methodology: This hospital based prospective cohort study was carried out from October, 2016 to September, 2017 (1 year) in the in-patient Department of Neurology at the National Institute of Neurosciences & Hospital (NINS & H), Dhaka, Bangladesh. All the patients with age 18 years or more of both sexes with features of TBM fulfilling the case definition criteria was included as the study population. The outcome was measured at 6 and 9 months by modified Rankin Scale (mRS) with no disability (score=0-1), mild disability (score = 2), moderate disability (score=3-4), severe disability (score=5) and dead (score=6). For statistical analysis outcome was classified as death and survival group. A number of clinical, laboratory and radiological parameters were evaluated initially by univariate and finally multiple regression analysis. Results: A total 54 TBM patients were included in this study. Over 70% of the patients were adolescent or young adult (< 30 years) with mean age of 28.2 ± 12.3 years and 63% were female. Staging of the TBM showed that nearly half (48.1%) were at stage II and 37% cases were in stage III disease. Baseline imaging (CT-scan and MRI) showed basal meningeal enhancement in 40.7% cases, hydrocephalus in 40.7%, infarction 46.3% and tuberculoma in 29.6% cases. Final diagnosis was established as definite TBM in 3(5.6%) cases, probable TBM 30(55.6%) and possible TBM in 21(38.9%) cases. In terms of 6-months outcome, 16(29.6%) cases died and 10(18.5%) had recovered without any neurological sequelae; however, mild, moderate and severe disability were in11.1%, 27.8% and 13% cases respectively. At the 9 months of evaluation 13 (24.0%) had complete recovery without any neurological sequelae, 22 (40.9%) patients survived with various degree of disabilities like visual impairment, hemi or paraplegia, cognitive impairment, rests died giving a total mortality of 19(35.1%). In univariate analysis, age >50 years (p=0.019), duration of illness before initiation of treatment (>45 d) (p = 0.041), convulsion (p = 0.010), altered sensorium (p<0.001), delayed initiation of treatment >1 month (p=0.041) and stage III TBM (p<0.001) were significantly associated with mortality. In multivariate analyses stage III TBM (p=0.004), altered sensorium (p=0.036), delayed initiation of treatment >1 month (p=0.043) emerged as independent predictors of mortality. Conclusions: In conclusion stage III TBM, altered sensorium and delayed initiation of treatment more than 1 month are the independent predictors of mortality in TBM patients. Journal of National Institute of Neurosciences Bangladesh, January 2021, Vol. 7, No. 1, pp. 14-19