BMA May 2021

Official Organ of Bangladesh Medical Association
Vol. 50
49 No. 2
3 September
May 2021
2020
Original Articles
Effect of extra-corporeal shock-wave therapy in the management of chronic plantar fasciitis 1
Hojaifa MM, Rahman S, Saha TC, Hosain M, Rahman HH, Ahmed M, Islam MMM, Alam MM
Early signs of autism and it’s relation with gestational factors: an urban based study in Bangladesh 9
Sharmin S, Halim KS, Sultan Z, Haque KM
Co-morbidities and family history among methamphetamine users 15

Maruf MM, Jahan N, Khan MZR, Haq AI, Akhter J, Rishad MM, Kamal MAM
Association of helicobacter pylori and portal hypertensive gastropathy in patients with cirrhosis of liver 21
Islam MS, Chowdhury MFK, Arju J, Miah MSA, Hasan MA, Adhikary D, Mahbub-Uz-Zaman K, Shoaib M, Kabir MA
Comparison of serum zinc and copper level in psoriatic and non-psoriatic individual 28
Haque S, Mahmud MM, Habib RB
Severity of pain according to visual analog scale in adhesive capsulitis of shoulder in diabetic patients 32
Hosain M, Rahman S, Alam MM, Islam SMM, Islam KA, Rahman MM, Bhuiyan MK
Patterns of post-endoscopic retrograde cholangiopancreatography (ERCP) complications 35

Habib MR, Ahmed F, Gain G, Hasan R, Ishaque SM, Saifuddin D
Cardiovascular risk factors amongst the patient living with HIV attending at anti-retroviral 40
therapy center of Bangladesh
Hossain A, Biswas SK, Hasan MN, Ahmed I, Bhuiyan AKMR, Ahmed K, Islam S, Abdullah ABM
Case Report
An eleven months old infant with very early onset inflammatory bowel diseases (IBD): 45
a rare case report
Ahamed N, Khadga M, Majumder W
Obituary 52
Bangladesh Med J. 2021 May; 50(2)
Editorial Board
Chairman : Dr. Syed Atiqul Haq
Executive Editor : Dr. A.K.M. Mosharraf Hossain
Managing Editor : Dr. Kazi Shafiqul Halim (Zimmu)
Assistant Editors : Dr. S.M. Mustafa Zaman (Babul)
Dr. Mamun Al Mahtab (Shwapnil)
Dr. Ataul Haque
Dr. Abu Shahin
Members
Dr. Mir Misbahuddin Dr. Md. Faisal Hasbun
Dr. Mohammad Shahidullah Dr. Shekhar Kumar Mondal
Dr. Julfiqar Rahman Khan Dr. Kallol Dey
Dr. Abu Naser Rezbi Dr. Khandaker Al-Mamun
Dr. Anisur Rahman Anjum
Dr. Mehedi Hasan
Dr. Manzur Hussain
Dr. Dipali Paul
Dr. Md. Nazrul Islam
Dr. Mustafizur Rahman Dr. Quazi Abul Azad
Dr. Md. Nazrul Islam Dr. Md. Nasir Uddin Mithu
Dr. Abdullah Al Mamun Dr. Md. Nazmul Hasan
Dr. Sharif Shah Jamal Dr. Md. Saifullah Russel
Dr. Abu Masud Md. Noorul Karim Dr. Sharmina Jalil
Dr. Sushanta Barua Dr. Mustafa Jalal Mohiuddin
Dr. Antu Bhattcharjja Dr. Md. Ehteshamul Huq Choudhury
Publishing Division
Managing Editor : Dr. Kazi Shafiqul Halim (Zimmu)
Assistant Managing Editors : Dr. Md. Nazmul Islam (Munna)
Dr. Tanvir Islam
Dr. Sharif Md. Noman Khaled Chwdhury
Members
Dr Habibur Rahman (Dulal) Dr. Md. Hafizur Rahman
Dr Sarfaraj Khan Dr. Saiful Hoque Talukder
Dr. Anamul Rashid Chowdhury Dr. Pallab Kumar Saha
Dr. Rezwanul Kabir Titu Dr. Sheikh Shahed Rahman
Dr. Mustafa Arif Dr. Sheikh Bodiuzzaman
Dr. Mizanur Rahman Juwel Dr. Md. Mahbubur Rahman (Babu)
Dr. Noor Alam Dr. Md. Sk. Shahid Ullah
Dr. Mahmudur Rahman Dr. Krishna Rani Majumder
Dr. Mohammad Kamruzzaman Sarker Dr. Farzana Alam (Toon)
Dr. Md. Shariful Matin Dr. Mst. Manjuman Ara Sarker
Dr. Shafayat Mohammad Shantanu Dr. Rahat Bin Habib
Dr. Faroque Md. Mohsin Dr. Noor Riffat Ara
Dr. Md. Harun-Or-Rashid Dr. Naimul Hasan Plabon
Dr. Shahed Imran Dr. Saidul Hossain Pial
222i
BMA Executive Committee for The Year 2017-2018

Sl. Name Name of Post
1. Dr. Mustafa Jalal Mohiuddin President
2. Dr. Kanak Kanti Barua Vice President (Dhaka City)
3. Dr. Jamal Uddin Khalifa Vice President (Dhaka Division)
4. Dr. Md. Kamrul Hassan (Salim) Vice President (Barisal Division)
5. Dr. Sheikh Mohammed Shafiul Azam Vice President (Chittagong Division)
6. Dr. Sk. Baharul Alam Vice President (Khulna Division)
7. Dr. Md. Mostafa Alam (Nannu) Vice President (Rajshahi Division)
8. Dr. Md. Delwar Hossain Vice President (Rangpur Division)
9. Dr. Murshed Ahmed Chowdhury Vice President (Sylhet Division)
10. Dr. A N M Fazlul Hoq Pathan Vice President (Mymensingh Division)
11. Dr. Md. Ehteshamul Huq Choudhury Secretary General
12. Dr. Mohd. Zahid Hussain Treasurer
13. Dr. Md. Kamrul Hasan (Milon) Joint Secretary General
14. Dr. Md. Tarique Mehedi Parvez Organizing Secretary
15. Dr. Shahryar Nabi (Shakil) Scientific Secretary
16. Dr. Md. SK. Shahid Ullah Office Secretary
17. Dr. Md. Mahbubur Rahman (Babu) Publicity & Public Relation Secretary
18. Dr. Sohel Mahmud Social Welfare Secretary
19. Dr. Purabi Rani Debnath Cultural & Entertainment Secretary
20. Dr. Kazi Shafiqul Halim (Zimmu) Library & Publication Secretary
21. Dr. Md. Abul Hashem Khan International Affairs Secretary
22. Dr. Mohammed Salim Member, Central Executive Committee
23. Dr. Md. Abdul Aziz Member, Central Executive Committee
24. Dr. Md. Moniruzzaman Bhuiyan Member, Central Executive Committee
25. Dr. Mohammad Mushtuq Husain Member, Central Executive Committee
26. Dr. Md. Jamal Uddin Chowdhury Member, Central Executive Committee
27. Dr. Md. Shafiqur Rahman Member, Central Executive Committee
28. Dr. Md. Sharfuddin Ahmed Member, Central Executive Committee
29. Dr. Qazi Shahidul Alam Member, Central Executive Committee
30. Dr. Md. Abu Raihan Member, Central Executive Committee
31. Dr. M Nazrul Islam Member, Central Executive Committee
32. Dr. Zahurul Huq Sachchu Member, Central Executive Committee
33. Dr. Md. Abu Yusuf Fakir Member, Central Executive Committee
34. Dr. Ehsanul Kabir Joglul Member, Central Executive Committee
35. Dr. Md. Zulfikar Ali (Lenin) Member, Central Executive Committee
36. Dr. Uttam Kumar Barua Member, Central Executive Committee
37. Dr. Chitta Ranjan Das Member, Central Executive Committee
38. Dr. Md. Jabed Member, Central Executive Committee
39. Dr. Hasanur Rahman Member, Central Executive Committee
40. Dr. Md. Babrul Alam Member, Central Executive Committee
41. Dr. Hossain Muhammad Mustafijur Rahman Member, Central Executive Committee
42. Dr. Muhammad Harun-Ar-Rashid Member, Central Executive Committee
43. Dr. Mahmud Hasan Member, Central Executive Committee
44. Dr. M Iqbal Arslan Member, Central Executive Committee
45. Dr. Syed Atiqul Haq Chairman, Bangladesh Medical Journal &
Member, Central Executive Committee
46. Dr. Rokeya Sultana Member, Central Executive Committee
47. Dr. Badiuzzaman Bhuiyan (Dablu) Member, Central Executive Committee
48. Dr. Kamrul Hasan Khan Member, Central Executive Committee
49. Dr. Momenul Haq Member, Central Executive Committee
50. Dr. Md. Shahidullah Sikder Member, Central Executive Committee
51. Dr. Pabitra Kumar Debnath Member, Central Executive Committee
ii
Information for Authors

Submission of manuscripts: The unstructured abstract of 150 words should follow the
Papers are accepted for publication with an understanding title page. It should provide the context or background for
that they are submitted solely to the Bangladesh Medical the study and should state the study’s purpose, basic
Journal and are subject to peer review and editorial revision. procedures (selection of study subjects or laboratory animals,
Statement and opinions expressed in the papers, observational and analytical methods), main findings (giving
communications and letters herein are those of author(s) and specific effect size and their statistical significance, if
not necessarily of the editors or publishers. Three hard copies possible), and principal conclusion.
along with a soft copy should be sent to the executive editor The text should be presented in the form of Introduction,
of Bangladesh Medical Journal, BMA Bhaban, 15/2, Methods, Results and Discussion.
Topkhana Road, Dhaka-1000. References:
Bangladesh Medical Journal publishes the following:
These should be given in the text using the Vancouver system.
Full papers, review articles, letters to the editors, debate and
They should be numbered consecutively in the order in
opinion papers, editorials, on being a doctor, medical news,
which they first appear in the text using superscript. If a
medical jokes/poem. reference is cited more than once the same number should be
Letters to the editor – letters are invited that discuss, criticize used each time. References cited only in tables and figures
or develop themes on national or international issues related and not in the text should be numbered in sequence from the
to doctors, medical science or medical profession. Clinical last number used in the text and in the order of mention of
observations, original research presented in a research letter the individual tables and figures in the text. At the end of the
format or case reports or series may be included in letters to paper, on a page(s) separate from the text, references should
the editors. Comments on papers published in Bangladesh be listed in numerical order. The journal adheres closely to
Medical Journal are also encouraged. Acceptance will be at the Vancouver style of references (see http:// www.nlm.
the discretion of the editorial board, and editorial changes nih.gov/bsd/uniform_ requirements. html, updated 2013).
may be required. Wherever possible, letters from responding
Sample references are given below –
authors will be included in the same issue.
Form of full papers submitted for publication: 1. Standard Journal Article
Full papers should be no more than 4000 words. The onus of List the first six authors followed by et al:
preparing a paper in a form suitable for sending to press lies Halpern SD, Ubel PA, Caplan AL. Solid-organ transplantation
with the author. Authors are advised to consult a current in HIV-infected patients. N Engl J Med. 2002 Jul 25;
issue in order to make themselves familiar with the journal 347(4): 284-7
regarding typographical and other conventions, layout of
As an option, if a journal carries continuous pagination
tables etc. Authors are encouraged to consult the latest
throughout a volume (as many medical journals do) the
guidelines produced by the International Committee of
Medical Journal Editors (ICMJE), which contains a lot of month and issue number may be omitted:
useful generic information about preparing scientific papers Halpern SD, Ubel PA, Caplan AL. Solid-organ transplantation
(http://www.icmje.org/manuscript_a.html) Manuscripts in HIV-infected patients. N Engl J Med. 2002; 347:284-7
should be typed on one side of white good quality A4 size More than six authors:
paper, with wide margins of at least 2cm and using double
Rose ME, Huerbin MB, Melick J, Marion DW, Palmer AM,
space throughout, the preferred font being Garamond size
Schiding JK, et al. Regulation of interstitial excitatory amino
12. Words at the end of lines should not be hyphenated
unless hyphens are to be printed. Page numbering is acid concentrations after cortical contusion injury. Brain Res.
required. Spelling should generally be that of the Concise 2002;935(1-2):40-6
Oxford Dictionary, 11th ed. Oxford: Clarendon press. Each Optional addition of a database's unique identifier for the
component of the manuscript should begin on a new page in citation:
the sequence of title page, abstract, text, reference, tables and Halpern SD, Ubel PA, Caplan AL. Solid-organ transplantation
legends for illustration. The title page should include the title
in HIV-infected patients. N Engl J Med. 2002 Jul
of the paper, name of the author(s), and name of the
25;347(4):284-7. PubMed PMID: 12140307
departments(s) to which the work should be attributed. The
first six authors of a work should be named, followed by “et Organization as author:
al.” if there are more than six. Diabetes Prevention Program Research Group.
iii
Hypertension, insulin, and proinsulin in participants with Tables :

impaired glucose tolerance. Hypertension. 2002;40(5): Table should have brief title for each, should be numbered
679-86 No author given:
consecutively using Roman numerals and be cited in the text
21st century heart solution may have a sting in the tail. BMJ. in consecutive order. Internal horizontal and vertical rules
2002;325(7357):184 should not be used.
Volume with supplement: Illustration :
Geraud G, Spierings EL, Keywood C. Tolerability and safety All drawings should be made with black Indian ink on white
of frovatriptan with short- and long-term use for treatment
paper. Photographs and photomicrographs should be
of migraine and in comparison with sumatriptan. Headache.
supplied as glossy black and white prints unmoundted. All
2002;42 Suppl 2:S93-9.
photographs, graphs and diagrams should be referred to as
Issue with supplement: figures numbered consecutively in the text in Arabic
Glauser TA. Integrating clinical trial data into clinical numerals.
practice. Neurology. 2002;58(12 Suppl 7):S6-12.
Abbreviation :
Article published electronically ahead of the print version: Yu
WM, Hawley TS, Hawley RG, Qu CK. Immortalization of Except for units of measurement, abbreviations are
yolk sac-derived precursor cells. Blood. 2002 Nov 15; discouraged. Consult scientific style and forma. The CBE
100(10):3828-31. Epub 2002 Jul 5. manual for authors, editor and publishers (Sixth edition New
York: Cambridge University Press, 1994) for lists of standard
2. Books and Other Monograph Personal author(s):
abbreviation. The first time an abbreviation appears, it should
Murray PR, Rosenthal KS, Kobayashi GS, Pfaller MA. be preceded by the words for which it stands.
Medical microbiology. 4th ed. St. Louis: Mosby; 2002.
Drug names :
3. Other Published Material MaterialNewspaper article:
Generic name should generally be used. When proprietary
Tynan T. Medical improvements lower homicide rate: study brands are used in research, include the brand name in
sees drop in assault rate. The Washington Post. 2002 Aug 12; parentheses in the methods section.
Sect. A:2 (col. 4).
Permission :
Dictionary and similar references:
Materials taken from other source must be accompanied by a
Dorland's illustrated medical dictionary. 29th ed.
written statement from both author and publishers giving
Philadelphia: W.B. Saunders; 2000. Filamin; p. 675.
permission to the journal for reproduction. Obtain
4. Unpublished Material (In press or Forthcoming:) permission in writing from at least one author of papers that
Tian D, Araki H, Stahl E, Bergelson J, Kreitman M. is still in press, unpublished data and personal
Signature of balancing selection in Arabidopsis. Proc Natl communications.
Acad Sci U S A. Forthcoming 2002.
The editor of Bangladesh Medical Journal reserves the
5. Journal Article on the Internet customary right to style and if necessary shortens the material
Abood S. Quality improvement initiative in nursing homes: accepted for publication and to determine the priority and
the ANA acts in an advisory role. Am J Nurs [Internet]. time of publication. Editor assumes that the manuscript
2002 Jun [cited 2002 Aug 12];102(6):[about 1 p.]. Available submited by the author is based on honest observations. It is
from: http://www.annals.org/ cgi/reprint/ 145/1/62.pdf not a task of the editor to investigate scientific fraud paper.
iv
Original Article
Effect of Extra-corporeal Shock-wave Therapy in the Management of Chronic Plantar Fasciitis

*Hojaifa MM1, Rahman S2, Saha TC3, Hosain M4, Rahman HH5, Ahmed M6, Islam MMM7, Alam MM8
ABSTRACT treatment of plantar fasciitis and its therapeutic outcomes.60

Plantar fasciitis is a progressive degenerative condition of the patients were allocated randomly into intervention group
plantar fascia which is reported to be one of the most common (Group A) and control group (Group B). Data were composed
causes of lower heel pain in adults. Extracorporeal Shock Wave through face to face interview using a questionnaire based on
Therapy is being used for the management of plantar fasciitis 1.Visual analogue scale, 2.Modified Roles and Maudsley
now a day. The aim of the study was to find out the effects of score, and 3.100-point Scoring System for Plantar Fasciitis.
Extracorporeal Shock-wave therapy in patients with chronic But after 8 weeks, score was found lower in Group A than
plantar fasciitis. A randomized clinical trial was conducted Group B (p<0.05).The usual total pain score was higher in
from May to October 2015, on 60 patients aged more than 18 100-point Scoring System for Plantar Fasciitis (p<0.001)
years with plantar fasciitis attending in the department of after 8 weeks of treatment as well average function score
Physical Medicine and Rehabilitation (PMR) in the Dhaka (0.001) in Group A. Patient satisfaction was also found
Medical College Hospital (DMCH) to observe the effectiveness higher in Group A by using Modified Roles and Maudsley
of Extracorporeal shock-wave therapy (ESWT) in the score. Extracorporeal shock-wave therapy showed effective, so it
can be suggested for the patients.
1. *Dr. Musa Muhammad Hojaifa, Assistant
Professor, Department of Physical Medicine & Keywords: Plantar fasciitis, extracorporeal shock-wave
Rehabilitation, Sheikh Hasina National Institute of therapy (ESWT)
Burn & Plastic Surgery (SHNIBPS), Dhaka.
Phone: 01614109909, Email: hojaifa@yahoo.com INTRODUCTION
2. Dr. Sohely Rahman, Ex. Professor & Head, Plantar fasciitis (PF) is a progressive degenerative disorder
Department of Physical Medicine & of the plantar fascia subsequent from recurrent trauma at
Rehabilitation, Dhaka Medical College Hospital its beginning on the calcaneus. Plantar fasciitis is the
3. Dr. Tulsi Chandra Saha, Assistant Professor, commonest cause of inferior heel pain in adults. Other
Department of Physical Medicine & names for plantar fasciitis include painful heel syndrome,
Rehabilitation, Mugda Medical College, Dhaka. heel spur syndrome.1
4. Dr. Mohammad Hosain, Medical Officer,
Department of Physical Medicine & The word “fasciitis” means inflammation is an inherent
Rehabilitation, Bangabandhu Sheikh Mujib component of this condition. However, recent research
Medical University (BSMMU) suggests that some presentations of Plantar fasciitis
5. Dr. Hasan Habibur Rahman, Assistant Professor, manifest non-inflammatory, degenerative processes and
Department of Physical Medicine & should more be termed “plantar fasciosis”.2 Plantar fasciitis
Rehabilitation, SHNIBPS is synonymous with inflammation of the plantar fascia. In
6. Dr. Monjur Ahmed, Assistant Professor, fact, the suffix “-ïtis” essentially implies an inflammatory
Department of Physical Medicine &
disease. Plantar fasciitis is widely described in the literature
Rehabilitation, Saheed Ziaur Rahman Medical
College, Bogura as having a multifactorial and widely disputed etiologyThe
term Plantar fasciitis is used to describe a painful heel with
7. Dr. Mollah Mohammad Mujahidul Islam,
Assistant Professor, Department of Physical inflammation of the plantar fascia at its origin. Plantar
Medicine & Rehabilitation, Bangabandhu Sheikh fasciitis is one of the common cause of heel pain, affecting
Mujib Medical, Faridpur 10% or more of the general population.4 It may be due to
8. Dr. Md. Mahfuzul Alam, Assistant Professor, strain to the origin of the plantar fascia or to biomechanical
Department of Physical Medicine & abnormalities of the foot.5 Though a heel spur may
Rehabilitation, Kurmitola General Hospital, present, but up to 27% of patients were without
Dhaka, Bangladesh. symptoms.6 It mentions a clinical condition of pain in the
*For Correspondence plantar aspect of the heel, characteristically worse on
1
arising in the morning and after periods of prolonged control group were done by lottery method and single
sitting. The etiology of plantar fasciitis is not clear and blinding method was applied.
probably multifactorial. Some rheumatologic disease like
Patients attending in the Physical Medicine &
sero-negative spondyloarthopathy also may develop
Rehabilitation department, Dhaka Medical College
plantar fasciitis.
Hospital, who were suffering from plantar fasciitis and
However, management advocated for plantar fasciitis have more than 18 years of age, were the study population.
included rest, ice, stretches, non-steroidal anti-inflammatory
drugs.7, corticosteroid injection8, iontophorosis, Diagnostic criteria of Plantar Fasciitis
orthotics, Tuli heel cups10,night splints11 ,heat,
9 · Aching, piercing in sole of foot.
ultrasound12, below the knee non weight bearing casts5 , · Foot pain that occurs immediately steps out of bed or
and short leg walking casts13. A very few number of get to feet after persistent periods of sitting.
patients undergo surgery. Extra corporeal shock wave
· Pain that may decline subsequently patients have been
therapy is well established for the treatment of urological on feet for a though, only to reappearance later in the
condition. It was introduced in the 1980s for the treatment day.
of insertion tendinopathies14.ESWT is an application
· Abrupt heel pain that builds steadily
procedure where shock waves are passed through the skin
to the painful part of the foot, by means of a special device. · Foot pain that has carry on for more than a few days
Extracorporeal means external to the body. The · Limping
shock-waves are machine-driven sound waves; they are
audible, low energy sound waves, which work by increasing Inclusion criteria
blood stream to the injured area. This accelerates the body’s · Age limit more than 18 years
healing process .It usually requires a course of three to four • Unilateral single-site plantar medial heel pain
treatment, one to two weeks apart.
• Symptoms greater than 3 months
Extracorporeal shock-wave therapy for musculoskeletal
• Participation in a prearranged stretching package within
conditions is assumed to offer extended analgesia and aids
the last 3 months
the healing process. It has been suggested as management
for chronic plantar fasciitis.15Patients with chronic plantar • Tenderness on confined pressure above the medial
fasciitis will be more efficiently treated by ESWT, so calcaneal tuberosity with passive dorsiflexion of the foot
recommend ESWT to be used for patients who are not • Visual Analogue Scale (VAS) score more than 5 (0- to
improving after 3 months of conservative measures.16It is 10-cm scale) for pain throughout the first few minutes
safe and effective and has produced a very good rate of of walking in the morning
success in relief of pain and functional status.17 • Modified Roles and Maudsley Score of 3 (FAIR) or 4
(poor)
The aim of this study is to assess further the clinical
efficiency of high energy shock wave therapy for the • Readiness to relinquish any other concomitant therapies
treatment of chronic plantar fasciitis throughout a twelve for the duration of the study
therapeutic session. Exclusion criteria
· Previous surgery, conservative or physical therapy
MATERIALS AND METHODS
management within 3 months
A Randomized clinical trial (RCT) was accompanied in
• Pesplanus, pescavus or any other foot deformity
the Physical Medicine and Rehabilitation (PMR)
Department, Dhaka Medical College Hospital, Dhaka, • Corticosteroid injection within few days
Bangladesh to establish the effect of Extra-corporeal • Documented autoimmune or systemic disease
Shock-wave Therapy in the management of chronic • Coagulation abnormalities
plantar fasciitis. One was a intervention group which is • Peripheral vascular disease
treated with Extracorporeal shock wave therapy (ESWT)
• Diabetes
along with NSAIDs, Exercises, orthotic as heel cushion/
shoe modification like slight high heel with heel cushion • Local tumor
while control group did not receive Extracorporeal • Any previous trauma/fracture
shock-wave therapy (ESWT). Intervention group and • Infections
2
Sixty patients with chronic plantar fasciitis who satisfy the At the beginning of analysis, expressive analysis was done.
selection criteria were taken as sample. They were Means and standard deviations were calculated for
distributed into two groups (Group-A and Group-B). Each continuous variables when frequencies and percentages were
group comprises of 30 patients. Sampling technique was calculated for categorical variables. Student’s t-test was
Simple random sampling by lottery. At first suitable performed to assess the mean differences. Statistical
participants were nominated and then separated into two significance was defined as p<0.05 and p<0.01 was defined as
groups; Group A and Group B. highly significant. Data were presented by tables and graphs.
Group A: ESWT+ NSAID+ Exercise+ Orthotics
RESULT
Group B: NSAID+ Exercise+ Orthotics
This Randomized Controlled Trial was conducted among
a) ESWT: Patient was treated with shock-wave therapy 60 persons with chronic plantar fasciitis of both sexes. The
three times weekly for four weeks of a total 12 60 patients were further distributed arbitrarily into two
sessions. The top of the applicator was placed directly groups; Group A and Group B. Patients in Group A were
to the proximal aspect of plantar fascia. Direction was treated with Extracorporeal shock-wave therapy (ESWT)
90degree to the joint. Gel is used for granting along with NSAIDs, Exercises, orthotic as heel cushion and
penetration. Shock-wave treatment was administered
Group B were managed with shoe modification like slight
for 10 minutes per session at an 800 shocks with
high heel with heel cushion. Data were analyzed with SPSS
frequency of 4Hz, an intensity of 2-3 Bars.
software using appropriate statistical methods and were
b) NSAIDs: Tab. Etoricoxib 90 mg at night orally for presented in this chapter in tables and graphs. The finding
two weeks was prescribed with coverage of Cap. were divided into several sections and organized as follows;
Omeprazole 20mg twice daily. Same commercial
preparation was used. Background characteristics
VAS scores of both groups at 0 week, 2nd week, 4th week,
c) Exercise: Plantar fascia stretching at a rate of 10
8th week.
repetitions twice daily was prescribed and demons-
trated to all patients. Modified Roles and Mausdley scores of both groups at 0
d) Orthotics: Heel cushions/ Medial arch support. week, 2nd week, 4th week,8th week.
Data were collected through face to face interview. Before 100- Point scoring system for plantar fasciitis (pain score,
the interview, the detail of the study was explained to each function score and total score) of both groups at 0 week,
eligible participant. 2nd week, 4th week, 8th week.
Demographic variable: Background characteristics

a. Age b. Sex c. Educational status d. Socio-economic Background information was collected from the
condition participants. It included participant’s age, sex, educational
Three scales were used in this study status and socio-economic status. These characteristics
(1) Visual analogue scale (1-10) were displayed in tables and figures.
(2) Modified Roles and Maudsley score Age

(3) 100-point Scoring System for Plantar Fasciitis Table 1 shows average age of the patients was 48.13 years
Data processing and exploration with standard deviation of ±9.88 years. Minimum age of
the participants was 32 years where the maximum was 67
Data processing and exploration was done by using
Statistical Packing for the Social Sciences (SPSS) software years. The mean age of Group A was 47.27 years (±9.19)
Version 16.At first questionnaire was checked for while it was a little bit higher in Group B (49.00±10.67).
completeness after completion of data collection. Data
were entered into computer using SPSS 16. Then data Table 1 Age distribution in two groups
were checked thoroughly after frequency run and
necessary cleaning and editing done. An analysis plan was Age in year Mean ±SD Minimum Maximum
developed as per specific objectives of the study. Group-A 47.27 9.19 32 62
Distribution was checked for normality and log Group-B 49.00 10.67 32 67
transformation was done if any variable had data that was
Total 48.13 9.88 32 67
not normally distributed.
3
Educational status
35
30 Educational status of the participants was divided into four
25 categories: the participants who were illiterate or can sign
20 only or did not pass primary school was categorized as
15
10 “below primary”, the participants who completed primary
5 Female education but did not pass SSC were categorized as
0
Male
“primary to SSC” and the participants who passed SSC or
Group A
Group B HSC was categorized as “SSC to HSC” and above them
Male Female
Total
were leveled as “graduate and above”.
Fig.-1: Sex distribution in groups
Table II shows all participants, among them 31.6% had
Figure 1 shows among the participants, female were 55% completed SSC or HSC, 30% participants completed their
(33) and the rest 45% (27) were male. Among 30 graduation or above. In group A, 16.7% participants were
participants of Group A, 14 were male and 16 were female. below primary level of education.
Among equal number of participants in Group B, 13 were
male and 17 were female.
Table II : Educational status of participants of both groups

Educational status Below primary Primary to SSC SSC to HSC Graduate and above
Group A 4 (13.3%) 8 (26.7%) 8 (26.7%) 10 (33.3%)
Group B 6 (20.0%) 5 (16.7%) 11 (36.6%) 8 (26.7%)
Total 10 (16.7%) 13 (21.7%) 19 (31.6%) 18 (30.0%)
Socio-economic status
35
Figure 2 shows socio-economic status of the participants
was divided into lower socio-economic, lower-middle,
30
higher-middle and higher class on the basis of their
monthly family income. Among the participants, belonged
25 to lower middle socio-economic class (average income
12,000 taka) 31 (51.6%), higher middle class (average
20 monthly income 20,000 taka) participants were 13
(21.7%). There were no participant in higher class
15 (monthly income >20,000 taka) while 16 (26.7%) in lower
class (average monthly income were <12,000 taka). The
10 proportion remained almost unchanged when they were
divided into Group A and Group B.
5
Visual Analogue Scale (VAS) scores
0 Visual Analogue Scale (VAS) scores of both intervention
Group A Group B Total group (Group A) and control group (Group B) were
recorded at various intervals. Patients were advised to point
Lower ClassLower Middle Class their score on a Visual analogue scale and the score was
recorded. VAS scores were recorded at beginning of the
Lower Middle Class
study (0 week), after 2 week, after 4 week and after 8 week.
Higher Middle Class After that, student’s t-test was performed to measure the
mean difference among two groups at different time
Fig 2 : Socio-economic status of the participants interval.
4
Table III shows Visual Analogue Scale (VAS) scores that Modified Roles and Maudsley Score
were recorded at the beginning of the study for both of the
Modified criteria of Roles and Maudsley score was
groups. The mean VAS scores were almost equal for the
developed on the basis of patient compliance about a
both groups (Group A- 7.47±0.63; Group B-7.67±0.80).
At the end of second week, VAS scores was dignified again treatment. There are four grading in this scale; score 1=
and till then scores remained close for both groups (Group Excellent, score 2= Good, score 3= Fair, score 4= Poor.
A-7.20±0.76; Group B- 7.40±0.62). This technique was Table IV (a) shows at the beginning of the study, 26
repeated at the end of fourth week and then mean score was patients experienced poor with pain and 4 felt fair in
set up lower in Group A (5.40±0.72) than that of Group B
Group A, while it was 24 and 6 respectively in Group.
(6.33±0.61). Scores were recorded for the last time at the
After 2 weeks, 15 patient experienced fair and 1 patient
end of eight week. The mean score remained lower in
Group A (4.07±0.94) than in Group B (5.20±0.66). The experienced good in Group A, while 13 patients felt fair
differences found statistically significant (p value >0.05) at and no patient felt good in Group B. At the end of
fourth and eighth week. treatment, 8 patients felt excellent and 17 patients felt
good in Group A. No patient felt poor in Group A after
Table III Visual Analogue Scores of both groups completion of treatment. After completion of treatment,
Group Mean ±SD P value no patient felt excellent while three patients felt poor in
Group B.
VAS (0 week) Group A 7.47 0.629 NS
Group B 7.67 0.802 Table IV (b) shows after 2 weeks of treatment, the Group
A had mean Modified Roles and Maudsley (MRM) score
VAS (2 week) Group A 7.20 0.761 NS
3.43±0.57 while the score was 3.57±0.50 in Group B.
Group B 7.40 0.621 MRM score was lower (more compliance) after 4 weeks of
VAS (4 week) Group A 5.40 0.724 <0.05 treatment in Group A (2.57±0.51) than in Group B
Group B 6.33 0.606 (3.23±0.61). The situation remained unchanged after 8
week (1.90±0.67 in Group A and 2.67±0.43 in Group B).
VAS (8 week) Group A 4.07 0.944 <0.01
All of the differences were statistically significant.
Group B 5.20 0.664
VAS= Visual Analogue Scale
Table IV (a) MRM score of both groups

Group Poor Fair Good Excellent
0 week Group A 26 (87.7%) 4 (13.3%) 0 (0.0%) 0 (0.0%)
Group B 24 (80.0%) 6 (20.0%) 0 (0.0%) 0 (0.0%)
2nd week Group A 14 (46.7%) 15(50.0%) 1 (3.3%) 0 (0.0%)
Group B 17 (56.6%) 13 (43.3%) 0 (0.0%) 0 (0.0%)
4th week Group A 0(0.0%) 16 (53.3%) 14 (46.7%) 0 (0.0%)
Group B 12 (40.0%) 16(53.3%) 2 (6.7%) 0 (0.0%)
8th week Group A 0 (0.0%) 5 (16.7 %) 17 (56.7%) 8 (26.7%)
Group B 3 (10.0%) 20 (66.7%) 7 (23.3%) 0 (0.0%)
Table IV (b) MRM score of both groups

Group Mean ±SD P value
MRMS(2 week) Group A 3.43 0.568 <0.05
Group B 3.57 0.504
MRMS(4 week) Group A 2.57 0.507 <0.01 ̽
Group B 3.23 0.606
VAS (8 week) Group A 1.90 0.662 <0.01 ̽
Group B 2.67 0.434
MRMS= Modified Roles and Maudsley Score, ̽= Highly Significant (HS)
5
100 –Point Scoring System for plantar fasciitis score pain score (36.87±8.31) than Group B (33.40±8.01) and
“100 –Point Scoring System for plantar fasciitis”, measures the difference was statistically significant.
pain in two domains; 70-points for pain score and
Function score
30-point for function score. Both pain score and function
score were measured and compared. Table VI shows function scores were also almost equal
for both groups at 0 week (Group A-13.60±0.89; Group
Pain score B-13.80±1.06) and end of 2nd week (Group A-14.00
Table V shows pain scores were almost equal for both ±1.39; Group B-14.33±1.32). after 4th week, Group A
groups at 0 week (Group A-19.93±7.03; Group scored a little higher (18.87±2.73) than Group B
B-20.20±6.18) and end of 2nd week (Group (16.93±1.98). None the above differences was
A-20.20±6.53; Group B-20.67±6.78). At the end of 4th statistically significant. After 8th week Group A achieved
week, Group A scored higher (27.27±6.78) than Group B better function score (21.47±2.97) than Group B
(24.67±6.33). But the above differences were not (19.13±2.97) and the difference found statistically
statistically significant. After 8th week Group A had better significant (p<0.05).
Table V : 100 –Point Scoring System for plantar fasciitis (pain score) of both groups
100-PSS(pain score); 0 week Group A 19.93 7.032 NS
Group B 20.20 6.183
100-PSS(pain score); 2nd week Group A 20.20 6.531 NS
Group B 20.67 6.774
100-PSS(pain score); 4th week Group A 27.27 6.782 NS
Group B 24.67 6.332
100-PSS(pain score); 8th week Group A 36.87 8.312 <0.05
Group B 33.40 8.013
Table VI : 100 –Point Scoring System for plantar fasciitis (function score) of both groups
100-PSS(function score); 0 week Group A 13.60 0.894 NS
Group B 13.80 1.064
100-PSS(function score); 2nd week Group A 14.00 1.390 NS
Group B 14.33 1.322
100-PSS(function score); 4th week Group A 18.87 2.726 NS
Group B 16.93 1.982
100-PSS(function score); 8th week Group A 21.47 2.968 <0.05
Group B 19.13 2.968
6
Total score for 100- Point Scoring System for plantar Visual Analogue Scale (VAS) scores of both intervention
fasciitis group (Group A) and control group (Group B) were
recorded at various intervals. VAS scores were recorded at
Table VII shows total scores were also almost equal for both
the beginning of the study for both of the groups. The
groups (Group A-33.5±7.83; Group B-34.00±6.93) at
mean VAS scores were almost equal for the both groups
week and by the end of 2nd week (Group A-34.20±7.62;
(Group A-7.47±0.63; Group B-7.67±0.80). After then, at
Group B-34.00±7.76), and those were not statistically
the end of second week, VAS scores were measured again
important as well. After 4th week, Group A had a higher
and till then scores remain close for both groups (Group
(46.13±8.34) than Group B (41.60±7.52). This difference
A-7.20±0.76; Group B-7.40±0.62). This procedure was
was statistically significant (p<0.05). After 8th week of
repeated after fourth week and then the mean score was
management, Group A attained better score
found lower in Group A (5.40±0.72) than that of Group B
(58.33±10.46) than Group B (52.53±8.74) and this (6.33±0.61). Scores were recorded for the last time at the
difference was found statistically significant (p<0.01). end of 8th week. The mean score remained lower in group
A (4.07±0.94) than in Group B (5.20±0.66). The mean
difference were found statistically significant (p value >
Table VII: Total score for 100- Point Scoring System for 0.05) at fourth and eighth week.
plantar fasciitis
Similar study was conducted by Krishnan et al., in 2012 in
Group Mean ±SD P value Delhi, India among 25 patients. The mean pretreatment
100-PSS (0 week) Group A 33.53 7.825 NS VAS for the entire group was 9.2±0.7. Four weeks after
Group B 34.00 6.928 treatment the VAS decreased to 3.4±1.9. This difference
was statistically significant (p<0.05). VAS scores were
100-PSS (2nd week) Group A 34.20 7.622 NS
improved in both of the studies though improvement was
Group B 34.00 7.764 greater in the study of Krishnan et al.
100-PSS (4th week) Group A 46.13 8.337 <0.05
On the other hand, at the beginning of the study, 26
Group B 41.60 7.518
(87.7%) patients experienced poor with pain and 4
100-PSS (8th week) Group A 58.33 10.456 <0.01 (13.3%) felt fair in Group A, while it was 24 (80.0%) and
Group B 52.53 8.740 & (20.0%) respectively in Group B. After 2 weeks, 15(
50.0%) patient experienced fair and 1 patient experienced
good in Group A, while 13 (43.3%) patient felt fair and no
DISCUSSION
patient felt good in Group B. At the end of treatment,
Plantar fasciitis is a most common presenting disorder of 8(26.7%) patients felt excellent and 17(56.7%) patients
foot in which symptoms become chronic and functionally felt in Group A. No patient felt poor in Group A after
incapacitating. It occurs in similar proportions in all treatment completed. After completion of treatment, no
culture, interferes with equality of life and work patient felt excellent while three patients felt poor in
performances. It is common reason for medical Group B. In the study of Krishnan et al., 2012 four weeks
consultations. Along with other treatment, recently, ESWT post treatment, 18(72%) heels were rated as `1` (excellent),
has been advised for treatment of this condition. A 4 (16%) as `2` (good), and 1(4%) as `3`(fair) and `4`
randomized clinical study was accompanied on 60 patients (poor or unchanged).Though excellent were more in
with plantar fasciitis attending in the physical medicine and Krishnan et al’s study, the scenario in both study was
rehabilitation department in the Dhaka Medical College similar.
Hospital to assess the efficacy of Extracorporeal Shock-wave
Another study was conducted by Chen et al., in Taiwan
therapy (ESWT) in the treatment of plantar fasciitis and its
in1999 on similar topic by using 100-point scoring system
therapeutic outcome. The patients were randomly divided
among 74 patients. The average total pain scores were
into two groups by lottery; Group-A and Group-B. In
29.3±14.6 pretreatment and 49.2±13.9 post treatment
Group-A, Extracorporeal shock-wave therapy (ESWT)
(p<0.001). The average function scores were 15.2±4.6
along with NSAIDs, Exercises, orthotic as heel cushion/
pretreatment and 21.6±6.0 post treatment (p<0.001).
shoe modification like slight high heel with heel cushion
and Group-B NSAIDs, Exercises, orthotics as heel cushion/ On the other hand this study also revealed similar result.
shoe modification will be given for a period of 8 weeks. The average total pain score were 19.93±7.03 pretreatment
7
and 38.87±8.31 post treatment (p, 0.001). The average Extracorporeal Shock Wave Therapy for Plantar
function scores were 13.60±0.89 pretreatment and Fasciitis. JAMA 2002;288:1364-1372
21.47±2.97 post treatment (p<0.001).This study was
7. Wolgon M, Cook C, Graham C, Mauldin D.
found consistent with most of the other studies.
Conservative treatment of plantar heel pain:
long-term-follow-up.Foot Ankle Int.1994; 15:97-
CONCLUSIONS
102.
This study found the effect of Extra-corporeal Shock-wave
Therapy in the treatment of chronic plantar fasciitis when 8. Blockey NJ. The painful heel.BMJ 1956; ii: 1277-8
treated together with other treatment choices. The patients 9. Gill L, Kiebzak G, outcome of nonsurgical treatment
treated with Extra-corporeal shock-wave therapy along for plantar fasciitis. Foot Ankle Int.1996; 17:527-532
with other options had better presentation than those who
did not receive extracorporeal shock-wave therapy. The 10. Schepsis AA, Leach RE, Gorzyca J. Plantar fasciitis:
effect was better after 4th week and it was clear after 8 week etiology, treatment, surgical results, and review of the
of extracorporeal shock-wave therapy. There was no literature. Clin Orthop. 1991; 256:185-196.
significant difference between two groups after two weeks 1. Wapner KL, Sharkey PF. The use of night splints for
of treatment. So it may be recommended that treatment of recalcitrant plantar fasciitis. Foot
extracorporeal shock-wave therapy might be rewarding
Ankle.1991;12:135-137.
after 4 weeks of treatment. Extracorporeal shock-wave
therapy showed better compliance, and can be suggested 12. Crawford F, Snaith M. How effective ultrasound in
by the physicians. the treatment of heel pain? Ann Rheum Dis.
1996;55:256-267
REFERENCES 13. Tisdel CL, HarperMC. Chronic plantar heel pain:
1. Roxas M. Plantar fasciitis: Diagnosis and Therapeutic treatment with a short leg walking cast. Foot Ankle
Considerations. Alternative Medicine Review 2005; Int. 1996;17:41-42
10(2):83-93 14. Dahmen GP, Meiss L, Nam VC, Skruodies
2. Aldridge T. Diagnosing heel pain in adults. Am Fam B.Extrakorporale Shosswellen therapie (ESWT) im
Physician 2004; 70:332-338. knochennahen Weichteilbereich an der Schulter.
Extracta Orthopaedica 1992;11:25-7
3. Dimarcangela MT, Yu TC: Diagnostic imaging of heel
pain and plantar fasciitis. Clin Podiatr Med Surg 15. Rompe JD, Hopf C, Nafe B, Burger R. Low-energy
14:284, 1997. extracorporeal shock-wave therapy for painful heel: a
4. Haake M, Buch M, Schoellner C, Mueller HH. prospective controlled single-blind study. Arch
Extracorporeal shock wave therapy for plantar Orthop Trauma Surg 1996;115:75-9.
fasciitis: randomized controlled multicenter trial. BMJ 16. Aqil A, Siddiqui MRS, Solan M, Redfern DJ, Gulati
2003; 327:1-5 V, Cobb JP. Extracorporeal shock-wave therapy in
5. Gill LH.Plantar fasciitis: diagnosis and conservative treating chronic plantar fasciitis: A meta-analysis of
management. J Am AcadOrthopSurg 1997; 5: 109-17. RCTs. Clin Orhop Relat Res. June,2013.
6. Buchbinder R, Ptasznik R, Gordon J, Buchanan J, 17. Dastagir N. Extracorporeal shock-wave therapy for
Prabaharan V, Forbes A. Ultrasound-Guided treatment of plantar fasciitis.JPMA 2014;64:675-678.
8
Original Article
Early Signs of Autism and It’s Relation with Gestational Factors: An Urban Based Study in
Bangladesh
⃰ Sharmin S1, Halim KS2, Sultan Z3, Haque KM4
Abstract the children having early signs of autism, history of normal

A cross-sectional study was conducted to observe the birth weight was found more in term pregnancy (62.5%)
prevalence autism spectrum disorders (ASD) and its than its preterm counterpart (60.0%). Growth parameter
correlation with gestational factors in country population was higher in normal birth weight (68.8%) than low birth
between January and December of 2016. The study weight (60.0%). Similarly, growth parameter was also
population was nursery school child aged 3-5 years whose higher in children that are from 3rd gravida (75.0%) than
parents were willing to participate in the study. In this study, that of 2nd gravida (66.7%) and 1st gravida (61.5%).
the children are excluded whom already being identified as Birth weight was also higher in >2 years birth spacing
any forms of autism spectrum disorders. Convenient sampling (60.0%) than that of <2 years (50.0%). Complication was
technique was followed to select the samples from 47 schools more in home delivery (50.0%) than institutional delivery
of Uttara, Ashulia and Nikunjo area of Dhaka City (20.8%). Birth injury happened more in home delivery than
Corporation and Tongi area of Gazipur City Corporation institutional delivery. Similarly, complication during
under Dhaka Division, Bangladesh. A total of 1000 children delivery was higher in >2 years birth spacing (30.0%) than
were recruited in the study. The research instrument was a that of <2 years (0%), However, the difference was not
semi-structured questionnaire based on Early Screening of significant statistically in any of the comparisons (P>0.05).
Autistic Traits (ESAT) tool. Based on the diagnosis of the Hence, no causal relation was found between autism and
cases, parents were invited to another interview to fill out gestational factors.
questionnaire related to some parental and gestational factors
Keywords: Autism spectrum disorder, early signs of autism,
to assess the relationship with autism. The study found early
prevalence, gestational factors
signs of autism in 2.6% cases (26 in 1000), by using Early
Screening of Autistic Traits (ESAT) questionnaire. Among
INTRODUCTION
1. *Dr. Saida Sharmin, Assistant Professor, Depart- Autism spectrum disorders (ASD) are a diverse group of
ment of Community Medicine, International conditions. Commonly seen in the beginning in infancy
Medical College, Tongi, Gazipur- 1711. Cell
and toddler years, those developmental disorders are
Phone:+8801711353805; Email: drsaida2012
@gmail.com characterized by lac of social interaction and
communication, constricted and dreary interests and
2. Prof. (Dr.) Kazi Shafiqul Halim, Professor,
Department of Epidemiology, National Institute of behaviours.1 Characteristics of autism may be detected in
Preventive and Social Medicine (NIPSOM), early childhood, but autism is often not diagnosed until
Mohakhali, Dhaka-1212. much later.2 Although several studies have hypothesized
3. Dr. Zobayed Sultan, Child Health Specialist, and showed that some of the parental, postpartum or
Sherpur, Bogura-5840. obstetric conditions are associated with autism,2-4 the
4. Dr. Kazi Mahbubul Haque, Assistant Professor, problematic effects, or causations and overall conclusions
Department of Community Medicine, of those studies were found often inconsistent.5 In this
Brahmanbaria Medical College, Brahmanbaria-
regard, research into prenatal factors were focused on
3400.
usually parental factors, like age, comorbidity,
⃰ For Correspondence
medications, while perinatal research were focused on
9
usually possible trauma during the birth process with its Screening of Autistic Traits (ESAT) questionnaire tool to
complications like Caesarean section, breech determine early signs of autism.10 Early Screening of
presentation, fetal distress, postpartum hemorrhage and Autistic Traits (ESAT) is a primary screening checklist
prolonged labour, incidence of multiple gestations, with 19 items that was designed for infants 0-36
pregnancy with co-morbidities and complications, month(s) old. It is based on prominent early signs and
preterm and/post-term birth etc. Similarly, newborn symptoms of autism spectrum disorders (ASD), and
research concentrated on neonatal distress, including low designed to be completed by parents/caregivers during
birth weight and neonatal complications.6-9 However, in children’s health visits. Failure on three or more items
our country, there is no such research reports available to indicates the need for further evaluation.10 Based on the
date; hence we lack evidence. During the last 10 years, diagnosis of the cases, parents were invited to another
autism has appeared as a major public health issue around interview to fill out questionnaire related to some
the globe.1 Though the degree of impairment and parental factors and gestational factors which could be
consequences might differ among the patients, ASD is a helpful to assess their relationship with autism.
lifelong condition. Immense support is required to
Proportions of early sign of autism were determined by
overcome the conditions and social situations.1 It is
frequency and percentage. Other data ware also shown in
common in ASD condition that children are deprived
tables with frequency and percentage. In order to see the
from the proper routine education.1 Therefore, studies
association of gestational factors and autism in those
related to epidemiology and underlying factors are
children, Chi-square (χ2) test was done. All the tests were
important especially on the relation of pre-, peri- and
two tailed; P<0.05 was considered statistically significant.
neonatal risk factors on ASD from an ethnically and
Data analysis was done using SPSS (Statistical Package for
socially diverse country like Bangladesh. Considering
Social Science) version 16.0 software. This research was
those points, we did this study to see the relationship
approved by the Institutional Ethical Committee of
between gestational factors/exposures and autism in
National Institute of Preventive and Social Medicine
children in an urban area.
(NIPSOM), Dhaka, Bangladesh.
RESULTS
This study was cross-sectional and conducted in the span
of January to December of 2016. The population of Table-I shows a prevalence of early signs of autism in 2.6%
study was school going children aged 3-5 years whose cases (26 in 1000). Children having deficits or failure on
parents were willing to participate in this study. We three or more items were detected as having early signs of
excluded children who were already diagnosed as having autism. 4(0.4%) had deficiency to show interest in
autism spectrum disorder. However, a convenient different objects, 4(0.4%) could not express their feeling as
sampling technique was followed to select the samples deserved by the situation, 2(0.2%) could not react to
from 47 schools of Uttara, Ashulia, Nikunjo areas of normal sensory stimulation, 7(0.7%) did not cry or call,
Dhaka City Corporation and Tongi area of Gazipur City while left alone. Stereotype repetitive body movements
Corporation under Dhaka Division, Bangladesh. A total were observed in 6(0.6%), 1(0.1%) could not bring objects
of 1000 children aged 3-5 years, who fulfilled the as directed, 8(0.8) failed to show interest on others,
selection criteria, were recruited in the study. The 6(0.6%) did not like to be cuddled, 5(0.5%) never smiled
instrument was pre-tested among 10 children in to others, and 4(0.4%) did not like to play with others.
Azampur Govt. Primary School at Uttara Area under Besides, 1(0.1%) failed to react to spoken language,
Dhaka City Corporation for clarity, accuracy, lucidity 3(0.3%) failed to speak conjoining 2/3 words together,
and find out the validity of the questions. Minor 1(0.1%) failed to gaze at something shown or pointed to.
modifications were considered in the final interview Finally, 4(0.4%) children were found who could not ever
schedule. The research instrument contained a pretend like making a cup of tea using a toy cup & teapot
semi-structured screening questionnaire, based on Early from the toys.
10
Table I: Early signs of autism as screened by using ESAT tool (n=1000)

Variables Yes (Percentage) No (Percentage)
Interested in different object 996 (99.6) 4 (0.4)
expresses feeling (crying/smiling) on expected/appropriate time 996 (99.6) 4 (0.4)
React normal way to sensory stimulation 998 (99.8) 2 (0.2)
If child is left alone, does it start crying/ calling? 993 (99.3) 7 (0.7)
Without stereotype repetitive movement (banging head/ rocking body) 994 (99.4) 6 (0.6)
Own accord, bring objects over you 999 (99.9) 1 (0.1)
Showing interest to other children or adults 992 (99.2) 8 (0.8)
Child likes to be cuddled 994 (99.4) 6 (0.6)
child ever smiled at you or others 995 (99.5) 5 (0.5)
Child likes to play with others 996 (99.6) 4 (0.4)
React to spoken language to for instance (by looking/ listening/ smiling/ babbling) 999 (99.9) 1 (0.1)
Child can speak a few words or utter various words 997 (99.7) 3 (0.3)
Child can follow your gaze to see what you are pointing to 999 (99.9) 1 (0.1)
Can the child ever pretend, make a cup of tea using a toy cup & teapot? 996 (99.6) 4 (0.4)
Early signs of autism present
(as done by using ESAT tool) 26 (2.6) 974 (97.4)
Table-II shows that gestational age was term 16(61.5%), 2 years and 10(38.5%) respondents birth spacing was
rest was preterm 10(38.5%). Normal birth weight greater than 2 years. Mode of delivery were, Caesarean
16(61.5%), low birth weight 10(38.5%). Birth injury was section 20(76.9%), followed by normal vaginal delivery
present in 2(7.75%). H/O milestone of growth 5(19.2%) and Forceps’ delivery 1(3.8%). No complication
17(65.4%). 1 gravida 13(50.0%) and 2(7.7%) respondents during delivery 20(76.9%) and 6(23.1%) respondents
had birth spacing (comprising previous issue) was less than were complication during delivery.
Table II: Gestational factors at a glance (n=26)
Variables Frequency Percentage Variables Frequency Percentage

Gestational age Gravida
Preterm 10 38.5 1st 13 50.0
2nd 9 34.6
Term 16 61.5
3rd 4 15.4
Weight at birth
Birth spacing comprising previous
Low birth weight 10 38.5
<2 years 2 7.7
Normal birth weight 16 61.5 >2 years 10 38.5
Birth trauma /injury Mode of delivery
No 24 92.3 Normal vaginal delivery 5 19.2
Yes 2 7.7 Caesarean section 20 76.9
Forceps’ delivery 1 3.8
H/O milestone of growth
Complication during delivery
No 9 34.6
No 20 76.9
Yes 17 65.4
Yes 6 23.1
11
Table-III shows that normal birth weight was in term Table VI: Birth spacing of respondents and birth weight
pregnancy 62.5% preterm group 60.0%. However, the
Birth Birth Weight χ2 P value
result was found statistically not significant (P>0.05).
Spacing Low Normal
<2yrs 1(50.0%) 1(50.0%)
Table III: Gestational age and weight at birth >2yrs 4(40.0%) 6(60.0%) .069 >0.05
Gestational Weight at birth χ2 P Total 5(41.7%) 7(58.3%)
age Low Normal value
Birth Weight Birth Weight
Table-VII shows that, complication during delivery was
Preterm 4(40.0%) 6(60.0%) higher in home delivery (50.0%) than institutional
Term 6(37.5%) 10(62.5%) .016 >0.05 delivery (20.8%), though the difference was not
Total 10(38.5%) 16(61.5%) statistically significant (P>0.05).
Table-IV shows that, parameters of growth were higher in

Table VII: Mode of delivery of the respondents and
normal birth weight (68.8%) than that of low birth weight
complications
(60.0%), the result found statistically not significant
though (P>0.05). Mode of Complication χ2 P
delivery during delivery value
No Yes .885 >0.05
Table IV: Weight at birth and milestone of growth
Home Delivery 1(50.0%) 1(50.0%)
Weight at birth Milestone of growth χ2 P
Institutional Delivery 19(79.2%) 5(20.8%)
No Yes value
Total 20(76.9%) 6(23.1%)
Low birth weight 4(40.0%) 6(60.0%)
Normal birth weight 5(31.2%) 11(68.8%) .208 >0.05
Total 9(34.6%) 17(65.4%) Table-VIII shows that, birth injury was higher in home
delivery (50.0%) than institutional delivery (4.2%),
Table-V shows that, parameters of growth were higher in though the difference was not statistically significant
the 3rd gravida (75.0%) than that of the 2nd gravida (P>0.05).
(66.7%) and the 1st gravida (61.5%). However, the result
was not found statistically significant (P>0.05).
Table VIII: Mode of delivery of respondents and birth
Table V: Gravida of the respondents and milestone of injury
growth Mode of delivery Birth injury χ2 P
Gravida Milestones of growth χ2 P value No Yes value
No Yes Home Delivery 1(50.0%) 1(50.0%)
1st 5(38.5%) 8(61.5%) Institutional Delivery 23(95.8%) 1(4.2%) 5.462 >0.05
2nd 3(33.3%) 6(66.7%) .255 >0.05
Total 24(92.3%) 2(7.7%)
3rd 1(25.0%) 3(75.0%)
Total 9(34.6%) 17(65.4%)
Table-IX shows that, complications during delivery was
Table-VI shows that, birth weight was higher in >2 year higher in >2 year birth spacing (30%), while no
birth spacing (60.0%) than that of <2 year birth spacing complication was in <2 year birth spacing (0%).
group (50.0%), the result was not statistically significant However, the result was found statistically not significant
though (P>0.05). (P>0.05).
12
Table IX: Birth spacing of the respondents and delivery were 21% more likely to be diagnosed as having ASD.22
complications Many of the earlier studies that examined pre-, and
perinatal risk factors in autism2-4,23-25 could not report
Birth Complication χ2 P
significant differences, due to smaller sample size26, as we
Spacing during delivery value
assume research on such a sensitive issue impacts willful
No Yes .800 >0.05
participation in a disability-averse society. Similar
<2yrs 2(100%) 0(0%) happened to ours. The present study was limited to
>2yrs 7(70.0%) 3(30.0%) cross-sectional design that signifies that the association
Total 9(75.0%) 3(25.0%) found in this study does not necessarily mean to establish
any causal relationship. Moreover, probability sampling
technique could not be employed to recruit the study unit;
DISCUSSION our samples were selected conveniently due to time and
budget constraints. As a result, there might be a selection
The study estimated that the prevalence of ASD was 2.6%
bias. Last but not the least, most of the information about
(n=1000) and it is in agreement with other
gestational factors was collected with a questionnaire based
population-based study, such as 2.64% in South Korea11,
on the memory of the respondents, which may be liable to
Japan12 and China13. In contrast, a study done in our
neighbouring country, India, on its diverse populations a recall bias.
reported the ASD prevalence was 1.4% among children
CONCLUSIONS
aged 6-9 years.14 It is estimated that worldwide about one
in 160 children has the ASD.15 However, it has shown This study finds that the prevalence of autism spectrum
increasing trends in the western world.16-17 In this study, disorder is 2.6% in urban population of Bangladesh.
ASD cases were determined in the overall sample, which However, no causal relationship was found between autism
were in mainstream school population, previously and gestational factors in children in our study. This was a
undiagnosed and untreated. small-scale cross-sectional study conducted in a few schools
in urban region within a limited time frame and
Earliest in 1956, that is just only a few years after ASD was
constrained budget. Further studies are recommended by
first described, Pasamanick and colleagues tried to report
using large, population-based epidemiological samples to
the link between complications during pregnancy and
explore associations between perinatal variables and the
autism.18 Since then, plenty of interpretations have been
risk of autism all over Bangladesh.
portrayed and studies trying to identify risk factors of
autism; but those hardly clarify the relation between
REFERENCES
autism and adverse exposures during the pre-, peri- and
infant periods. Nonetheless, increasing evidence also 1. American Psychiatric Association. Diagnostic and
suggests a role of genetic factors in the origins of Statistical Manual of Mental Disorders. 4th ed. Text
autism.19,20 Still it remains unclear whether “certain Revision (DSM-IV-TR). American Psychiatric
complications at birth are causal, play a secondary role in Association; 2013.
shaping clinical expression in individuals with genetic
2. Lord C, Mulloy C, Wendelboe M, Schopler E. Pre-
vulnerability, or represent some of the shared causal
and perinatal factors in high-functioning females and
factors” in the development of ASD.19 males with autism. J Autism Dev Disord.
In this study, there was no significant association between 1991;21(2):197-209.
gestational age and weight at birth (P>0.05). However, 3. Piven J, Simon J, Chase GA, Wzorek M, Landa R,
Schendel et al. reported that birth weight <2.5 kg and Gayle J, et al. The etiology of autism: pre-, peri- and
preterm birth at <37 weeks gestation were associated with neonatal factors. J Am Acad Child Adolesc Psychiatry.
2-fold increase risk of autism, as studied on a Danish 1993;32(6):1256-63.
population.21 We did not find any relationship between
4. Guinchat V, Thorsen P, Laurent C, Cans C, Bodeau
gravida and autism (P>0.05); however, Curran et al.
N, Cohen D. Pre-, peri- and neonatal risk factors for
reported an increased risk of autism with higher number of autism. Acta Obstet Gynecol Scand
gravida, in Swedish population.22 Unlike ours, they also 2012;91(3):287-300.
confirmed that children born by elective Caesarean section
13
5. Kolevzon A, Gross R, Reichenberg A. Prenatal and 15. Elsabbagh M, Divan G, Koh YJ, Kim YS, Kauchali S,
perinatal risk factors for autism: a review and Marcín C, et al. Global prevalence of autism and other
integration of findings. Arch Pediatr Adolesc Med. pervasive developmental disorders. Autism Res.
2007;161(4):326-33. 2012;5(3):160-79.
6. Hisle-Gorman E, Susi A, Stokes T, Gorman G, 16. Croen LA, Grether JK, Hoogstrate J, Selvin S. The
Erdie-Lalena C, Nylund CM. Prenatal, perinatal, and changing prevalence of autism in California. J Autism
neonatal risk factors of autism spectrum disorder. Dev Disord. 2002;32(3):207-15.
Pediatr Res. 2018;84(2):190-198. 17. Autism and Developmental Disabilities Monitoring
7. Mamidala MP, Polinedi A, Kumar P, Rajesh N, Network Surveillance Year 2006 Principal
Vallamkonda OR, Udani V, et al. Prenatal, perinatal Investigators; Centers for Disease Control and
and neonatal risk factors of Autism Spectrum Prevention (CDC). Prevalence of autism spectrum
Disorder: a comprehensive epidemiological disorders – Autism and Developmental Disabilities
assessment from India. Res Dev Disabil. 2013;34(9): Monitoring Network, United States, 2006. MMWR
3004-13. Surveill Summ. 2009;58(10):1-20.
8. Rosenberg RE, Law JK, Yenokyan G, McGready J, 18. Pasamanick B, Rogers ME, Lilienfeld AM. Pregnancy
Kaufmann WE, Law PA. Characteristics and experience and the development of behavior disorders
concordance of autism spectrum disorders among 277 in children. Am J Psychiatry. 1956;112(8):613-8.
twin pairs. Arch Pediatr Adolesc Med. 2009; 19. Guinchat V, Thorsen P, Laurent C, Cans C, Bodeau
163(10):907-14. N, Cohen D. Pre-, peri- and neonatal risk factors for
9. Larsson HJ, Eaton WW, Madsen KM, Vestergaard M, autism. Acta Obstet Gynecol Scand. 2012;91(3):
Olesen AV, Agerbo E, et al. Risk factors for autism: 287-300.
perinatal factors, parental psychiatric history, and 20. Al Backer NB. Developmental regression in autism
socioeconomic status. Am J Epidemiol. spectrum disorder. Sudan J Paediatr. 2015;15(1):21-6.
2005;161(10):916-25
21. Schendel DE, Overgaard M, Christensen J, Hjort L,
10. Dietz C, Swinkels S, van Daalen E, van Engeland H, Jørgensen M, Vestergaard M, et al. Association of
Buitelaar JK. Screening for autistic spectrum disorder psychiatric and neurologic comorbidity with
in children aged 14-15 months. II: population mortality among persons with autism spectrum
screening with the Early Screening of Autistic Traits disorder in a Danish population. JAMA Pediatr.
Questionnaire (ESAT). Design and general findings. J 2016;170(3):243-50.
Autism Dev Disord. 2006;36(6):713-22.
22. Curran EA, Dalman C, Kearney PM, Kenny LC,
11. Kim YS, Leventhal BL, Koh YJ, Fombonne E, Laska Cryan JF, et al. Association between obstetric mode of
E, Lim EC, et al. Prevalence of autism spectrum delivery and autism spectrum disorder: a
disorders in a total population sample. Am J population-based sibling design study. JAMA
Psychiatry. 2011;168(9):904-12. Psychiatry. 2015;72(9):935-42.
12. Saito M, Hirota T, Sakamoto Y, Adachi M, Takahashi 23. Bolton PF, Murphy M, Macdonald H, Whitlock B,
M, Osato-Kaneda A, et al. Prevalence and cumulative Pickles A, Rutter M. Obstetric complications in
incidence of autism spectrum disorders and the autism: consequences or causes of the condition? J Am
patterns of co-occurring neurodevelopmental Acad Child Adolesc Psychiatry. 1997;36(2):272-81.
disorders in a total population sample of 5-year-old
24. Bilder D, Pinborough-Zimmerman J, Miller J,
children. Mol Autism. 2020;11(1):35. McMahon W. Prenatal, perinatal, and neonatal factors
13. Sun X, Allison C, Wei L, Matthews FE, Auyeung B, associated with autism spectrum disorders. Pediatrics.
Wu YY, et al. Autism prevalence in China is 2009;123(5):1293-300.
comparable to Western prevalence. Mol Autism. 25. Zhang X, Lv CC, Tian J, Miao RJ, Xi W,
2019;10:7. Hertz-Picciotto I, Qi L. Prenatal and perinatal risk
14. Arora NK, Nair MKC, Gulati S, Deshmukh V, factors for autism in China. J Autism Dev Disord.
Mohapatra A, Mishra D, et al. Neurodevelopmental 2010;40(11):1311-21.
disorders in children aged 2-9 years: population-based 26. Gardener H, Spiegelman D, Buka SL. Prenatal risk
burden estimates across five regions in India. PLoS factors for autism: comprehensive meta-analysis. Br J
Med. 2018;15(7):e1002615. Psychiatry. 2009;195(1):7-14.
000
14
Original Article
Co-Morbidities and Family History Among Methamphetamine Users

*Maruf MM1, Jahan N2, Khan MZR3, Haq AI4, Akhter J5, Rishad MM6, Kamal M A M 7
Abstract most (94.8%) respondents, followed by cannabinoids (56.5%)

The abuse of methamphetamine, locally known as Yaba locally, and opiates (38.3%). Among the respondents about one-third
has increased in Bangladesh recently. The study was designed to (33.9%) had current physical co-morbidities. Co-morbid
determine the proportion of co-morbidities, in terms of physical, psychiatric disorders were present among 29.6% of the
psychiatric and other substances, and family history of substance respondents. Among the respondents, more than one-fourth
use and other psychiatric disorders among methamphetamine (27.8%) had family history of substance use, 20.9% had family
abusers in Bangladesh.This was a cross-sectional study. Data history of other psychiatric illnesses. All the methamphetamine
were collected from the available medical documents of a users had used other substances. A substantial proportion of
private hospital dedicated for the management of substance methamphetamine users had physical and other psychiatric
abusers in Dhaka, Bangladesh. Information of the individuals comorbidities and family history of substance and other
admitted in the hospital during 1 January, 2014 to 31 psychiatric disorders. This essential issue should be considered in
December, 2015 due to substance related disorders having the management strategy of methamphetamine use.
history of using methamphetamine within one month of Keywords: Bangladesh, co-morbidity, family history,
hospitalization were enrolled in the study. Completed data of methamphetamine, substance, yaba
115 individuals were taken and data analysis was performed
using Statistical Package for Social Sciences (SPSS) version INTRODUCTION
24.Most (91.3%) of the respondents were male. Mean age of
the respondents was 24.6 (±5.8) years. Half of the respondents Substance use disorders have become a major public health
(50.4%) belonged to the age group 21-30 years. Most (89.6%) problem in Bangladesh. Curiosity about substances, peer
of them resided in urban area and was Muslim (94.8%). pressure, seeking enjoyment and availability of drugs are
Majority (52.2%) was unmarried. Regarding education status, among the important causes of substance dependence in
majority (34.8%) completed graduation. About one-third Bangladesh. Frequent use of drugs causes educational
(33.9%) were currently unemployed. All the dropout, unemployment, financial crisis, family
methamphetamine users had used other substances. Among the disharmony, marital discord and many other social
other co-morbid substances, nicotine was the substance used by disadvantages. Substance abusers became an additional
burden to the family and society.
1. *Dr. Mohammad Muntasir Maruf, Assistant
Professor of Psychiatry, National Institute of Mental There are much variations in the estimate of substance
Health, Dhaka, Call: +88-01711339516, e-mail: abusers in the studies conducted in Bangladesh due to the
marufdmc@gmail.com difference of study place and data collection technique.
2. Dr. Nasim Jahan, Associate Professor of Psychiatry, While national survey on mental health revealed that 0.63%
BIRDEM General Hospital, Dhaka. of the adult population (18 years and above) in Bangladesh
3. Dr. Muhammad Zillur Rahman Khan, Associate had been suffering from substance related and addictive
Professor and Head, Department of Psychiatry, disorders, study conducted in outpatient department of
Shaheed Suhrawardi Medical College, Dhaka. National Institute of Mental Health (NIMH), Dhaka
4. Dr. Arman Ibne Haq, Assistant Professor and Head, revealed that 7.66% of the respondents were suffering from
Department of Psychiatry, Bangladesh Medical substance related disorder. A study among patients
College Hospital, Dhaka. attending general practice showed that 2.88% were suffering
5. Dr. Jesmin Akhter, Classified Specialist in Psychiatry, from substance use disorders while study conducted in a
Department of Psychiatry, Combined Military private clinic in Dhaka city showed that 29.6% of the
Hospital (CMH), Dhaka. patients were suffering from substance related disorders.
6. Dr. Mahbub Mayukh Rishad, Registrar, Department Though studies conducted in the ending years of last century
of Medicine, Popular Medical College, Dhaka. reported opiates group as the primary drug of substance,, recent
7. Dr. MA Mohit Kamal, Professor, Former Director-cum- studies indicate that methamphetamine use has been increased
Professor, National Institute of Mental Health, Dhaka. in Bangladesh., The reports by print and electronic media
*For correspondence showing the recent trend of substance use, drug trafficking and
15
seizure of substances by law enforcement agencies in RESULTS

Bangladesh also support the notion. Locally methamphetamine Table I shows the most (91.3%) of the respondents were
is used in the name of “Yaba” which is a mixture of male. Mean age of the respondents was 24.6 (±5.8) years. The
methamphetamine and caffeine. There has been an increase in youngest respondent was of 16 years, the oldest 55 years. Half
seizure of Yaba and other methamphetamine-containing of the respondents (50.4%) belonged to the age group 21-30
substances since 2008, with more than 1.3 million pills seized years, followed by 31-40 years’ group (26.2%). Most (89.6%)
in 2011 and 20.1 million pills seized in 2015. of them resided in urban area and was Muslim (94.8%).
Regarding education status, majority (34.8%) completed
There is only one government drug de-addiction centre graduation. About one third (33.9%) were currently
with facilities for inpatient treatment in Dhaka, the capital unemployed. More than half (52.2%) were unmarried.
city of Bangladesh. Some substance abusers of the city can
get inpatient treatment from National Institute of Mental Table I: Socio-demographic characteristics of the
Health. Other health-care facilities for management of respondents (n=115)
substance abuse belong to private sector. Patients of these
private hospitals can be reliable source of the information Socio-demographic
Frequency Percentage
regarding the current pattern of substance abuse, variation characteristics
in the availability of these substances and alteration in Gender
profile of the substance abusers, so as to enable the Male 105 91.3
formulation of management strategies. With this view, the Female 10 8.7
present study was designed to assess the socio-demographic Age (in years)
profile and co-morbidities related to the use of ≤ 20 20 17.4
methamphetamine among individuals admitted in a private 21-30 58 50.4
hospital dedicated for the substance abusers in Dhaka. 31-40 30 26.2
41-50 5 4.3
> 50 2 1.7
This was a cross-sectional study. Data were collected from
Residence
the available medical documents of a private hospital for
the management of substance use. The hospital was Urban 103 89.6
situated in Dhaka, the capital city of Bangladesh. It was Semi-urban 12 10.4
dedicated for the management of individuals with Religion
substance use for about 20 years. Both outpatient and Islam 109 94.8
inpatient services were available there. There was a team of Hinduism 4 3.5
psychiatrists, clinical psychologists, peer counsellor and Others 2 1.7
physicians in that hospital. With the permission of the Education
authority of the hospital, data of all the individuals Primary 7 6.1
admitted in the hospital during 1 January, 2014 to 31 Secondary 18 15.6
December, 2015 due to substance related disorders were
Higher Secondary 39 33.9
checked by the researchers. Information of the individuals
who had history of using substances containing Graduation 40 34.8
methamphetamine within one month of hospitalization Post-graduation 11 9.6
were enrolled in the study. Total 205 individuals with Current occupation
substance related disorders were admitted in the hospital Unemployed 39 33.9
during that period. Of them, 130 (63.4%) had history of Student 20 17.4
methamphetamine abuse. Information of the admitted Home-maker 5 4.3
individuals were taken from the individuals and their legal Businessman 32 27.9
guardians and diagnoses were confirmed by the consultant Service-holder 9 7.8
psychiatrists of the hospital. Information were written in Others 10 8.7
the medical documents by the on-duty physicians of the
Marital status
hospital. There were lack of information and
incompleteness in some documents. Completed data of Unmarried 60 52.2
115 individuals were taken and data analysis was Married 36 31.3
performed using Statistical Package for Social Sciences Widow/Widower 2 1.7
(SPSS) version 24. All the ethical issues were addressed and Separated 6 5.2
confidentiality was maintained throughout the study. Divorced 11 9.6
16
Table II shows the all the amphetamine users had used Table V shows the co-morbid psychiatric disorders were
other substances. Among the other substances, nicotine present among 29.6% of the respondents, of which
was the substance used by most (94.8%) respondents, personality disorders was the commonest
followed by cannabinoids (56.5%) and opiates (38.3%).
Table II: Use of other substances among methampheta- Table V: Psychiatric (other than substance related
mine users (n = 115) disorders) co-morbidities among the respondents (n= 115)
Substances Frequency* Percentage
Nicotine 109 94.8 Psychiatric co-morbidities
Cannabinoids 65 56.5 Absent 81 70.4
Opiates 44 38.3 Present 34 29.6
Alcohol 33 28.7 Types of psychiatric problems*
Benzodiazepines 17 14.8 Personality disorders 20 17.4
Others 10 8.7 Anxiety disorders 9 7.8
* Multiple responses Depressive disorders 7 6.1
Bipolar and related disorders 5 4.3
Table III Shows the majority (42.6%) of the respondents
Obsessive compulsive and related 5 4.3
started to take methamphetamine between 16-20 years of age
disorders
Table III: Age of starting methamphetamine use (n = 115) Schizophrenia spectrum and other 4 3.5
psychotic disorders
Age of starting (in years) Frequency Percentage
≤15 19 16.5 Others 5 4.3
16-20 49 42.6 *multiple response
21-25 32 27.8
26-30 11 9.6
Table VI shows that 69.6% of the respondents were
>30 4 3.5
admitted to the hospital against their will.
Table IV shows the Among the respondents 33.9% had
some kinds of acute or chronic physical co-morbidities, of
which urinary tract infection, bronchial asthma and Table VI: Type of current admission (n = 115)
dyslipidemia were common
Type of admission Frequency Percentage
Table IV: Physical co-morbidities among the respon- Voluntary 35 30.4
dents (n=115) Involuntary 80 69.6
Physical co-morbidities Frequency Percentage

Absent 76 66.1 Table VII shows that 33.9% respondents had no previous
Present 39 33.9 history of admission it was the first hospitalization for the
Types of physical problems* treatment of substance use. Others (66.1%) had previous
Urinary tract infection 9 7.8 history of hospitalized treatment.
Bronchial asthma 8 6.9
Dyslipidemia 8 6.9
Dermatological problems 7 6.1 Table VII: History of previous admission (n= 115)
Dental problems 7 6.1
Neurological problems 5 4.3 Previous Admission Frequency Percentage
Diabetes mellitus 5 4.3 No previous admission 39 33.9
Hypertension 5 4.3 1-2 times 35 30.4
Gynaecological problems 3 2.6
3-4 times 18 15.7
Hypothyroidism 3 2.6
Others 3 2.6 5-6 times 13 11.3
>6 times 10 8.7
*multiple response
17
Table VIII Shows the family history substance use among More than half (52.2%) of the subjects were unmarried. It
respondents 27.8% had family history of substance use may be because more than two-thirds (67.8%) of the
other than nicotine and caffeine, 20.9% had family history respondents were below 30 years of age. Among the
of other psychiatric illnesses. subjects, 9.6% was divorced and 5.2% was separated but it
was not conclusive whether separations or divorces were
reasons or consequences of methamphetamine use.
Table VIII: Family history of substance use and other Regarding educational status, majority (34.8%) completed
psychiatric illnesses (n = 115) graduation. Alam et al. (1999) found that majority
Family history Frequency Percentage (58.5%) of his study sample belonged to secondary and
higher secondary level.8 In current study, the education
Family history of substance use (other than nicotine and status may be a reflection of the higher socioeconomic
caffeine) status of the sample, which was also the fact of other recent
Absent 83 72.2 studies in private de-addiction clinic.1,9 Nevertheless,
about one-fifth (21.7%) of the respondents was below
Present 32 27.8
higher secondary level. It was not also conclusive whether
Family history of other psychiatric illnesses the dropout is a consequence of the methamphetamine
use.
Absent 91 79.1
Present 24 20.9 One-third (33.9%) of the subjects were currently
unemployed. The unemployment rate is lower than the
findings of the study by Alam et al. (1999) and Hossain et
DISCUSSION al. (2005).8 In our study, businessmen were found in a
The completed data of 115 subjects with significant proportion (27.9%) which corresponds to the
other studies conducted in private clinics.1,9
methamphetamine use revealed that most (91.3%) of them
were male. The earlier studies conducted in Dhaka city in All the methamphetamine users also used other substances.
the last decade of the last century also found the male It may indicate that methamphetamine users were
predominance in this regard7,8 but comparing to many of interested in experimenting more types of substances or
those studies rate of female users are higher in the current there was easy availability. In our study, among the other
study. In a more recent study conducted in a private drug co-morbid substances, nicotine was used by most (94.8%)
de-addiction centre reported 9.5% female among the individuals. The rate was more than double of the finding
by Alam et al. (1999) and slightly lower than the finding of
inpatients with substance use disorder.1 In another recent
other study among opiate abusers.9 All the substance
study found that 8.4% of hospitalized opiate abusers were
abusers were found to have abused tobacco in a study by
female.9 It may be assumed that more females are abusing
Hossain et al. (2005). Cannabinoids (56.5%) and opiates
substances than two-three decades ago. The findings may (38.3%) were the other common co-morbid substances in
also be due to the fact that the study was conducted among our study. In a study among hospitalized substance abusers,
the hospitalized substance abusers. the most common substance group was opiates followed by
Mean age of the subjects was 24.6 (±5.8) years. The cannabinoids.1
youngest was of 16 years, the oldest 55 years. Half of the Regarding the age of onset of methamphetamine use,
subjects (50.4%) belonged to the age group 21-30 years, 16-20 years was the starting age group for majority
followed by 31-40 years’ group (26.2%). The previous (42.6%), followed by 21-25 years age group (27.8%). The
studies conducted among the substance abusers in similar age group was found as the age of onset for majority
Bangladesh and India also found more abusers in a of the respondents of the other studies regarding substance
relatively younger age group.1,8 abuse in Bangladesh.1 In an Iranian study, age of onset of
methamphetamine use was 20.3 ± 3.3 years. A
Most (89.6%) of the subjects resided in urban area. As the
considerable proportion (16.5%) of our subjects started to
study place was in the capital city, majority were expected
use methamphetamine before or at the age of 15 years.
to be from urban background. Regarding religion, most
(94.8%) of the respondents were Muslim as Bangladesh is Individuals with substance use disorders are known to have
a Muslim-dominant country with 90.4% Muslim people. a high prevalence of co-morbid medical and psychiatric
18
conditions that often complicate clinical care. Chronic The study was conducted in a selected urban private
methamphetamine use results in a variety of medical hospital dedicated for the substance users. So, the study
consequences, including cardiovascular disease, pulmonary population is not representative of the whole community.
problems, neurological problems, and dental disease. In Data of all the admitted individuals with metham-
our study, about one-third (33.9%) of the subjects had phetamine related disorders during a specified period were
current physical co-morbidities, of which urinary tract included, no sampling was done. As most of the
infection, bronchial asthma and dyslipidemia were information was collected from the medical and related
common. documents, there was no scope to check for the reliability
Psychiatric symptoms have been well-documented in of all the information.
methamphetamine abusers. Anxiety, depression, insomnia,
CONCLUSIONS
and psychosis are among the most commonly reported
symptoms. In our study, more than one-fourth (29.6%) of This study provides information about sociodemography,
the respondents had co-morbid psychiatric conditions. co-morbidities and family history of substance and other
Personality disorders was the commonest diagnosis, psychiatric illnesses related to methamphetamine use. All
followed by anxiety disorders and depressive disorders. An were poly-substance users with a number of respondents
American study revealed that a significant proportion of with cannabinoids use. A significant proportion of
methamphetamine abusers had co-morbid primary methamphetamine users had physical and psychiatric
psychotic, mood and anxiety disorders. In a Bangladeshi co-morbidities. Family history of substance and other
study among male patients with major depressive disorder, psychiatric illnesses was present in a considerable
8.3% of the respondents had lifetime history of proportion of the subjects. The study findings would help
methamphetamine abuse. In another study among in management and prevention strategy of metham-
substance abuser male juvenile offenders in Bangladesh, phetamine use in Bangladesh.
77.4% had psychiatric disorders. In case of female juvenile
offenders, 10% of the respondents with psychiatric REFERENCES
disorder had history of substance abuse. In current study,
physical and psychiatric disorders were confirmed from the 1. Maruf MM, Khan MZR, Jahan N. Pattern of
medical and related documents of the hospitalized patients substance use: study in a de-addiction clinic. Oman
who were assessed by the consultant psychiatrist for Med J 2016;31(5):327-331. doi: 10.5001/omj. 2016.
psychiatric problems and concerned medical specialist for 66.
the physical problems. 2. Pathan MAS, Nahar JS, Rahman W. Risk and
protective factors in substance dependence: an update.
More than two-thirds (69.6%) of the respondents were
Bang J Psychiatry 2010;24(2):44-8.
admitted to the hospital against their will. It may indicate
that methamphetamine users were not motivated to take 3. Firoz AHM, Karim ME, Alam MF, Rahman AHM,
treatment. For about one third (33.9%) respondents, it was Zaman MN, Chandra V. Community-based
the first hospitalization for the treatment of substance use. multicentric service-oriented research on mental
Others (66.1%) had previous history of hospitalized illness with focus on prevalence, medical care,
treatment. It reconfirms the relapsing nature of substance awareness and attitude towards mental illness in
related disorders and is consistent with the findings of Bangladesh. WHO published data, 2003-2005. Bang
Hossain et al. (2005) where 63.6% of the respondents were J Psychiatry 2006:20(1):9-32.
treated for 2-5 times. 4. Mohit MA, Das MK, Azad MC, Mahmud MH, Alam
Genetic factors are strongly implicated in substance use MF, Karim ME, et al. Diagnoses of patients attending
disorders. Substance use in general is largely dependent on out-patient department (OPD) of National Institute
availability and social environment but the genes of Mental Health, Dhaka. Bang J Psychiatry 2001
contribute to the propensity to develop harmful use and June;15(1):5-12.
dependence. In current study, among the respondents, 5. Alam MN. Psychiatric morbidity in general practices.
more than one-fourth (27.8%) had family history of Bangladesh Med Res Counc Bull 1981;4(1):22-39.
substance use other than nicotine and caffeine, 20.9% had
family history of other psychiatric illnesses. Similar 6. Fahmida A, Wahab MA, Rahman MM. Pattern of
findings were revealed in a study among opiate abusers.9 psychiatric morbidity among the patients admitted in
19
a private psychiatric clinic. Bang J Med Science the Iranian youth aged 19-29: a cross-sectional study.
2009;8(1-2):23-8. Addict Health 2019 Jul;11(3):138-147. doi:
10.22122/ahj.v11i3.231.
7. Ahsan MN, Alam MF, Ahmed S. Substance
dependence: urine analysis of one hundred and forty 17. Draper JC, McCance-Katz EF. Medical illness and
four patients. Bang J Psychiatry 1999;13(2):44-9. comorbidities in drug users: implications for
addiction pharmacotherapy treatment. Substance use
8. Alam MF, Ahsan MN, Ahmad S. Substance
misuse 2005;40:1899-921.
dependence: a south-asian perspective. Bang J
Psychiatry 1999;13(2):66-74. 18. Albertson TE, Derlet RW, Van Hoozen BE.
Methamphetamine and the expanding complications
9. Maruf MM, Jahan N, Bhowmik AD, Syed SE, Alam
of amphetamines. West J Med 1999;170(4):214–9.
MT, Rahman F, et al. Opioid use: Sociodemography
and some related factors. Bang J Psychiatry 2013; 19. Radfar SR, Rawson RA. Current research on
27(1):20-7. methamphetamine: epidemiology, medical and
psychiatric effects, treatment, and harm reduction
10. Ahmed AU, Maruf MM, Rashid MH, Haq AI, Roy J.
efforts. Addict Health 2014;6(3-4):146-54. PMID:
Substance abusers attending government treatment
facilities in Bangladesh. Archives of NIMH 2018; 25984282
1(1):1-7. 20. Salo R, Flower K, Kielstein A, Leamon MH, Nordahl
11. Department of Narcotics Control. Ministry of Home TE, Galloway GP. Psychiatric comorbidity in
Affairs, Bangladesh, 2016. http://dnc.portal.gov.bd › methamphetamine dependence. Psychiatry Res 2011
files › Annual Report, 2016 Apr;186(2-3):356-61. doi: 10.1016/j.psychres. 2010.
09.014.
12. Kumar V, Nehra DK, Kumar P, Sunila, Gupta R.
Prevalence and pattern of substance abuse: A study 21. Maruf MM, Alam MT, Khan NM, Khan MZR,
from deaddiction centre. Delhi Psychiat Journal 2013; Begum K, Mamun AA, et al. Substance abuse among
16(1):110-4. male patients with major depressive disorder. Bang J
Psychiatry 2012;26(1):54-63.
13. Bangladesh Bureau of Statistics. Bangladesh
population & housing census 2011: Socioeconomic 22. Maruf MM, Rahman F, Khan MZR, Jahan N.
and demographic report. Statistics and Informatics Psychiatric morbidity and substance abuse among
Division, Ministry of Planning, Bangladesh;2015. male juvenile offenders in Bangladesh. Life:
http://203.112.218.65:8008/WebTestApplication/us International J Health Life Sciences 2015;1(1):
erfiles/Image/National%20Reports/SED_REPORT_ 161-71. https://doi.org/10.20319/ lijshls. 2015.s11.
Vol-4.pdf 161171
14. Hossain KJ, Rahman MS, Hoque AHMM. 23. Maruf MM, Rahman F, Khan MZR, Jahan N.
Management of drug addiction: Importance of Socio-demography, substance abuse and offence
Naltrexone. Bang J Psychiatry 2005;19(2):66-78. among inmates with psychiatric disorders in female
juvenile centre, Bangladesh. People: International J
15. Bangladesh Bureau of Statistics. Health and morbidity Social Sciences 2015;1(1):500-8. https://doi.org/
status survey 2012. Statistics and informatics division, 10.20319/ pijss.2015.s21.500508
Ministry of Planning, Bangladesh;2013.
24. Cowen P, Harrison P, Burns T, Fazel M (eds). Shorter
16. Darvishzadeh H, Mirzaee M, Jahani Y, Sharifi H. Age Oxford Textbook of Psychiatry. 7th edn. Oxford, UK:
of onset of methamphetamine consumption among Oxford University Press;2017.
20
Original Article
Association of Helicobacter Pylori and Portal Hypertensive Gastropathy in Patients with Cirrhosis of Liver
Islam MS1, *Chowdhury MFK2, Arju J3, Miah MSA4, Hasan MA5, Adhikary D6, Mahbub-Uz-Zaman K7 Shoaib M8, Kabir MA9
Abstract mild PHG whereas 22 cases had severe form of PHG. Among
Portal hypertensive gastropathy (PHG) is a common 38 cases of cirrhosis with PHG who had negative UBT, 23
endoscopic finding in patients of cirrhosis of liver. The cause had mild PHG and 15 cases had severe form of PHG. The risk
and pathogenesis of PHG in cirrhotic patients is poorly of positive urea breath test was not statistically significant in
understood. Some studies showed, association of Helicobacter cirrhotic patients with PHG in comparison with cirrhotic
pylori (H. Pylori) with portal hypertensive gastropathy in patients without PHG (P=0.337, OR 1.303, 95% CI
cirrhosis of liver, but the evidence is not robust. The aim of this 0.759-2.235). In this study, statistically significant association
study was to assess the association of H. pylori infection and was not found between H. Pylori and PHG in cirrhotic
PHG in patients with cirrhosis of liver. This case control study patients.
was conducted in the Department of Gastroenterology,
Keywords: Cirrhosis of liver, helicobacter pylori (H. Pylori),
Bangabandhu Sheikh Mujib Medical University (BSMMU),
portal hypertensive gastropathy (PHG)
Dhaka, Bangladesh, from April 2016 to August 2018. A total
of 230 patients with cirrhosis of liver were included in this
INTRODUCTION
study. There were 115 cirrhotic patients with PHG as cases
and 115 cirrhotic patients without PHG as controls. Upper Portal hypertension is a common condition in cirrhosis of
gastrointestinal Endoscopy and 13C Urea Breath Test (UBT) liver. When hepatic venous pressure gradient (HVPG)
was done in both cases and controls. In this study, out of 230 >5mmHg is called portal hypertension.1 Cirrhosis of liver,
non-cirrhotic portal fibrosis and extra hepatic portal vein
cases, 147 (63.91%) found to have H. pylori infection.
obstruction are common causes of portal hypertension.
Among cirrhotic patients with PHG case, 77 (66.95%) was
Gastrointestinal haemorrhage, hepatic encephalopathy,
positive in UBT. Out of these 77 UBT positive cases, 55 had
hepato-renal syndrome, ascites are common complications
of portal hypertension.2 Liver cirrhosis and portal
1. Dr. Muhammed Saiful Islam. Medical Officer,
hypertensive gastropathy patients are very prone to develop
Sheikh Russel National Gastroliver Institute and
Hospital (SRGIH), Mohakhali, Dhaka. acute or chronic GI bleeding.3,4 Prevalance of portal
2. *Dr. Md. Fazlul Karim Chowdhury, Registrar, hypertensive gastropathy in cirrhotic patients is
SRGIH, Mohakhali, Dhaka. E-mail: chanchal4234 approximately 9-80%.5,6,7,8 Portal hypertensive
@gmail.com gastropathy causes change in the mucosa of the stomach in
3. Dr. Jahanara Arju. Medical Officer, School Health patients with portal hypertention. The most common
Clinic, Adarsha Sadar, Cumilla. cause of this is cirrhosis of liver. Mucosal changes occur in
4. Dr. Md. Shah Alam Miah, Assistant Registrar, PHG including friability of mucosa and the presence of
SRGIH, Mohakhali, Dhaka. erratic blood vessels.9
5. Dr. Md. Abual Hasan, Juniror consultant PHG is common both in cirrhotic and non-cirrhotic portal
(Medicine), Sadar Hospital. Jhalokathi. hypertension. The endoscopic findings of PHG is
6. Dr. Debprosad Adhikary, Registrar (Medicine), mosaic-like pattern of gastric mucosa.10 Whole of the
Satkhira Medical College Hospital, Satkhira.
stomach can be involved in portal hypertensive gastropathy
7. Dr. Khandker Mahbub-Uz-Zaman, Major, (PHG). Not only mucosal changes but also the severity
Classified Specialist in Medicine (Rheumatology),
mosaic pattern and red spots increase bleeding risk.11,12
CMH, Dhaka.
8. Dr. Mohammad Shoaib Chowdhury, Assistant Numerous mechanisms are involved in the development of
Professor Department of Gastroenterology PHG. High gastrin level causes huge amount of acid
BSMMU, Dhaka. secretion and altered blood flow, reduced prostaglandin
9. Dr. Md. Anwarul Kabir, Professor & chairman, secretion and the presence of H. pylori infection.13,14,15,16
Department of Gastroenterology, BSMMU, Dhaka. In PHG gastric mucosal ability to regenerate has lost.17
*For Correcpondence Another study showed increased susceptibility of portal
21
hypertensive gastropathy by bile acid and H. pylori patients on NSAIDs or history of gastric surgery were
infection 18.. excluded from the study.
H. pylori is a gram negative organism is found in gastric DATA COLLECTION
mucosa or between the epithelial and mucous layer of At first, stable cirrhotic patients were selected for study as
stomach. In developing country the prevalence of H.pylori per inclusion and exclusion criteria. After proper
is higher than the developed countries17.The prevalence counseling an informed written consent was taken from
and association of H.pylori in cirrhosis of liver is under every participant. Information about demographic and
debate18,19,20. H. pylori infection is one of the most clinical profile and laboratory parameters was collected on
common cause of peptic ulcer disease. In cirrhosis of liver the predesigned data sheet. Detailed clinical history
H.pylori may have a role in developing PHG21,22. including history of jaundice, drug abuse, alcohol intake,
Sensitivity and specificity of serological test to diagnose blood transfusion, haematemesis, melaena etc was elicited
H.pylori is very low. Other than H.pylori , no bacteria is from the participants. General physical and systemic
found to be involved in the development of PHG24. examination was done for presence of ascites, splenomegaly
and other peripheral signs of liver cirrhosis such as
PHG does not provide a favorable environment for
jaundice, palmar erythema, spider naevi, alopecia,
colonization by H. pylori, suggesting no contribution of
gynaecomastia, testicular atrophy etc. Complete blood
the bacteria in the pathogenesis of PHG25.
count, liver function tests including serum bilirubin,
Urea breath test (UBT) which is widely used to diagnose aminotransferase (ALT, AST) enzymes level ANA, 24
H.pylori infection.UBT relies on bacterial hydrolysis of hours’ urinary copper, prothrombin time, serum albumin,
orally administered urea tagged with a carbon isotope 13C. viral markers (HBsAg, Anti-HCV), renal function test and
Hydrolysis of urea generates ammonia and tagged CO2 imaging by abdominal ultrasound was done.
which can be detected in breath samples. The specificity of
UBT is 95% and sensivity is about 80-95%26 .Association Endoscopy of upper gastrointestinal tract was performed in
of H. pylori with PHG is still now a debating issue. The a single endoscopy unit using a video endoscope
mucosal lesion of stomach and several extra-gastric (OLYMPUS GIF-H190) at gastroenterology department
conditions are associated with H.pylori infection. of BSMMU to identify the presence of portal hypertensive
Unexplained vitamin B12 deficiency, Idiopathic gastropathy, assess its severity and also oesophageal or
thrombocytopenic purpura (ITP) and Iron deficiency fundal varices. Upper GI endoscopy was done by single
anaemia (IDA) is associated with H.pylori infection28. If H. endoscopist to avoid interovserber variability. The severity
pylori is associated with portal hyperensive gastropathy of PHG was graded according to McCormack,s
eradication of H. pylori may be beneficial in the classification and the severity of liver cirrhosis was assessed
management of PHG, if H. p. To the best of our by using Child-pugh classification.
knowledge, in Bangladesh no such study has been carried 13C UBT was performed to identify H. pylori infection at
out. So this study was carried out to find out the gastroenterology department of BSMMU in accordance
association of H. pylori infection with PHG in patients with the manufacturer’s recommendations (HCBT-01,
with cirrhosis of liver. Headway 13C Urea Breath Analyzer, China). UBT was
MATERIAL AND METHODS done after an abstinence of proton pump inhibitor,
antibiotics, bismuth compounds for two weeks and fasting
This case control study was conducted in the Department
for 6 hours on the day of procedure.
of Gastroenterology, BSMMU, Dhaka, Bangladesh during
the period of April 2016 to August 2018. A total of 230 STATISTICAL ANALYSIS
patients with cirrhosis of were included in this study. There After collection of data, all data were checked and cleaned.
were 115 cirrhotic patients with PHG as cases and 115 After cleaning, the data were entered into computer and
cirrhotic patients without PHG as controls. Patients with statistical analysis of the results being obtained using
age < 18 years, peptic ulcer disease found in upper Statistical Packages for Social Sciences (SPSS). Numerical
gastrointestinal endoscopy, patients with intake of proton variables were expressed as mean and standard deviation,
pump inhibitors, bismuth compounds, antibiotics (within whereas categorical variables were expressed in percentage.
2 weeks), H. pylori eradication within past 2 month, Numerical variables were compared using student’s t test
22
and categorical variables were analyzed by Chi-square test. patients of cirrhosis with PHG and 83(72.2%) of male and
The risk was expressed in odd’s ratio with 95% confidence 32 (27.8%) of female cirrhotic patients of cirrhosis without
interval (CI). P value of less than 0.05 was considered PHG. There was no significant gender difference in cases
statistically significant. and controls.
ETHICAL CONSIDERATION
Before starting this study, the research protocol was Table II: Distribution of the patients according to
submitted to the institutional review board of BSMMU, gender in two groups
Dhaka and IRB clearance was taken. All participants were Gender Cases Controls p value
informed about the objectives, methodology and purpose (n=115) (n=115)
of the study in easily understandable way. Informed n (%) n (%)
written consents were obtained from all participants
Male 88 (76.5) 83 (72.2)
without any influences prior to sample collection. 0.450ns
Female 27 (23.5) 32 (27.8)
RESULTS
ns= not significant
This case control study was conducted in the Department
Chi-square test was done for the level of significance.
of Gastroenterology, BSMMU, Dhaka, Bangladesh during
the period of April 2016 to August 2018. A total of 230
patients with cirrhosis were included in this study. There Table III shows the distribution of study patients according
were 115 cirrhotic patients with PHG as cases and 115 to clinical features. The cases and controls show no
cirrhotic patients without PHG as controls. significant differences in presentation of clinical features.
Table I shows the age distribution of the study patients
according age-group in patients of cirrhosis with or
without PHG. Most of the patients were of age more than Table III: Distribution of the patients according to
40 years in both groups. The mean age was 54.37 years for clinical features in two groups
cases and 52.03 years for controls. The age difference
Clinical feature Cases Controls p value
among the cases and controls was not significant.
(n=115) (n=115)
n (%) n (%)
Table I: Distribution of the patients according to age in
two groups Jaundice 30 (26.1) 19 (16.5) 0.096ns
Age (years) Cases Controls p value Ascites 94 (81.7) 83 (72.2) 0.085ns
(n=115) (n=115) Leg oedema 73 (63.5) 61 (53.0) 0.109ns
n (%) n (%)
Anaemia 73 (63.5) 63 (54.8) 0.180ns
21 – 30 2 (1.7) 4 (3.5)
Leukonychia 10 (8.7) 7 (6.1) 0.450ns
31 – 40 12 (10.4) 20 (17.4)
Spider 18 (15.7) 17 (14.8) 1.000ns
41 – 50 31 (27.0) 31 (27.0) 0.109ns
Splenomegaly 62 (53.9) 51 (44.3) 0.147ns
51 – 60 37 (32.2) 32 (27.8)
>60 33 (28.7) 28 (24.3) ns= not significant
Mean±SD 54.37 ± 10.97 52.03 ± 11.05 Chi-square test was done to measure the level of
significance
Ns=not significant
Unpaired t test was done to measure the level of significance
Table IV shows the laboratory parameters in cases and
Table II shows the gender distribution of cases ad controls. controls. The patients of cases and controls had no
There were 88 (76.5%) male and 27 (23.5%) female significant difference in the laboratory finding.
23
Table IV: Investigation findings of the patients in two groups

Investigations Cases Controls
(n=115) (n=115) p value
[mean±SD] [mean±SD]
Hb (g/dl) 10.77 ± 1.40 11.08 ± 1.14 0.066ns
ESR (mm in 1st hour) 49.64 ± 16.75 45.89 ± 17.55 0.098ns
TC (No/mm3) 6196.35 ± 2164.04 6648.69 ± 1819.77 0.088ns
Platelet count (per mm3) 131426.09 ± 95576.63 151464.91 ± 56544.94 0.055ns
Serum creatinine (mg/dl) 1.05 ± 0.27 1.00 ± 0.27 0.225ns
Na+ (meq/L) 132.62 ± 4.30 133.56 ± 4.61 0.109ns
K+ (meq/L) 3.91 ± 0.44 4.02 ± 0.40 0.057ns
ALT (U/L) 38.98 ± 21.28 36.74 ± 12.48 0.331ns
AST (U/L) 49.96 ± 26.33 48.28 ± 21.77 0.600ns
S. Bilirubin (mg/dl) 1.75 ± 1.08 1.48 ± 1.10 0.063ns
S. Albumin (g/L) 25.11 ± 5.07 26.13 ± 3.46 0.075ns
Prothrombin time
Control 11.90 ± 0.16 11.88 ± 0.12 0.252ns
Patient 17.32 ± 3.31 16.71 ± 2.61 0.119ns
INR 1.46 ± 0.29 1.41 ± 0.25 0.189ns
ns=not significant
Unpaired t test was done to measure the level of significance
Table V shows the case and control patients of cirrhosis Table VI shows the distribution of cases and controls
with different etiology. There were 63 (54.7%) patients in according to Child-Pugh score. Most of the patients of
cases and 60 (52.1%) patients in controls with CHBV cases and controls were of Child-Pugh class B and
infection. Chronic hepatitis C virus infection was found in Child-Pugh class C. There were no significant difference in
11 (9.6%) of patients in cases and 14 (12.2%) of patients in the Child-Pugh class of cases and controls.
controls as a cause of cirrhosis. There was no etiological
difference among the cases and controls.
Table VI: Distribution of the patients according to
Child pugh score in two groups
Child Pugh Class Cases Controls p
Table V: Distribution of the patients according to
(n=115) (n=115) value
etiology in two groups (n=230)
n (%) n (%)
Etiology Cases Controls p
A 12 (10.4) 20 (17.5)
(n=115) (n=115) value
B 48 (41.7) 55 (48.2) 0.074ns
n (%) n (%)
HBsAg 48 (41.7) 43 (37.4) 0.500ns C 55 (47.8) 39 (34.2)
HbsAg-Anti-HBc 15 (13.0) 17 (14.7) 0.849ns ns= not significant

Chi-square test was done to measure the level of
Anti HCV 11 (9.6) 14 (12.2) 0.525ns significance
ns=not significant Table VII shows the distribution of cases according to grade
Chi-square test was done to measure the level of of PHG. There were78(67.8%) of patients with mild PHG
significance whereas 37(32.2%) of patients had severe PHG.
24
Table VII: Distribution of cases according to grade of DISCUSSION

PHG (n=115) This case control observational study was conducted in the
Department of Gastroenterology, BSMMU. The objective
PHG Frequency (n) Percentage (%)
of the study was to find out the association of H. Pylori
Mild 78 67.8
infection with PHG in the patients of cirrhosis of liver. We
Severe 37 32.2
included 115 patients as cases (cirrhosis of liver with PHG)
Table VIII shows distribution of patients according to the and 115 patients as controls (cirrhosis of liver without
test result of UBT. There were 77 (67.0%) patients of case PHG) for this study who attended inpatient and
outpatient department of Gastroenterology, BSMMU
and 70 (60.9%) patients of control with positive UBT.
during the study period.
There were 38 (33.0%) patients of case and 45 (39.1%)
patients of control had negative UBT. There was no In the present study, the mean age of patients was 54.37 ±
statistically significant difference in test result among the 10.97 years in cases and 52.03 ± 11.05 years in controls
cases and controls with OR 1.303 at 95% CI, with majority of patients were from fourth to sixth decade
0.759-2.235. Patients with PHG did not have significant of life with no significant difference of age (p=0.109). A
increase risk of H.pylori infection. study was conducted in India in 2014 to see the association
of H. pylori with PHG and the mean age of cases was
54.80±10 years and mean age of controls was 52.09 ± 10.3
Table VIII: Distribution of the patients according to
13C Urea Breath Test in two groups years which was almost similar to this study24. The gender
distribution of the cases and controls in our study were
13C Urea Cases Controls p OR well-matched with no significant difference (p=0.450).
Breath Test (n=115) (n=115) value (95% CI) Regarding clinical feature, jaundice was present in 26.1%
n (%) n (%) cases and in 16.5% controls. 81.7% patients in case group
Positive 77 (67.0) 70 (60.9) 1.303 had ascites whereas 72.2% patients in control group
Negative 38 (33.0) 45 (39.1) 0.337ns (0.759- presented with ascites. Aforementioned study showed
2.235) ascites in 71.4% cases and in 58.6% controls24. Anaemia
ns= not significant was more common in cases (63.5%) than controls (54.8%)
Chi-square test was done to measure the level of significance which may reflect bleeding from PHG in case group but
not reached statistical significance (p=0.180).
Table IX shows the distribution and association of H. pylori Splenomegaly, a cardinal feature of portal hypertension,
with severity of PHG. Out of 77 H. pylori positive patients was present in 53.9% cases and in 44.3% controls.
with PHG, 55 patients had mild PHG whereas 22 patients In our study we found that chronic HBV was the most
had severe form of PHG. There were 38 patients with PHG common etiology of cirrhosis of liver (41.7% in case group
had negative UBT out of which 23 had mild PHG and 15
and 37.4% in control group ) followed by chronic HCV
patients had severe form of PHG. There was no significant
(9.6% in case group and 12.2% in control group).
association among the patients of H. pylori infection and
Whereas HBV in 21.4% cases and in 25% controls,
severity of PHG (p= 0.290).
alcohol in 48.6% cases and in 52% controls were in
previous study. HBV was the most common cause of
cirrhosis in our study which may be due to higher
Table IX: Association of H. pylori with severity of PHG prevalence of HBV in our country.
(n=115)
We quantified the severity of liver disease using the Child
PHG H. pylori p Pugh classification. In case group twelve patients (10.04%)
Positive Negative value had liver cirrhosis with Child class A, 48 (41.7%) Child
(n=77) (n=38) class B and 55 (47.8%) Child class C whereas the
n (%) n (%) frequency in control group was 20%, 55% and 39%
Mild(78) 55 (70.5) 23 (29.5) 0.290ns respectively. Our study showed no significant difference
Severe(37) 22 (59.5) 15 (40.5) between cases and controls regarding Child-Pugh classes,
with most of the patients from Child-Pugh B and
ns= not significant
Child-Pugh C (p=0.074).
Chi-square test was done to measure the level of significance
25
In our study, out of 230 patients with cirrhosis, 147 medicine. USA: Mc Graw-Hill Companies Inc; 2012:
patients were H. pylori positive with overall proportion of 308.
H. pylori infection was 63.91%, which was comparable to
2. Nusrat S, Khan MS, Fazili J, Madhoun MF. Cirrhosis
another study done by Abbas et al.29 who found a
and Its Complications: Evidence Based Treatment.
prevalence of H. pylori was 62.1% and Safwat et al30. who
World Journal of Gastroenterology 2014;
found prevalence of H. pylori was 60%.
20(18):5442-5460.
The concern of our study was to find out the association of
3. Rabinovitz M, Yoo Y, Schade RR, Dindzans VJ, Thiel
H. pylori with portal hypertensive gastropathy in cirrhosis
DH, Gavaler JS. Prevalence of endoscopic findings in
of liver. In our study, we had positive UBT in 77 (67.0%)
510 consecutive individuals with cirrhosis evaluated
patients of cirrhosis with PHG and 70 (60.9%) patients of
prospectively. Dig Dis Sci 1990; 35:705-710.
cirrhosis without PHG. Thirty-eight patients with PHG
had negative UBT out of which 23 had mild PHG and 15 4. de Franchis R and Primignani M. Natural history of
patients had severe form of PHG. There was no significant portal hypertension in patients with cirrhosis.
association of H. pylori with presence of PHG in cirrhotic ClinLiver Dis 2001; 5: 645-663. Primignani M,
patients (p= 0.337 with OR 1.303 at 95% CI: Carpinelli L, Preatoni P, Battaglia G, Carta A, Prada A
0.759-2.235). Hammad et al.31 conducted a similar study et al. Natural history of portal hypertensive
in Egypt and reported H. pylori infection among 70% cases gastropathy in patients with liver cirrhosis. The New
and 63.3% controls and insignificant association of H. Italian Endoscopic Club for the study and treatment
pylori with PHG. of esophageal varices (NIEC). Gastroenterology 2000;
The severity of PHG was mild in 55 H. pylori positive 119:181-187.
patients and 23 H. Pylori negative patients whereas severe 5. Primignani M, Carpinelli L, Preatoni P, Battaglia G,
PHG was present in 22 H. pylori positive and 15 H. Pylori Carta A, Prada A et al. Natural history of portal
negative patients. The severity of PHG and H. Pylori hypertensive gastropathy in patients with liver
infection had no significant association in cirrhotic cirrhosis. The New Italian Endoscopic Club for the
patients. These findings were similar as studied by Bahnacy study and treatment of esophageal varices (NIEC).
et al 32. H. pylori positivity decreased when the severity of Gastroenterology 2000; 119:181-187.
PHG increased. As there is severe hemorrhagic congestion
and oedema of the gastric mucosa in PHG, so it may not 6. Iwao T, Toyonaga A, Sumino M, Takagi K, Oho K,
provide a favourable environment for the colonization of Nishizono M et al. Portal hypertensive gastropathy in
H. pylori. In contrast Sathar et al.24 and Safwat et al. 30 had patients with cirrhosis. Gastroenterology 1992;
noticed a significant association between H. pylori and 102:2060-2065.
severity of PHG (p< 0.001). They had suggested that H. 7. Sarin SK, Shahi HM, Jain M, Jain AK, Issar SK,
pylori colonization of the stomach of cirrhotic patients Murthy NS. The natural history of portal hypertensive
likely to be contributory to the pathogenesis of PHG. gastropathy: influence of variceal eradication. Am J
CONCLUSIONS Gastroenterol 2000; 95: 2888-2893.
No significant association was found between H. pylori 8. Zaman A, Hapke R, Flora K, Rosen HR, Benner
infection and PHG in cirrhotic patients in this study. The K.Factors predicting the presence of esophageal or gastric
data also showed that, severity of PHG was not associated varices in patients with advanced liver disease. Am J
with H. pylori infection. Further prospective studies with a Gastroenterol 1999; 94: 3292-3296.
large number of samples are required to see the association
9. Garcia-Tsao G and Ripoll C. Management of
of H. pylori with PHG.
Gastropathy and Gastric Vascular Ectasia in Portal
REFERENCES Hypertension. Clin Liver Dis. 2010; 14(2): 281-295.
1. Bacon BR. Cirrhosis and its Complications. In: Longo 10. Cubillas R and Rockey C. Portal hypertensive
DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, gastropathy: a review. Liver International. 2010;
Loscalzo J (editors). Harrison's Principle of Internal 1094-1102.
26
11. Primignani, M. et al. ‘Natural history of portal 22. Kamalaporn, P. et al. ‘Factors predisposing to peptic ulcer
hypertensive gastropathy in patients with liver cirrhosis. disease in asymptomatic cirrhotic patients.’ Aliment
The New Italian Endoscopic Club for the study and Pharmacol Ther, 2005:21, pp. 1459–1465.
treatment of esophageal varices (NIEC).’ 23. Urso, G. et al. ‘Role of Helicobacter pylori in patients
Gastroenterology, 2000:119, pp. 181–187. with portal hypertensive gastropathy by liver cirrhosis
12. Ferraz, J.G and Wallace J.L.‘Underlying mechanisms of hepatitis C virus-related.’ Minerva Gastroenterol Dietol,
portal hypertensive gastropathy.’ J Clin Gastroenterol, 25 2006:52, pp.303–308.
(Suppl 1), pp. S73–S78. 24. Sathar, S.A., Kunnathuparambil, S.G., Sreesh, S.,
13. Sarfeh, I.J., Tarnawski, A., Mason, G.R., Mach, T., Ivey, Narayanan, P., Vinayakumar, K.R. ‘Helicobacter pylori
R.J. ‘Portal hypertension and gastric mucosal injury in infection in patients with liver cirrhosis: prevalence and
rats.’Gastroenterology, 1983:84, pp.987-993. association with portal hypertensive gastropathy.’ Ann
Gastroenterol, 2014:27, pp. 48-52.
14. Sarfeh, I.J., Tarnawski, A., Maeda, R., Raymont, K.,
25. Batmanabane, V., Kate, V., Ananthakrishnan, N.
Mason, G.R., Ivey, K.J. ‘The gastric mucosa in portal
‘Prevalence of Helicobacter pylori in patients with portal
hypertension: effects of topical bile acid.’ Scand J
hypertensive gastropathy - a study from South India.’
Gastroenterol, 1984:9(Suppl 92), pp.189-194.
Med Sci Monit, 2004:10, pp.133-136.
15. Hopkins, R.J., Girardi, L.S., Turney, E.A.‘Relationship 26. Douglas, R. Morgan & Sheila E. Crowe. CHelicobacter
between Helicobacter pylori eradication and gastric ulcer pylori infection’. Sleisenger and Fordtran’s
and duodenal ulcer reduced recurrence: a review.’ Gastrointestinal and Liver disease. 10th edition,
Gastroenterology, 1996:110, pp.1244-1252. Philadelphia, Elsevier, Saunders, 2016:51, pp.856-867.
16. Akatsu, T. et al. ‘Consequences of living-donor liver 27. Merli M et al. ‘The natural history of portal hypertensive
transplantation for upper gastrointestinal lesions: High gastropathy in patients with liver cirrhosis and mild
incidence of reflux esophagitis.’ Dig Dis Sci, 2006:51, pp. portal hypertension.’ Am J Gastroenterol, 2004:99, pp.
2018–2022. 1959–1965.
17. Sarfeh, I.J., Soliman, H., Waxman, K., Coccia, M., 28. El-omar E, McLean MH. ‘Davidson’s Principles and
Rypins, E.B., Bui, H.X., Tarnawski A.‘Impaired Practice of Medicine’.23rd edition, Philadelphia,
oxygenation of gastric mucosa in portal hypertension. Elsevier,2018,pp.764-842.
The basis for increased susceptibility to injury.’ Dig Dis 29. Abbas, Z., Yakoob, j., WM, u., T, S., Hamid, S., Jafri,
Sci, 1989:34, pp. 225-228. W.Effect of Helicobacter pylori and its virulence factors
18. Edward, Lew. ‘Peptic Ulcer Disease’. Current Diagnosis on portal hypertensive gastropathy and interleukin
&Treatment, Gastroenterology, Hepatology,& (IL)-8, IL-10, and tumor necrosis factor-alpha levels.
Endoscopy. 3rd edition, McGraw-Hill Education, Saudi Journal of Gastroenterology., 2014:20(2), 120-127.
2016:15:197-208. 30. Safwat E, Hussein HA and Hakim SA. ‘Helicobacter
pylori in Egyptian patients with HCVrelated liver
19. Pellicano, R., Leone, N., Berrutti, M., Cutufia, M.A.,
cirrhosis and portal hypertensive gastropathy’: Prevalence
Fiorentino, M., Rizzetto, M. ‘Helicobacter pylori
and relation to disease severity. Life Sci J
seroprevalence in hepatitis C virus positive patients with
2015;12(3):168-173.
cirrhosis.’ J Hepatol,2000: 33, pp.648-650.
31. Hammad OM.‘correlation of Portal hypertensive
20. Tsai, C.J. ‘Helicobacter pylori infection and peptic ulcer gastropathy with Helicobacter pylori infection, liver
disease in cirrhosis.’ Dig Dis Sci, 1998:43, pp.1219-1225. dysfuntion, hypersplenism and oesophageal
21. Yeh, J.L., Peng, Y.C., Tung, C.F. et al. ‘Role of varices.Medical J Cario Univ;77:597-601.
Helicobacter pyloriin cirrhotic patients with dyspepsia: a 32. Bahnacy, A., Kupcsulik, P., Eles, Z., et al. ‘Helico-bacter
13C-urea breath test study.’ Adv Ther, 2001:18, pylori and congestive gastropathy.’ Z. Gastroenterol.,
pp.140-150. 1997:35, pp.109-12.
27
Original Article
Comparison of Serum Zinc and Copper Level in Psoriatic and Non-Psoriatic Individual
*Haque S1, Mahmud MM2, Habib RB3
Abstract erythematous plaques with thick silvery scale. Typical nail

Psoriasis is a common chronic inflammatory disease of skin changes and joint involvement are also the diagnostic
and multiple organs of body. The exact etiology of psoriasis is features of psoriasis. There is no specific antigenic factors
not yet certain. It is assumed that trace elements may have has been found as causative agents in pathogenesis of this
some role in pathogenesis of psoriasis. They can act as disease.2 There are very limited data available on role of
co-enzymes for metabolism and can act as antioxidants against zinc and copper in pathogenesis of psoriasis.3
free radicals. Therefore they can participate in epidermal Oxidative stress is one of the important etiological factor
proliferation and inflammatory process of psoriasis. This study that may initiate psoriasis. Antioxidant systems have been
aimed to evaluate the relation between psoriasis and trace found to be significantly impaired in the blood and lesions
elements namely zinc and copper. This study was conducted on of psoriatic patients.4 An deficient antioxidant system has
40 diagnosed cases of psoriasis and 40 non psoriatic been linked to elevated levels of reactive oxygen species
individuals in the department of Dermatology and (ROS) in the pathophysiology of this disease. Deficiency of
Venereology in Bangabandhu Sheikh Mujib Medical trace metals like zinc and copper can cause oxidative stress.
University, Dhaka. Biochemical analyses of serum copper and Trace elements regulate enzymatic activity of keratinocytes
zinc were analyzed and compared statistically with cases and and an imbalance in trace elements causes changes in
healthy controls. Serum zinc level was significantly lower and enzymatically dependent keratinization.5
serum copper level was significantly higher in patient with
psoriasis compared to control (p= < 0.001). Individuals with In human body zinc is the second most common trace
moderate to severe psoriasis had significantly lower zinc levels element after iron. Structure stability is assured by zinc
and significantly higher copper levels than patients with mild protein binding in some enzymes, such as Copper and
psoriasis, according to Psoriasis area and Severity Index Score Zinc superoxide dismutase and catalytic activity is
(p= < 0.05). Correction of serum zinc and copper level could provided by the active copper site.6
be beneficial for psoriasis patients.
Copper (Cu) is linked to several metalloproteins.
Keywords: Psoriasis, serum zinc, serum copper, PASI score Superoxide dismutase, a copper-containing metalloenzyme,
protects against free radical damage. SODs are copper and
INTRODUCTION zinc containing enzymes that convert super oxide radical to
Psoriasis is a multifactorial disease in which certain peroxide which can be removed subsequently by catalase
environmental factors interact with people who have a and other antioxidant defenses. Ceruloplasmin, a plasma
genetic predisposition to develop immune dysregulation protein, binds to copper ions and protects cells from
and inappropriate keratinization.1 The common oxidative damage caused by free copper ions, which
characteristics of psoriasis is symmetrically involved produce hydroxyl radicals.6
There is no comprehensive study of trace elements

1. *Dr. Shawana Haque, Assistant Professor,
Department of Biochemistry, CARe Medical estimation in Psoriasis in Bangladesh. In the present study,
College, Dhaka, Email: shawana.haque@ serum zinc & copper levels were analyzed & their
yahoo.com, Mobile: 01760748156 relationship with the severity of psoriasis was assessed.
2. Dr. Md. Mostaque Mahmud, Assistant Professor, MATERIALS AND METHODS
Department of Dermatology & Venereology,
From July 2018 to June 2019, a cross sectional study was
Bangabandhu Sheikh Mujib Medical University
(BSMMU), Dhaka. conducted at the department of Dermatology &
Venereology, Bangabandhu Sheikh Mujib medical
3. Dr. Rahat Bin Habib, Assistant Professor,
Department of Pediatrics, Shaheed Syed Nazrul University, Dhaka. For this study 40 diagnosed case of
Islam Medical College, Kishoreganj. psoriasis age range 18 to 70 years were selected as cases &
40 non psoriatic individuals were selected as controls from
*For correcpondence
the outpatient department of BSMMU, Dhaka. Patients
28
who had other skin disorders, cardiac & metabolic had copper level > 140 were considered as patients with high
problems, liver and renal diseases, pregnant and lactating copper level. Depending on PASI score the cases are divided in
mother were excluded from this study. two groups. Patients with PASI score < 10 (mild psoriasis) were
considered as group I and patients with PASI score > 10
After the study subjects were selected, the study's goals, (moderate to severe psoriasis) were considered as group II.
objectives, risks, benefits were explained to the patients.
After taking the informed written consent the participants' All data were collected, preserved and analyzed statistically
personal & medical histories were recorded thoroughly. by using IBM SPSS (version 20). The level of significance
for quantitative data was determined using an independent
Under all aseptic precaution 5 ml blood sample was student's t test. The level of significance of qualitative data
collected from study subjects. Serum zinc & copper was was expressed as frequency and percentage and analyzed by
assessed by colorimetric method in Stat Fax 3300 chi-square test.
semi-autoanalyzer. The severity of the disease was assessed
by a dermatologist on the basis of psoriasis area and severity RESULTS
index (PASI) score.
Table-I showed that 50% of the cases were male and 50%
Reference value of serum zinc concentration is 80-120 µg/dl & were female, whereas 47.5% of controls were male and
serum copper is 70-140 µg/dl.6 Participants who had zinc level rests were female. Age, weight, height, BMI & family
< 80 µg/dl were considered as zinc deficient patients & who history of study subjects were indifferent statistically.
Table I: Demographic profile of study group (n=80)
Variables Case (n=40) Control (n=40) p- value

Mean ± SD Mean ± SD
Gender · Male 20 (50%) 19 (47.5%)
· Female 20 (50%) 21 (52.5%)
Age of the respondent 38.6 ± 10.6 40.4 ± 10.4
Duration of psoriasis (in year) 3.8 ± 1.8 - > 0.05ns
Weight of the respondent (in Kg) 58.1 ± 7.1 58.3 ± 5.8
Height of the respondent (in cm) 163 ± 3.8 164.3 ± 3.3
BMI of the respondent (kg/sqm) 21.8 ± 2.2 21.6 ± 1.9
· Present 7 2
Family history of psoriasis
· Absent 33 38
Data was expressed as mean ± SD and comparison between groups was done by Student’s t test. Qualitative data was analyzed by
Chi-square test to compare among the groups. n= number of subjects, p-value < 0.05 is significant, ns= not significant.
Reference Range 100.0% 92.5%

(80 - 120 μ g/dL)
90.0% 85.0% 90.0%
Low ( < 80 μ g/dL ) 80.0%
80.0%
70.0%
70.0%
70.0% 60.0% 55.0%
50.0% 45.0%
60.0%
40.0%
50.0% 30.0%
40.0% 20.0%
30.0% 7.5%
10.0%
30.0%
0.0%
20.0% 15.0% Serum copper level in cases Serum copper level in controls
10.0%
Reference range ( 70-140 μg/dL) High ( > 140 μg/dL)
0.0%
Serum zinc level in cases Serum zinc level in controls Fig.-2: Among the total participants 55.0% and 7.5% had
Fig -1: Among the total participants 30.0% and 15.0% had high level of copper in cases and controls respectively as
zinc deficiency in cases and controls respectively as shown in shown in
29
Table –II shows the mean values of zinc & copper in both cases & controls. Mean value of serum zinc in psoriasis is
significantly low (66.9 ± 12.4 µg/dL) compared to controls, which was significant (p < 0.001). Mean value of serum copper
in psoriasis is significantly high (142.9 ± 29.5 µg/dL) compared to controls, which was also significant (p < 0.001 ). Table
–II also showed that serum zinc is significantly lower & serum copper is significantly higher in patients of group-II
compared to group-I.
Table-II: Comparison of serum zinc & copper level in study population (n=80) and their relationship with PASI
Score in cases (n=40)
Variable Serum Zinc (µg/dL) Serum Copper (µg/dL) p- value

Study Subjects Case 66.9 ± 12.4 142.9 ± 29.5 < 0.001
Control 85.7 ± 11.9 121.2 ± 18.2
Group according to PASI Score Group: I
(PASI Score < 10) 70.9 ± 13.1 130.7 ± 25.7 < 0.05
Group :II
(PASI Score > 10) 63.1 ± 10.6 155.1 ± 28.4
Data was expressed as mean ± SD and comparison between groups was done by Student’s t test. n= number of subjects,
p-value < 0.05 is significant, ns= not significant.
DISCUSSION infections which can lead to abnormal skin changes and

Zinc (Zn) is an essential trace metal for synthesis of trigger psoriasis. So oral Zn supplementation could be used
protein, activity of various enzymes and removal of free as a psoriasis adjuvant therapy.16
radicals from our body.7,8 Zn also helps in the formation
of structural proteins during the keratinization process.9 In In this study, serum copper levels in psoriasis patients were
our study we found that serum zinc level was significantly found higher than in controls. This result is consistent with
lower in patients with psoriasis compared to controls. This the study of other researchers.3,8,11,17 Some researchers
result is consistent with the study of other found low levels of copper in their investigations, which
researchers.3,10-12 In contrast to our findings, Butnaru et contradicts our findings.10,18 We also found that serum
al.13 found that serum Zn levels were higher in psoriasis copper was significantly higher in patients with moderate
patients. However, some researchers did not find any to severe psoriasis than in patients with mild psoriasis
significant changes in serum Zn levels in patients with which is in accordance to other studies.19,20 These
psoriasis compared with healthy controls.8,14,15 inconsistent results may arise from different study designs.
Zn is a constituent of DNA and RNA polymerases Serum Cu is primarily bound to ceruloplasmin which is a
enzymes. These enzymes are needed for protein synthesis in multifunctional enzyme that helps to keep Cu levels
the affected skin. Low level of zinc in psoriasis may found normal in serum.8,11 Ceruloplasmin has recently been
due to decrease serum protein or albumin which may occur discovered to be an acute inflammatory response protein
as a consequence of the removal of a large quantity of scales that may scavenge free radicals.21,22 As psoriasis is a chronic
from the body surface.11 inflammatory skin disease that has a higher level of
In our study we also found that serum zinc level was oxidative stress so ceruloplasmin activity is increased.11 The
significantly low in patients with moderate to severe levels of ceruloplasmin and serum Cu are positively
psoriasis than in patients with mild psoriasis. Keratinocyte correlated..21So, high serum Cu levels might be found in
exfoliation increases in people with severe psoriasis, psoriasis patients due to elevated ceruloplasmin levels. Our
perhaps leading to more severe skin lesions. Immune study only included a small number of population and
dysfunction and decrease antioxidant activity are also more research with larger number of patients is needed to
found in patients having low serum zinc level and these prove the involvement of trace elements in the
patients are more vulnerable to viruses and bacterial pathogenesis of psoriasis.
30
CONCLUSIONS 11. Sheikh G, Masood Q, Majeed S, Hassan I.

According to the findings of this study patients with Comparison of levels of serum copper, zinc, albumin,
psoriasis have a lower serum zinc level & greater serum globulin and alkaline phosphatase in psoriatic patients
copper level compared to control. Serum copper and zinc and controls: A hospital based case-control study.
levels are correlated to the Psoriasis Area Severity Index Indian Dermatol Online J. 2015; 6(2):81–3.
which can be used as a marker for determining disease 12. Afridi HI, Kazi TG, Kazi N, Kandhro GA, Baig JA,
severity. Correction of trace element imbalances may Shah AQ, Khan S, Kolachi NF, Wadhwa SK, Shah F,
improve in psoriasis treatment and outcome. Jamali MK. Evaluation of cadmium, chromium,
nickel, and zinc in biological samples of psoriasis
REFERENCES patients living in Pakistani cement factory area. Biol
Trace Elem Res. 2011;142(3):284-301.
1. Griffiths CE, Barker JN. Pathogenesis and clinical
features of psoriasis. The Lancet. 2007; 370 (9583): 13. Butnaru C, Pascu M, Mircea C, Agoroaei L,
263-71. Solovăstru L, Vâţă D, Butnaru E, Petrescu Z. Serum
zinc and copper levels in some dermatological
2. Krueger JG, Bowcock A. Psoriasis pathophysiology:
diseases. Rev Med Chir Soc Med Nat Iasi.
current concepts of pathogenesis. Ann. Rheum. Dis.
2005; 64(2): 30-6. 2008;112(1):253-7.
3. Basavaraj KH, Darshan MS, Shanmugavelu P, Rashmi 14. Cao JQ, Cui R, Zhang ZX, Xu HQ, Feng J.
R, Mhatre AY, Dhanabal SP, Rao KS. Study on the Determination of serum trace elements in patients
levels of trace elements in mild and severe psoriasis. with psoriasis. Zhongguo Mafen Pifubing Zazhi.
Clinica Chimica Acta. 2009; 405(1-2):66-70. 2005; 21:617–9.
4. Alwasiti EA, Al-Rubayee WT, Al-Tammimy SM. 15. Halevy S, Giryes H, Friger M, Grossman N, Karpas
Serum Copper, Zinc and Oxidative Stress in Patients Z, Sarov B, Sukenik S. The role of trace elements in
with Psoriasis. Iraqi J Med Sci. 2011; 9(2): 137-42. psoriatic patients undergoing balneotherapy with
Dead Sea bath salt. Isr Med Assoc J.
5. Ahmed F, Fanning K, Schuhmann H, Netzel M,
2001;3(11):828-32.
Schenk P. Microalgae: a valuable source of natural
carotenoids with potential health benefits. 16. Lei L, Su J, Chen J, Chen W, Chen X, Peng C.
Carotenoids: Food Sources, Production and Health Abnormal serum copper and zinc levels in patients
Benefits. New York, NY: Nova Biomedical. 2013 Jan with psoriasis: A meta-analysis. Indian J.Dermatol.
1:143-63. 2019;64(3):224-30.
6. Carl A Burtis, Edward Ashwood, David E Burns. Teitz 17. Mohamad NS. Trace elements homeostatic
Textbook of Clinical Chemistry and Molecular imbalance in mild and severe psoriasis: a new insight
diagnostics. 5th ed. St. Louis: Missouri; 2012. in biomarker diagnostic value for psoriasis. Our
7. Zeng Q, Yin J, Fan F, Chen J, Zuo C, Xiang Y, Tan L, Dermatol Online. 2013;4(4):449-52.
Huang J, Xiao R. Decreased copper and zinc in sera of 18. Lee SY, Lee HK, Lee JY, Lee JS. Analyses of serum
Chinese vitiligo patients: A meta‐analysis. J. dermatol. zinc and copper concentrations in psoriasis. Korean J
2014; (3):245-51. Investig Dermatol. 1996; 3:35–8.
8. Ala S, Shokrzadeh M, Golpour M, Salehifar E, Alami 19. Portnoy B, Molokhia M. Zinc and copper in
M, Ahmadi A. Zinc and copper levels in Iranian psoriasis. Br J Dermatol. 1972;86 (2):205.
patients with psoriasis: A case control study. Biol Trace
20. Greaves MW. Zinc and copper in psoriasis. Br J
Elem Res. 2013;153 (1):22–7.
Dermatol. 1971; 86 (4):439.
9. Yin LL, Zhang Y, Guo DM, An K, Yin MS, Cui X.
21. Yang WL, Wang RL, Zhang YC. Serum ceruloplasmin
Effects of zinc on interleukins and antioxidant enzyme
values in psoriasis-induced mice. Biol Trace Elem Res. and copper levels in psoriasis patients. Zhongguo Pifu
2013;155 (3):411–5. Xingbinxue Zazhi. 1993:85–6.
10. Mohan Rao V, Deepthi M, Ramalingam K, Prasad 22. Nikolic A, Cabarkapa V, Novakov Mikic A,
Naidu M, V. Shaik M. Study on serum copper, zinc Jakovljevic A, Stosic Z. Ceruloplasmin and
and selenium trace element levels in Psoriasis. Indian J antioxidative enzymes in pre-eclampsia. J Matern
Clin Exp Dermatol. 2019;5(3):239-42. Fetal Neonatal Med. 2016;29 (18):2987–93.
31
Original Article
Severity of Pain According to Visual Analog Scale in Adhesive Capsulitis of Shoulder in Diabetic Patients
*Hosain M1, Rahman S2, Alam MM3, Islam SMM4, Islam KA5, Rahman MM6, Bhuiyan MK7
Abstract adhesive capsulitis of the shoulder among diabetic individuals

The aim of the present study was to assess the severity of pain attending in physical medicine and rehabilitation department
according to visual analog scale in adhesive capsulitis patients of a tertiary care hospital was 27%. Most of the adhesive
with DM. A descriptive, cross sectional study was conducted capsulitis patients suffering from moderate type of pain which
from January to June 2019 among 200 patients attending at visual analogue score is 4-6.
Physical Medicine and Rehabilitation Department, Keywords: Adhesive capsulitis, diabetes mellitus, visual
Bangabandhu Sheikh Mujib Medical University after analogue score.
obtaining requisite consent from the patients. Data were
collected through the assessment of patients in the Outpatient INTRODUCTION
Department. The collected data were analyzed by using SPSS Adhesive capsulitis is a well-defined disorder characterized
(version 20.1) to assess the severity of pain according to visual by progressive pain and stiffness of the shoulder which
analog scale in adhesive capsulitis patients. The study was usually resolves spontaneously after about 18 months.1 The
approved by the institutional ethical committee of BSMMU. patients typically present with progressive painful
Mean age of patients with adhesive capsulitis was 54.85±9.35 restriction in range of movement of the glenohumeral joint
years among them more than one third (35%) was 51-55 without any preceding trauma. They exhibit a capsular
years of age group. Among the patients 61% was female and pattern of restriction with external rotation being the most
39% was male. Among the patients 54(27%) had adhesive restricted followed by abduction in the plane of the scapula
capsulitis, and 146(73%) did not have. Nearly two third and then flexion.2 Diabetes mellitus is a chronic metabolic
female patients (65%) suffered from adhesive capsulitis of condition characterized by persistent hyperglycemia with
shoulder than male patients (35%). The hight number of resultant morbidity and mortality related primarily to its
adhesive capsulitis patients suffering from moderate type of associated micro vascular and macro vascular
pain and visual analogue score is 4-6, where one third of them complications.3 There is a well-documented relationship
suffer from severe type (VAS score 7-10). Overall frequency of between adhesive capsulitis and diabetes mellitus. 10.8%
1 *Dr. Mohammad Hosain, Medical officer, Physical diabetics and 2.3 % non-diabetics were found to have
Medicine and Rehabilitation Department, BSMMU. peri-arthrosis of the shoulder, a statistically significant
Phone: 01819231842, E-mail: drhossain17fmc@ difference between the two groups of patients (P<0.005).4
gmail.com There was three consecutive stages: pain, stiffness, and
2 Dr. Sohely Rahman, Professor and Ex. Head, Depart- recovery. The stiffness stage was usually related to the
ment of Physical Medicine and Rehabilitation, DMCH duration of the recovery stage. The total duration was
3 Dr. Md. Mahfuzul Alam, Assistant Professor, longer than is generally supposed (an average total of 30.1
Department of Physical Medicine and Rehabilitation, months in contrast to about 18 months as often
KGH postulated). Generally speaking, the longer the stiffness
4 Dr. S.M. Mazharul Islam, Assistant Professor, Department stage is, the longer is the recovery stage.5 Visual Analogue
of Physical Medicine and Rehabilitation, DMCH Scales (VAS) provides a simple technique for measuring
5 Dr. Khaza Amirul Islam, Medical Officer, subjective experience. They have been established as valid
Department of Hematology, SZMC and reliable in a range of clinical and research applications,
6 Dr. Md. Mubdiur Rahman, Assistant Registrar, although there is also evidence of increased error and
Department of Physical Medicine and Rehabilitation, decreased sensitivity when used with some subject groups.
MMC The pain VAS is a continuous scale comprised of a
7 Dr. Mohammad Kamruzzaman Bhuiyan, Medical horizontal (HVAS) or vertical (VVAS) line, usually 10
Officer, Physical Medicine and Rehabilitation centimeters (100 mm) in length, anchored by 2 verbal
Department, BSMMU descriptors, one for each symptom extreme. Instructions,
*For correspondence time period for reporting, and verbal descriptor anchors
32
have varied widely in the literature depending on intended 54, 27%

use of the scale. For pain intensity, the scale is most
commonly anchored by no pain (score of 0) and pain as
bad as it could be or worst imaginable pain (score of 100
[100-mm scale]. To avoid clustering of scores around a
preferred numeric value, numbers or verbal descriptors at
intermediate points are not recommended. 146, 73%
MATERIALS AND METHOD Present Absent

A descriptive, cross sectional study was conducted from
January 2019 to June 2019 among 200 diabetic patients Figure 1: Distribution of patients according to frequency of
attending at Physical Medicine and Rehabilitation Adhesive Capsulitis (n=54)
Department, Bangabandhu Sheikh Mujib Medical
University after obtaining requisite consent from the Figure 1 A total of 200 patients with diabetes were
patients. Purposive sampling was adopted for collecting included in the final analysis. Among the DM patients
data. The study was approved by the institutional ethical 54(27%) had adhesive capsulitis, and 146(73%) did not
committee. The assessment of patients was held directly in have adhesive capsulitis.
the Outpatient Department. Diagnosis of adhesive
capsulitis is clinical. Pain occurs insidiously in deltoid
region with shoulder stiffness. Pain at the end of external 35%
rotation. Restriction of the movement on both active and
passive testing. No abnormal X-Ray findings in the
shoulder joint. These characteristic of shoulder pain at
onset to three months duration were included. The 65%
relevant information was entered into the predesigned
proforma to estimate the severity of pain according to
visual analog scale in adhesive capsulitis patients with DM. Male Female
The collected data were entered into the computer and
analyzed by using SPSS (version 20.1) Figure 2: Pie chart showing presence of adhesive capsulitis
RESULT among male and female diabetic patient (n=54).
Table I Shows that Mean age of patients with adhesive Figure 2 Female patients (65%) suffered from more
capsulitis was 54.85±9.35 years. In 200 patient’s 35% was
adhesive capsulitis and male patients (35%).
51-55 years, 31% was 56-60years, 22% was 46-50 years
and 12% was 40-45 years. Among 200 patients with 61% Table II Shows that among the diabetic patients with
was female and 39% was male. adhesive capsulitis, 22 (41%) had VAS score 4-6
(moderate pain), 14 patients (26%) had VAS score 1-3
Table 1: Demographic characteristics of the study (mild pain), 18 patients (33%) had VAS score 7-10 (severe
population (n=200) pain).
Parameters Number Percentage

Age of the patients
40-45 years 24 12 Table 2: Severity of pain according to Visual Analog
46-50 years 44 22 Scale (n=54)
51-55 years 70 35
56-60 years 62 31 Visual analogue score No. of patients Percentage
Total 200 100 0 (No pain) 0 0
Sex
1-3 (Mild pain) 14 26
Male 78 39
Female 122 61 4-6 (moderate pain) 22 41
Total 200 100 7-10 (severe pain) 18 33
33
DISCUSSION ACKNOWLEDGEMENTS
Adhesive capsulitis is a distinctive clinical entity, usually The authors are grateful to the entire staff of the
occurring in the fifth and sixth decades. It may be department of the Physical Medicine and Rehabilitation
associated with trauma or with various illnesses, but most Department, Bangabandhu Sheikh Mujib Medical
cases are idiopathic. The evidence for disease relationships University for their cooperation and support during the
is uncovering, with the possible exception of diabetes study period.
mellitus. A total number of 200 patients with diabetes were
Conflict of interests: None
include in the final analysis. Among the patients 54(27%)
had adhesive capsulitis, and 146(73%) did not have
REFERENCES
adhesive capsulitis. So, prevalence of Adhesive Capsulitis
was 27%. A study was conducted by Khan et al. in a 1. Apley and Solomon's System of Orthopaedics and
tertiary care hospital of Bangladesh upon 300 diabetic and Trauma, Tenth Edition, page:365
300 non-diabetic individuals. There, frequency of
Adhesive Capsulitis in diabetic group was 20% and in 2. Zreik NH, Malik RA, Charalambous CP. Adhesive
non-diabetic group it was 5.66%.6 According to that study capsulitis of the shoulder and diabetes: A
our frequency result is higher. Probably because, a lot of meta-analysis of prevalence. Muscles Ligaments
diabetic patients with Adhesive Capsulitis come from Tendons J. 2016;6(1):26–34.
BIRDEM General Hospital, which is a diabetic hospital 3. Smith LL. Musculoskeletal manifestations of diabetes
and very near to BSMMU. Mean age of patients with mellitus. Br J Sports Med. 2003 Feb 1;37(1):30–5.
adhesive capsulitis was 54.85±9.35 years. Among 200
patients, majority 35% was between 50-55 years, 31% was 4. Bridgman JF. Periarthritis of the shoulder and diabetes
56-60 years, 22% was 46-50 years, 12% was 40-45 years. mellitus. Ann Rheum Dis. 1972;31(1):69–71.
In a case report in Bangladesh by Uddin et al. reported that 5. Reeves B. The natural history of the frozen shoulder
mean age of the patients was 53 years which is similar to syndrome. Scand J Rheumatol 1976;4:193-6.
our study.7 Other observer found maximum patients 39%
were between the age group of 51-60 which is also similar 6. Ara Doly E. Prevalence of Frozen Shoulder among
to our study.8 Among 200 patients with 61% was female Diabetes Mellitus Patients: a cross cut survey. Orthop
and 39% was male. In a study by Ahmed et al. reported Rheumatol Open Access J. 2018;9(2):9–11.
among 325 patients 52.3% were male and 47.7 % were 7. Uddin MM, Khan AA, Haig AJ, Uddin MK.
female which is not similar to us.9 In another study by Presentation of frozen shoulder among diabetic and
Khan et al. 31.67% patients were male and 68.33% were non-diabetic patients. J Clin Orthop Trauma.
female which is similar to our study.10 Among the patients 2014;5(4):193–8.
with adhesive capsulitis most of the patient 16(29.62%)
had VAS score 5-6, 14(25.92%) had VAS score 7-8, 8. Khan MSZ, Ahamed M, Hosain M, Doza AKMA,
12(22.22%) had VAS score 3-4, 8(14.81%) had VAS score Pattern of Musculoskeletal Disorders among Diabetic
1-2, and 4(7.4%) have VAS score 9-10. In a study among Patients Attending a Tertiary Care Hospital in Dhaka.
50 patients 32% had severe pain, 52% had moderate pain, Ibrahim Med Coll J. 2018;2(2):65–6.
and 16% had mild pain.11 Which is also similar to this 9. Ahmad S, Sohail Rafi M, Ahmed Siddiqui I, Hamidi
study. Adhesive capsulitis is a chronic disabling condition K, Mujahid Faruq N, Ahmad S, et al. The Frequency
associated with pain, which require long-term of Adhesive Capsulitis in Diabetes Mellitus Patients.
management in the form of physiotherapy and repeated Pakistan J Rehabil. 2012;11(2):49–55.
injections. Unfortunately, the treatment is more prolonged
in DM patients, and surgery may be required if the 10. Khan MSZ, Ahamed M, Hosain M, Doza AKMA,
condition is not treated early.12 Pattern of Musculoskeletal Disorders among Diabetic
Patients Attending a Tertiary Care Hospital in Dhaka.
CONCLUSION Ibrahim Med Coll J. 2018;2(2):65–6.
Study finds that more than one fourth (27%) diabetic patients
suffer from adhesive capsulitis of the shoulder. The disease 11. Irin KN. Characteristics of Adhesive Capsulitis
affects predominantly females in sixth decade of age. Most of Among the diabetic patients. Bangladesh J Physiother.
the adhesive capsulitis patients suffering from moderate type 2013;2007–8.
of pain which visual analogue score is 4-6. Further large scale 12. Diabète FI du. International Diabetes Federation.
study can be done for longer period to measure the pain score IDF Diabetes Atlas, 8th edn. Brussels, Belgium:
in different stages of adhesive capsulitis. International Diabetes Federation. 2017. 1–150p.
34
Original Article
Patterns of Post-endoscopic Retrograde Cholangiopancreatography (ERCP) Complications

*Habib MR1, Ahmed F2, Gain G3, Hasan R4, Ishaque SM5, Saifuddin D6
Abstract followed by proximal cholangiocarcinoma (13.7%),

In the treatment of common bile duct stones and palliative Ca-gallbladder with biliary infiltration (8.4%), Distal
decompression of malignant strictures, endoscopic retrograde cholangiocarcinoma (6.3%), Chronic calcific pancreatitis and
cholangiopancreatography (ERCP) is the gold standard. Periampullary carcinoma each (3.2%), Suspected SOD &
However, there are still concerns about procedure-related Chronic pancreatitis each (2.1%) and Worm in CBD and
complications and patient discomfort. The aim of the study is benign biliary stricture each (1.1%). In this study, the overall
to evaluate the pattern of post ERCP complications. This post-ERCP complication was 12.6%, with pancreatitis
prospective observational study was conducted at the accounting for 9.4%, bleeding accounting for 2.1%, and
Department of Gastroenterology, Bangabandhu Sheikh Mujib cholangitis accounting for 2.1%. From the study, it can be
Medical University (BSMMU), Dhaka from February to concluded that pancreatitis is the most frequent Post-ERCP
October 2017. A total of one hundred patients who were complication.
eligible for ERCP were included in this study but five patients Keywords: ERCP,c holangitis, obstructive jaundice, pancreatitis.
were excluded due to cannulation failure. Clinical
examination , biochemical, and radiological investigation INTRODUCTION
were performed before and after ERCP to assess the
Endoscopic retrograde cholangiopancreatography (ERCP)
complication that occurred. The majority of patients in this
was first introduced by the surgeon, McCune and
study were at and below the age of 50 years, with a mean age
co-workers1 as a diagnostic tool for evaluating diseases of
of 49.74 ± 14.07 years and the age range was between 18 to
80 years. Majority of the subjects were male (54.7%), and the biliary tract and pancreas. Eventually, it became a
male to female ratio was 1.21:1. The highest number of therapeutic modality. Although the ERCP procedure has
patients were diagnosed as choledocholithiasis (58.9%) progressed technically, it is still associated with potentially
serious complications2 and patient's discomfort.3
1. *Dr. Md. Rehan Habib, Assistant Professor, Endoscopic retrograde cholangiopancreatography (ERCP)
Department of Gastroenterology, Sir Salimullah is widely used for the treatment of a variety of
Medical College and Mitford Hospital (SSMC), pancreatico-biliary diseases. However, it is a high risk
Dhaka. Phona: 01712120831, Email: procedure that can result in complications such as acute
mdrehanhabib@ gmail.com pancreatitis, bleeding, cholangitis, cholecystitis, and
2. Dr. Farid Ahmed, Assistant Professor, Department perforation.4 The most common and serious complication
of Medical Gastroenterolagy, Sheikh Russel
of ERCP is Pancreatitis (PEP). According to recent
National Gastroliver Institute & Hospital
(SRGIH), Mohakhali, Dhaka research, the incidence of post- ERCP pancreatitis ranges
3. Dr. Gobinda Gain, Assistant Professor, between 2 and 5%.4-6 However, in severe cases, it is
Department of Medical Gastroenterology, SRGIH, associated with a high morbidity and mortality.6,7 By
Mohakhali, Dhaka identifying high-risk populations, it is possible to reduce
4. Dr. Rashedul Hasan, Assistant Professor, the occurrence and severity of post-ERCP pancreatitis.
Department of Gastroenterology, Sheikh Russel Several studies have revealed number of risk factors for
Gastroliver Institute And Hospital (SRGIH), post-ERCP pancreatitis.
Mohakhali, Dhaka,
5. Dr. S.M. Ishaque Professor of Gastroenterology, Cholangitis is a difficult-to-diagnose complication of
BSMMU, Shahbag, Dhaka ERCP. It can be an indication as well as a complication.
6. Dr. Dewan Saifuddin Ahmed, Professor of PEP occurs immediately after an ERCP, but cholangitis can
Gastroenterology BSMMU, Shahbag, Dhaka occur as a fulminant, uncontrolled sepsis within the first
*For correcpondence hours of an ERCP, or it can occur days or even weeks later.
It can be difficult to detect mild cholangitis in a patient
35
with multiple medical conditions. Cholangitis is primarily findings. The conventional sphincterotome was used to
caused by a failure or incomplete drainage.7,8 perform sphincterotomy selectively. Therapeutic
procedures were carried out in accordance with the
Bleeding after an ERCP is another common complication.
appropriate indication. Stone extraction was used to
The majority of bleeding is oozing from the precut
treat choledocholithiasis. Worm extraction was used to
sphincterotomy site, with no or minor clinical
treat worms in the common bile duct. Biliary stenting
consequences. Arterial bleeding that stops on its own can
was used as a palliative therapy in patients with
be difficult to detect because it resembles a temporary
malignant biliary obstruction. The consultant
pause caused by a vessel spasm.10
gastroenterologist checked on all patients after the
In Bangladesh, there are very few ERCP-related studies. procedure and again the next morning. Patients were
Accordingly, we sought to identify patterns of post-ERCP closely monitored for ERCP complications such as
problems. sedation-related complications, pancreatitis, cholangitis,
bleeding, and perforation.
METHODS
This prospective observational study was conducted in the RESULTS
Department of Gastroenterology, Bangabandhu Sheikh Out of the 100 eligible patients for ERCP, 5 were excluded
Mujib Medical University (BSMMU), Dhaka during the due to cannulation failure. Thus, n=95.
period of February 2017 to October 2017. A total of 100 Table I shows mean age of the patients was 49.74 ± 14.07
patients eligible for ERCP in Department of years within the range of 18 – 80 years. Males (54.7%)
Gastroenterology, BSMMU were enrolled in this study but were predominant than female (45.3%).
five of them were excluded due to cannulation failure. Prior
to data collection both verbal and written consent was
taken from the patients. Data were collected using a Table I: Demographic profile of the study subjects
preformed data collection sheet (questionnaire). (n=95)
Anticoagulant and antiplatelet medications were all Number of Percentage

stopped 72 hours before the procedure. Prior to ERCP, a patients (n) (%)
prophylactic dose of third generation cephalosporine was Age (groups)
routinely administered. To prevent sphincter of Oddi
≤40 26 27.4
spasm, hyosine-N-butyl bromide was also given
intravenously at the comencement of ERCP. The 41 - 50 30 31.6
procedure was carried out under fluoroscopic 51 - 60 20 21.1
supervision. The procedure was carried out with patients >60 19 20.0
under conscious sedation to help them relax and stay
Mean ± SD 49.74 ± 14.07
comfortable, or under general anaesthesia, depending on
the anaesthesiologist's individual assessment of the Gender
patients. Midazolam and pethidine was used for sedation Male 52 54.7
and analgesia respectively. Propofol was used as an
Female 43 45.3
anaesthetic agent during ERCP in the presence of an
anaesthesiologist. Patients were placed on an x-ray table
in the prone position while a duodenoscope was inserted Table II shows patients of choledocholithiasis (58.9%)
down the esophagus, through the stomach, and into the followed by proximal cholangiocarcinoma (13.7%), Ca
duodenum. The papilla of Vater was identified. For gallbladder with biliary infiltration (8.4%), Distal
contrast injection, a catheter was advanced past the cholangiocarcinoma (6.3%), Chronic calcific pancreatitis
sphincter of Oddi into the common bile duct (CBD). & Periampullary carcinoma each (3.2%), Suspected SOD
The pancreatic duct was cannulated selectively based on & Chronic pancreatitis each (2.1%) and Worm in CBD &
the ERCP indications and endoscopic or radiologic Biliary stricture each (1.1%).
36
Table II: Distribution of study subjects according to DISCUSSION

indication of ERCP (n=95) ERCP is one of the most technically demanding and
Indications Number of Percentage high-risk procedures performed by gastrointestinal
patients (n) (%) endoscopists (Adler et al.,2015, Colton and Curran,
Choledocholithiasis 56 58.9 2009). It requires significant focused training and
Proximal cholangiocarcinoma 13 13.7 experience to maximise success and minimise poor
outcomes (Colton, 2002, Testoni et al., 2010).
Ca gallbladder with biliary 8 8.4
infiltration In this study maximum patients were below the age of 50
Distal cholangiocarcinoma 6 6.3 years with a mean age of 49.74 ± 14.07 years (age range of
Periampullary carcinoma 3 3.2 18 – 80 years). More than half of the patients were above
Chronic calcific pancreatitis 3 3.2 70 years old.11 Males (54.7%) were predominant than
Chronic pancreatitis 2 2.1 female (45.3%) and male female ratio was 1.21:1.
Suspected SOD 2 2.1 The most common diagnosis was choledocholithiasis
Biliary stricture 1 1.1 (58.9%), followed by proximal cholangiocarcinoma
Worm in CBD 1 1.1 (13.7%), gallbladder carcinoma with biliary infiltration
(8.4%), distal cholangiocarcinoma (6.3%), chronic calcific
Table III shows stone extraction was done in 51.6% pancreatitis and periampullary carcinoma (3.2%),
patients, stenting in common bile duct in 40% patients suspected SOD and chronic pancreatitis (2.1%), and
and only papillotomy done in 7.4% patients and removal worm in CBD and biliary strict (1.1 % ).
of worm in 1.1% patients. Therapeutic procedure of the study subjects, stone
extraction done in 49 patients (51.6%), stenting in
common bile duct in 38 patients (40%), only paillotomy
Table III : Distribution of study subjects according to
done in 7 patients (7.4%) and removal of worm in 1
therapeutic procedure performed (n=95)
patient (1.1%).
Therapeutic procedures Number of Percentage
The overall complication rate in this study was 12.6%
patients (n) (%)
which is comparabe to other Bangladeshi studies.Islam et
Stone extraction 49 51.6 al.2 revealed 9.01% complications in their study conducted
Stenting in common bile duct 38 40 in BSMMU. Complications occurred in 11.6% cases in
Only papillotomy done 7 7.4 the study of Glomsaker et al.11. Complication rate in other
Removal of worm 1 1.1 studies were 11.2%13 and 4.9%4. The incidence of PEP in
a meta-analysis of 21 prospective studies was
approximately 3.5% - 18%. 15,6
Table IV shows pancreatitis was observed in 9.47%
patients, bleeding in 2.1% patients and cholangitis in Pancreatitis was seen in 9.4% patients, bleeding in 2.1%
1.1% patients. patients and cholangitis in 1.1% patients in this study. One
of the most common complications in post-ERCP is
pancreatitis. Islam et al.12 found pancreatitis 5.15% and
Table IV: Distribution of study subjects according to Glomsaker et al.11 found 3.1%. Cholangitis was observed
complications (n=95) 3.6% in the study of Glomsaker et al.11. The post-ERCP
cholangitis rate was 1% or less.17 In this study, cholangitis
Complication Number of Percentage
was less due to adequate per and post procedure control of
patients (n) (%)
infection. Kapral et al.8 found bleeding in 4.2% cases and
Pancreatitis 9 9.5 Glomsaker et al.11 found bleeding in 2.4% cases.
Bleeding 2 2.1
CONCLUSIONS
Chaolangitis 1 1.1
According to the findings of this study, pancreatitis is the
Total 12 12.6
most common complication of ERCP. Overall, 12.6% of
37
patients experience complications, with pancreatitis pancreatitis: a prospective multicenter study. Official
accounting for 9.4%, bleeding accounting for 2.1%, and journal of the American College of Gastroenterology|
cholangitis accounting for 2.1%. ACG. 2006;101(1):139-47.
9. Testoni PA, Mariani A, Giussani A, Vailati C, Masci E,

REFERENCES
Macarri G, Ghezzo L, Familiari L, Giardullo N,
1. McCune WS, Shorb PE, Moscovitz H. Endoscopic Mutignani M, Lombardi G. Risk factors for
cannulation of the ampulla of vater: a preliminary post-ERCP pancreatitis in high-and low-volume
report. Annals of surgery. 1968;167(5):752. centers and among expert and non-expert operators: a
2. Andriulli A, Loperfido S, Napolitano G, Niro G, prospective multicenter study. Official journal of the
Valvano MR, Spirito F, Pilotto A, Forlano R. American College of Gastroenterology| ACG.
Incidence rates of post-ERCP complications: a 2010;105(8):1753-61.
systematic survey of prospective studies. Official 10. Freeman ML. Complications of ERCP: Prediction,
journal of the American College of Gastroenterology| Prevention and Management. In: Baron T, Kozarek
ACG. 2007;102(8):1781-8. RA, Carr-Locke DL, eds. ERCP. Philadelphia:
3. Jeurnink SM, Steyerberg EW, Kuipers EJ, Siersema Saunders, Elsevier Inc, 2008:51-59.
PD. The burden of endoscopic retrograde
11. Glomsaker T, Hoff G, Kvaløy JT, Søreide K,
cholangiopancreatography (ERCP) performed with
Aabakken L, Søreide JA. Patterns and predictive
the patient under conscious sedation. Surgical
factors of complications after endoscopic retrograde
endoscopy. 2012;26(8):2213-9.
cholangiopancreatography. Journal of British Surgery.
4. Baron TH, Petersen BT, Mergener K, Chak A, Cohen 2013;100(3):373-80.
J, Deal SE, Hoffman B, Jacobson BC, Petrini JL, Safdi
12. Islam MS, Alam AH, Ahmed SU, Zaman KS, Islam
MA, Faigel DO. Quality indicators for endoscopic
M. Early Complications of Therapeutic Endoscopic
retrograde cholangiopancreatography. Gastroin-
Retrograde Cholangiopan Creatography: A
testinal endoscopy. 2006;63(4):S29-34.
Prospective Tertiary Hospital Study. Medicine Today.
5. Alizadeh AHM, Afzali ES, Mousavi M, Moaddab Y, 2011;23(2):63-6.
Zali MR. Endoscopic retrograde cholangio-
13. Masci E, Toti G, Mariani A, Curioni S, Lomazzi A,
pancreatography outcome from a single referral center
Dinelli M, Minoli G, Crosta C, Comin U, Fertitta A,
in Iran. Hepatobiliary & pancreatic diseases
Prada A. Complications of diagnostic and therapeutic
international: HBPD INT. 2010;9(4):428-32.
ERCP: a prospective multicenter study. The American
6. Cheon YK, Cho KB, Watkins JL, McHenry L, Fogel journal of gastroenterology. 2001;96(2):417-23.
EL, Sherman S, Lehman GA. Frequency and severity
of post-ERCP pancreatitis correlated with extent of 14. Freeman ML. Understanding risk factors and avoiding
pancreatic ductal opacification. Gastrointestinal complications with endoscopic retrograde
endoscopy. 2007;65(3):385-93. cholangiopancreatography. Current gastroenterology
reports. 2003;5(2):145-53.
7. Freeman ML, Nelson DB, Sherman S, Haber GB,
Herman ME, Dorsher PJ, Moore JP, Fennerty MB, 15. Cotton PB, Garrow DA, Gallagher J, Romagnuolo J.
Ryan ME, Shaw MJ, Lande JD. Complications of Risk factors for complications after ERCP: a
endoscopic biliary sphincterotomy. New England multivariate analysis of 11,497 procedures over 12
Journal of Medicine. 1996;335(13):909-19. years. Gastrointestinal endoscopy. 2009;70(1):80-8.
8. Cheng CL, Sherman S, Watkins JL, Barnett J, 16. Barthet M, Lesavre N, Desjeux A, Gasmi M,
Freeman M, Geenen J, Ryan M, Parker H, Frakes JT, Berthezene P, Berdah S, Viviand X, Grimaud JC.
Fogel EL, Silverman WB. Risk factors for post-ERCP Complications of endoscopic sphincterotomy: results
38
from a single tertiary referral center. Endoscopy. 2002; 18. Kapral C, Mühlberger A, Wewalka F, Duller C,
34(12):991-7. Knoflach P, Schreiber F. Quality assessment of
17. Katsinelos P, Lazaraki G, Chatzimavroudis G, endoscopic retrograde cholangiopancreatography:
Gkagkalis S, Vasiliadis I, Papaeuthimiou A, Terzoudis results of a running nationwide Austrian
S, Pilpilidis I, Zavos C, Kountouras J. Risk factors for benchmarking project after 5 years of
therapeutic ERCP-related complications: an analysis implementation. European journal of
of 2,715 cases performed by a single endoscopist. gastroenterology & hepatology. 2012;24(12):
Annals of gastroenterology. 2014;27(1):65. 1447-54.
39
Original Article
Cardiovascular Risk Factors amongst the Patient Living with HIV Attending at Anti-Retroviral Therapy
Center of Bangladesh
Hossain A1, Biswas SK2, *Hasan MN3, Ahmed I4, Bhuiyan AKMR5, Ahmed K6, Islam S7, Abdullah ABM8
Abstract triglyceridemia, high low-density lipoprotein (LDL) and low

Human immunodeficiency Virus (HIV) seropositive high-density lipoprotein (HDL) were found in 23%, 58%,
individual is at risk of developing disease of cardiovascular 14%. and 63% of the HIV patent, respectively. Hypertension
system (CVD). There are scarce of research work regarding this was present in 19% and diabetes in 15% of the patients. In
field in Bangladesh. Considering scarcity, this study was Framingham risk score, 19% of the participants had
conducted at anti-retroviral therapy (ART) center of intermediate to high risk of cardiovascular disease within 10
Bangabandhu Sheikh Mujib Medical University (BSMMU), years. The cardiovascular risk factors were common in HIV
Bangladesh to find out the frequency of the CVD and their patients attending ART center of BSMMU, where base line
common risk factors in HIV seropositive patients from March 10-years CVD risk was low. People living with HIV appear to
2017 to September 2019. Different CVD risk factors were be an imminent risk to develop CVD.
assessed in this study. The demographic data were assessed and Keywords: HIV, anti-retroviral therapy, 10-year
World Health Organization STEPS questionnaire were used cardiovascular disease risk.
to collect demographic data. The 10-year CVD risk was
calculated by using the Framingham coronary risk score INTRODUCTION
(FRS). Mean age of study population was 38, SD= 9.8. The common cardiovascular events are associated with
Among them sixty-five (65%) were men and thirty-five HIV infection. In HIV seropositive patient,
(35%) were women. About one third were overweight
atherosclerosis and cardiovascular disease are developed by
followed by 5% were obese. High cholesterolemia, high
several mechanism like vascular endothelial dysfunction,
abnormal coagulation process and systemic inflammatory
1. Dr Abid Hossian, MD Resident, Department of
Internal Medicine, Bangabandhu Sheikh Mujib response.1 It is found in different studies that
Medical University (BSMMU), Dhaka cardiovascular risk factors like smoking, dyslipidemia,
2. Prof. Dr. Sunil Kumar Biswas, Professor of Internal hypertension and central obesity were prevalent in the HIV
Medicine, Department of Internal Medicine, sero-positive patients.2,3 So, cardiovascular disease risk and
BSMMU, Dhaka cardiovascular risk factors in people living with HIV needs
3. *Dr. Md. Nazmul Hassan, Assistant Professor, to be studied. The data are scarce regarding cardiovascular
Department of Internal Medicine, BSMMU, diseases and risk factors in HIV populations in Bangladesh.
Email:nazmul_31st@bsmmu.edu.bd
So, this study would be helpful for both the clinician and
4. Dr. Imtiaz Ahmed, Assistant Professor,
the patients in making a rational approach in management
Department of Medicine, Sir Salimullah Medical
College, Dhaka. of overlapping HIV infection with cardiovascular diseases
5. Prof. AKM Matiur Rahman Bhuiyan, Department and this report may contribute to the monitoring of the
of Paliative Medicine, BSMMU, Dhaka cardiovascular disease prevention and control policy
6. Dr. Kohinur Ahmed, Assistant Professor, among HIV infected patient in our country. This study
Department of Gynaecology and Obstretics, may be helpful in reduction of the sufferings and burden of
Dhaka Medical Hospital, Dhaka. cardiovascular diseases in HIV patients.
7. Dr. Sadia Islam, Associate Professor and Head,
Department of Medicine, Delta Medical College MATERIALS AND METHODS
and Hospital
This was a cross-sectional observational study done from
8. Prof. ABM Abdullah, UGC Professor,
March 2017 to September 2019 in the ART Center of
Ex-Professor of Internal Medicine, BSMMU
Bangabandhu Sheikh Mujib Medical University. The
*For correspondence
socio-demographic characteristics were evaluated by
40
interviewing face to face using WHO STEPS Table 1 Study population socio demographic
questionnaire. Anthropometric measurements were characteristics( N=100)
performed following standard procedures. The venous Characteristic Male Female
blood samples were drawn and fasting blood glucose, Sex of the participants 65/100 35/100
HbA1c and fasting lipid profile were measured in Age (Range of years) 18-65 25-64
department of Biochemistry, BSMMU. (years) (years)
The participant was considered as diabetic who were Type of community
Rural 48 /65 30/35
already diabetic or fulfilled the criteria having HbA1c ≥
Urban 17/65 5/35
6.5% or fasting plasma glucose level ≥7 mmol/L. The US
Level of education
National Cholesterol Education Program (NCEP) III
Illiterate/Primary 38/65 29/35
guidelines was used to define dyslipidemia. All the
Secondary or Above 27/65 06/35
participant had provided written informed consent before Occupation
enrollment. Ethical approval was obtained from the Employed 48/65 3/35
Institutional Review Board (IRB) of Bangabandhu Sheikh Unemployed 17/65 32/35
Mujib Medical University. After collection of the data Marital status
analysis was performed by SPSS Version 22. Never married 8/65 0/35
Married 57/65 25/35
RESULTS Divorced/Widow 0/65 10/35
Table I shows a total of 100 participants were enrolled Route of transmission
between March 2017 to September 2019 in the ART Heterosexual 59/65 35/35
Center of Bangabandhu Sheikh Mujib Medical University. MSM 06/65 0/35
The age range of the participants were 18-64 years. Mean Blood borne 0/65 1/35
age was 38.05 ±9.85 years. Female participants were 35 Injectable syringe/Unknown 0 0
Opportunistic infection
(35%) and male participants were 65 (65%) in number
Pulmonary TB 05/65 02/35
and male: female ratio was 1.8:1. Among the male
Extrapulmonary TB 03/65 0/35
participant 48 resided in rural area where as 29 of female
CMV retinitis 0/65 1/35
participant were living in the rural area. Male were
HAART
educated above higher secondary level more in number
On HAART 64/65 35/35
than the female ( 27 vs 6) but there was a little difference Current PI use 14/65 1/35
in illiteracy level/primary level(38 v29). All the female
participant were married and divorced rate was higher in Body mass index characteristics, n= 100
Obese
them (10 vs 0). Regarding the transmission route 5%
heterosexuality is the predominant both in the male and Under weight
15%
female (59 vs 35) followed by MSM in case of male in our Overweight
study. The commonest opportunistic infection was 33%
Tuberculosis and only one patient was found to be have Normal
CMV retinitis. Except one patient among the male and 47%
100% of the female patient were receiving HAART. PPI

use was more common in the male participant (14 vs 1)
(Table-1). Fifteen participants (15%) were underweight,
Under weight Normal Overweight Obese
thirty three participants (33%) were overweight, five
participants (5%) were obese but forty seven participants Figure 1: Body mass index characteristics of study participants.
(47%) were normal in weight at presentation (Figure-1).
Very small amount (5%) of the participants were Figure 1 shows that 47% participants had normal body
physically active as per World Health Organization weight. 33% participant were overweight, 15% were
(WHO). underweight and 5% were obese
41
Table II shows the framingham risk scores, 81% patient was in low-risk group, 16% were in intermediate risk group
followed by 3% were in high-risk group population
Table II: Shows the Framingham risk scores of HIV infected peoples (N=100)
FRS All Male Female
Low risk (<10% cardiovascular disease risk) 81 (81%) 49 (75.4%) 32 (91.4%)
Intermediate risk (10%-20% cardiovascular disease risk) 16 (16%) 13 (20%) 3 (8.5%)
High risk (>20% cardiovascular disease risk) 3 (3%) 3 (4.6%) 0 (0%)
High LDL cholesterol 14%

Almost all the patients (99%) received ART among them
Hypertriglyceridaemia 58%
15% were treated protease inhibitors (PI) like lopinavir.
Low HDL 63%
The median duration of ART was 3 years.
Hypercholestrolaemia 25.00%
DISCUSSION
0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00%
This is probably the pioneer study in Bangladesh about the
Lipid proﬁle… CVD and its risk factors in HIV patients. The WHO
STEPS questionnaire was utilized to assess dietary habit,
Figure 2: Lipid profile characteristics of study participants.
physical activity, tobacco use and alcohol consumptions.
Figure 2: shows the lipid profile characteristics of study In the study population, male to female ratio was 1.8:1
participants frequency of hypercholesterolemia, with males comprising 65% of cases. Male predominance
hypertriglyceridemia, high LDL and low HDL were was also observed in several studies.4,5 Age range of our
present among 25%, 58%, 14% and 63% of the study population was 18 years to 65 years and median age
participants respectively was 35. Higher prevalence seen as this is sexually active and
reproductive age. Similarly, higher prevalence in this age
Metabolic Syndrome 26%
group was observed in previous studies conducted in
Abdominal Obesity 35% Bangladesh.4 About 67% of HIV patient completed up to
Diabe"s Mellitus 15.00% primary level education. These findings were similar the
Hypercholestrolaemia 25.00% study conducted in India.5 It is possible that educated
High LDL 14.00% people are more motivated and exposed to prevention
Hypertriglyceridemia 58% programs.
Low HDL 53.00%
Majority of participants were married (82%), eight (8%)
Family H/O of CVD 24.00%
participants were unmarried and ten (10%) were widows.
Obesity 5.00%
19.00%
High number of married persons having HIV/AIDS was
Hypertension
32.00%
also reported in other Indian studies.5 Almost all widows
Current Smoker
gave history of death of their spouses due to HIV/AIDS. In
0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00%
this study, most common possible route of transmission
Figure 3: Cardiovascular risk factors characteristics of was heterosexual (92%). This is due to probably
study participants. homosexuality is not common in Bangladesh.6
Majority of participants cited fever, weight loss and
Figue-3 shows overall frequency of Hypertension was 19%, diarrhea as symptoms within 6 months of HIV diagnosis.
Diabetes was 15 %, Hypercholesterolaemia 25%, High Tuberculosis was the commonest opportunistic infection
LDL was 14%, Hypertiglyceraldemia was 58%, Low HDL found in 10% patients in this study. This is near similar to
was 53%, family history of CVD was present in 24%, studies done in ICDDRB, Bangladesh4 but lower from the
Obesity was 5%. Among the male participant 32% other South Asian7 study done in 2006 which reported
participant were current smoker tuberculosis in 62% patients of their study populations.
42
That study was conducted a decade before, when wide prediction of presence of carotid atherosclerosis.16
spread use of ART was not possible. Now the good Framingham risk score showed 81% of participants had
availability and wide spread use of ART could be the reason low cardiovascular disease risk. Only 19% had
of this decrease in opportunistic TB infection in HIV intermediate to high risk based upon Framingham risk
seropositive patients, despite the high prevalence of score, which is par compared with rates observed among
tuberculosis in the Bangladesh. individuals with HIV in South Korea (29%) (17), Western
countries (19.6%-21.1%) (18) where sedentary life style
Ninety-nine participants (99%) were receiving ART of
were also high.
which fifteen (15%) were receiving protease inhibitors (PI)
in the form of boosted lopinavir-based therapy. The Limitations of this study include that this study was
median duration of ART exposure was 3 years. Only five conducted at only one ART center. Therefore, the study
(5%) of the participants were involved in physical activity findings may not be generalizable to people receiving HIV
consistent with WHO recommendations and only 2 study care from other centers. The cross-sectional design limits
participant’s dietary habits were in compliance with WHO our understanding of causal links between risk factors and
recommendation. According to the participant response the development of cardiovascular diseases.
low intake was due to their low financial condition. Other
study had shown less consumption of fruits and vegetable CONCLUSIONS
is associated with increase in CVD rsik.8,9 A high rate of Cardiovascular diseases among people living with HIV
unemployment (49%) was observed in this study, as 91% appear to be an imminent risk group. The 10-year
of female were housewife and 26.15% male had no jobs. cardiovascular disease risk was low. Risk factors for CVD
This high unemployment rate and stigma related to HIV were common and significantly related to individual living
infection, may cause high levels of stress to HIV with HIV. Stepping up of preventive services including
seropositive patients. screening services should be considered.
Thirty-nine participants (39%) reported to have ever
smoked, of which thirty-two (32%) were current smokers, REFERENCES
all of them being men. 25% of participants used tobacco 1. VenkatNarayan KM, Miotti PG, AnandNP, Kline
with betel leaf. Only 5 participants occasionally use LM, Harmston C, Gulakowski R III, Vermund SH.
alcohol, all of them being men. These behavioral risks are HIV and non-communicable disease comorbidities in
similar to Indian studies.10 the era of antiretroviral therapy: a vital agenda for
About 5% were obese and metabolic syndrome was present research in low-and middle-income country settings.J
Acquir Immune DeficSyndr. 2014; 67: S2-S7.
in 26% in our study. These findings are similar to other
study findings conducted in Asia.11 The female was more 2. Freiberg MS, Chang CCH, Kuller LH, Skanderson
obese than male in our study and the reason behind this M, Lowy E, Kraemer KL, Butt AA, Goetz MB, Leaf
may be physical inactivity. D, Oursler KA, Rimland D. 2013. HIV infection and
the risk of acute myocardial infarction. JAMA internal
Among metabolic risk factors, hypertension was observed medicine. 2013; 173(8): 614-22.
in nineteen (19 %) participants. Diabetes mellitus in males
and females were 15% similar to studies in Malaysia (12). 3. Triant VA, LeeH, Hadigan C, Grinspoon SK. 2007.
In this study, Hypercholesterolemia was present in 25% of Increased acute myocardial infarction rates and
cardiovascular risk factors among patients with human
the participants which is similar to the results from other
immunodeficiency virus disease. The Journal of
studies. Hypertriglycedaemia and low HDL was the
Clinical Endocrinology & Metabolism.2007;
predominant lipid abnormalities found in this study which
92(7):2506-12.
was consistent with other studies.13 High level of TG and
low HDL may be associated with low intake of fruits and 4. Matin N, Shahrin L, Pervez MM, Banu S, Ahmed D,
vegetables.14 Khatun M, Pietroni M. Clinical profile of
HIV/AIDS-infected patients admitted to a new
To detect the cardiovascular disease risk, Framingham risk specialist unit in Dhaka, Bangladesh - A
score was used because was a proven tool to assess CVD low-prevalence country for HIV. Journal of health,
risk in non-HIV patients 15 and it can also provide an early population, and nutrition. 2011; 29(1): 14-19.
43
5. Joge US, Deo DS, Lakde RN, Choudhari SG, Malkar cross-sectional survey. BMC Public Health. 2013;
VR, Ughade HH. Sociodemographic and clinical 13:758(1-11).
profile of HIV/AIDS patients visiting to ART Centre
13. Kuti MA, Adesina OA, AwoludeOA, Ogunbosi BO,
at a rural tertiary care hospital in Maharashtra state of
Fayemiwo SA, Akinyemi JO, AdetunjiAA, Irabor AE,
India. Int J Biol Med Res. 2012; 3(2):1568-72. Odaibo GN, Prosper O, Taiwo BO. Dyslipidemia in
6. Kumarasamy N, Solomon S, Flanigan TP, Hemalatha ART-Naive HIV-Infected Persons in Nigeria—
R, Thyagarajan SP, Mayer KH. Natural history of Implications for Care. Journal of the International
human immunodeficiency virus disease in southern Association of Providers of AIDS Care. 2015;
India. Clinical Infectious Diseases. 2003; 36(1): 14(4):355-59.
79-85. 14. KoebnickC, Garcia AL, Dagnelie PC, Strassner C,
7. Chakravarty J, Mehta H, Parekh A, Attili SVS, Lindemans J, Katz N, Leitzmann C, Hoffmann I.
Agrawal NR, Singh SP, Sundar S. Study on Long-term consumption of a raw food diet is
clinico-epidemiological profile of HIV patients in associated with favorable serum LDL cholesterol and
eastern India. Japi. 2006;54: 854-57. triglycerides but also with elevated plasma
homocysteine and low serum HDL cholesterol in
8. Takahashi MM, de Oliveira EP, Moreto F, humans. The Journal of nutrition. 2005;
Portero-McLellan KC, Burini RC. ‘Association of 135(10):2372-78.
dyslipidemia with intakes of fruit and vegetables and
15. Liu J, Hong Y, D'Agostino SRB, Wu Z, Wang W, Sun
the body fat content of adults clinically selected for a
J, Wilson PW, Kannel WB, Zhao D. Predictive value
lifestyle modification program’, Archivos Latino for the Chinese population of the Framingham CHD
americanos de Nutrición. 2010; 6(2):148–54. risk assessment tool compared with the Chinese
9. Martinez-GonzάlezMA, de la Fuente-Arrillaga C, Multi-Provincial Cohort Study. Jama. 2004;
López-del-Burgo C, Vάzquez-Ruiz Z, Benito S, 291(21):2591-99.
Ruiz-Canela M. ‘Low consumption of fruit and 16. De Socio GVL, Martinelli C, Ricci E, Orofino G,
vegetables and risk of chronic disease: a review of the Valsecchi L, Vitiello P, Martinelli L, Quirino T, Maggi
epidemiological evidence and temporal trends among P, Bonfanti P. Relations between cardiovascular risk
Spanish graduates’,Public Health Nutrition. estimates and subclinical atherosclerosis in naïve HIV
2011;14(12A):2309-15. patients: results from the HERMES study.
10. Lall P, Saifi R, Kamarulzaman A. ‘Tobacco International journal of STD & AIDS. 2010;
21(4):267-72.
consumption among HIV-positive respondents:
Findings from the third round of the National Family 17. Kim SB, Kim YC, Kim MH, Song JE, Oh DH, Ahn
Health Survey’, Nicotine& Tobacco Research.2016; JY, Ku NS, Kim HW, Jeong SJ, Han SH, Song YG. A
18(12):2185–93. comparison of the predicted risk for cardiovascular
disease between HIV-infected and uninfected persons
11. Hejazi N, Lee MHS, Lin KG, Choong CLK.Factors in Korea. Scandinavian journal of infectious diseases.
associated with abdominal obesity among 2013; 45(11): 855-62.
HIV-infected adults on antiretroviral therapy in
Malaysia. Global Journal of Health Science. 2010; 18. Soliman EZ, Sharma S, Arastéh K, Wohl D, Achhra
2(2):20–31. A, Tambussi G, O'Connor J, Stein JH, Duprez DA,
Neaton JD, Phillips A. Baseline cardiovascular risk in
12. Hejazi N, Rajikan R, Choong CLK, Sahar S. the INSIGHT Strategic Timing of Antiretroviral
Metabolic abnormalities in adult HIV infected Treatment (START) trial. HIV medicine. 2015;
population on antiretroviral medication in Malaysia: a 16:46-54.
44
Case Report
An Eleven Months Old Infant with Very Early Onset Inflammatory Bowel Diseases (IBD):
A Rare Case Report
*Ahamed N1, Khadga M2, Majumder W3
Abstract 10 days, having similar episodes for last five months. He was
Inflammatory bowel disease (IBD) in pediatric cases has been mildly pale, and had thrombocytosis with raised C reactive
seen rapidly increasing in number over the last decade. Now a protein (CRP), features of colitis in stool routine microscopic
days four types of pediatric IBD has been identified: less than test. The diagnosis was confirmed by colonoscopy and
ten years of age - early onset IBD, less than six years of age - histopathology study, which showed features of Crohn’s colitis.
very early onset IBD, less than two years of age- infantile IBD He was treated by anti-inflammatory drugs (steroid and
and less than twenty eight days of age - neonatal onset IBD. mesalazine) with a significant improvement in a short time.
Young children presented with more aggressive clinical features Keywords: Pediatric inflammatory bowel disease, monogenic
and severity is more than the older children and adults. Early VEO-IBD, very early onset IBD
onset disease presenting in children may have a monogenic
basis. Infantile IBD or neonatal IBD having the high rates to
INTRODUCTION
affect the first-degree relatives and there is very high chance to
develop resistance against immunosuppressive treatment. Very Inflammatory bowel disease (IBD) in children constitutes
early onset IBD (VEO-IBD) most commonly presenting per about 25% of all patients of IBD.1 "very early-onset IBD"
rectal bleeding with or without mucous stools, isolated colonic (VEO-IBD) means key symptoms of IBD or is diagnosed
disease, perianal involvement, skin lesions, whereas early onset before six years of age. Compared with children whose IBD
IBD (EO-IBD) commonly presented with abdominal pain develops later in life, those with VEO IBD and particularly
and weight loss. A thorough history, physical examination, those with infantile IBD are more likely to have single gene
biochemical markers, endoscopic evaluation with macroscop defects that alter immunity or epithelial barrier function
and microscopic findings are the only way to reach the may disturb, and often have a more severe disease course2,3.
diagnosis. The treatment of VEO-IBD is the same as that given The common disorders are interleukin-10 (IL-10)
to the adolescents and adults with IBD (eg, anti-inflammatory signaling defects, atypical severe combined immuno-
agents, immunomodulators, biologics, antibiotics, and deficiency (SCID), common variable immunodeficiency,
surgical approaches). Here, we report a rare case of very early chronic granulomatous disease and other neutrophil
onset IBD of a 11 months old male infant, who presented with defects, hyperimmunoglobulin M syndrome, Wiskott-
the complaints of blood and mucus mixed loose watery stool for Aldrich syndrome, agammaglo- bulinemia, familial
hemophagocytic lymphohistiocytosis, and IPEX (immune
dysregulation, polyendocrinopathy, enteropathy, X-linked)
1. *Dr. Nazmul Ahamed, Department of Pediatric
or other autoimmune related enteropathy.4
Gastroenterology and Nutrition, Bangabandhu
Sheikh Mujib Medical University (BSMMU), Near about, 50 genetic variants have been associated with
Dhaka. Phone: 01747481695, Email:
IBD and these disorders are collectively called as
dr.nazmulahamed1985@gmail.com
2. Dr. Mukesh Khadga, Department of Pediatric monogenic IBDs.5
Gastroenterology and Nutrition, BSMMU, Dhaka. Clinical features that give suspicion for monogenic IBD
3. Dr. Wahiduzzaman Majumder, Associate
include:6
Professor, Department of Pediatric
Gastroenterology and Nutrition, BSMMU, Dhaka. ● Early age of onset (eg, younger than six years,
4. Dr. Md Rukunuzzaman, Professor, Department of particularly younger than two years of age)
Pediatric Gastroenterology and Nutrition,
BSMMU, Dhaka ● Family history of IBD and/or immunodeficiency in
For correspondence multiple family members, usually with male
predominance, or consanguinity
45
● Frequent attack of infections or unexplained fever or related foods. On examination, baby was fretful, mildly
● Associated features suggestive for autoimmunity (eg, pale and anicteric, all vitals were within normal limit, no
primary sclerosing cholangitis, arthritis, anemia, or signs of dehydration and bilateral pedal oedema absent,
endocrine dysfunction) skin survey revealed normal findings, severe wasting was
present (weight- 6.6 kg, length: 69 cm WLZ score -3.6),
● Very severe IBD and/or resistance to conventional
abdomen examination revealed no organomegaly and
therapies for IBD
ascites was absent. Laboratory investigation showed
● Symptoms and/or signs suggestive of hemophagocytic haemoglobin (Hb)- 9.1 g/dl, WBC count- 16500/cmm,
lymphohistiocytosis (fever, hepatomegaly, cytopenias,
platelet count 8,50,000/cmm, ESR 90 mm in 1st hour,
high ferritin)
liver function test and fasting blood sugar were normal.
● Lesions of the skin, hair, or nails Stool RME showed Mucus and RBC ++, pus cell plenty,
● Current or previous history of cancer in the patient stool C/S was normal, S. albumin was 27 gm/l, C-reactive
protein 21 gm/l, fecal calprotectin was 850 µg/gm, S. tTG
Laboratory investigations include complete blood count
IgA was negative, stool for Clostridium difficile toxin
with ESR, intestinal inflammatory markers, stool RME
negative, USG of whole abdomen showed loaded bowel
and C/S. For immunodeficiency, identification of
loops having peristalsis. Primary immunodeficiency panel
immunological panel is important. For diagnosis of
was normal and HIV testing was negative. Initially we
VEO-IBD, endoscopy of lower and upper GIT now
managed this patient by giving lactose free diet with
remain the gold standard. Colonoscopy may show ulcer,
management of severe acute malnutrition due to its
pseudopolyps and histopathology confirms the diagnosis
secondary cause and some antibiotics. But patient’s
by showing features of chron’s colitis or ulcerative colitis.7
condition did not improve rather there was persistent
We hereby report a case of an 11 months old male infant
passage of mucoid stool, so we planned to do endoscopy of
who presented with blood and mucus mixed loose watery
lower GIT. Upto transverse colon was seen through
stool for 10 days and was diagnosed as very early onset IBD
colonoscopy due to friable gut wall and there might be
on the basis of laboratory, colonoscopy and histopathology
chance of bleeding. Macroscopically colonoscopy (Fig.1)
findings.
showed erythematous mucosa, friable with shallow ulcer
CASE REPORT and few pseudopolyps in descending colon but there was
A 11 months old male infant got admitted in the no rectal involvement. For biopsy, tissue took from
Department of Pediatric Gastroenterology and Nutrition, descending colon and sent for histopathologic
BSMMU with the complains of blood and mucus mixed examination. Histopathology report (Fig.2) showed
loose watery stool for 10 days for 10-12 episodes per day. infiltration of chronic inflammatory cell that suggestive of
Occasionally he also complains mucoid stool without colitis with absence of crypt abscess, cryptitis, goblet cell
blood several episodes with moderate in amount. He had depletion and absence of any granuloma. Usually for
history similar type of illness for previous five months but chron’s disease getting definitive submucosal tissue by
not regularly. Duration of each attack persist for two weeks biopsy not always possible, so granuloma may be absent
and managed with few antibiotics that results decrease the now a days. Then we treated the patient with oral
frequency of purging but not complete recovery. So that prednisolone 1mg/kg/day and oral mesalazine
he visited several registered physician and condition not so 40mg/kg/day. Gradually, the frequency and amount of
improved. He had history of exclusive breast feeding mucoid stool was reduced significantly, baby was gaining
(EBF) for first six months, then complementary feeding weight and he became playful. After 1 week CRP, was
was started with formula milk for 1 month. But after reduced to 18 mg/l, Hb 9.9 gm/dl, ESR 55 mm in 1st
starting complementary feeding, he developed watery hour and platelet count 7,50,000/cmm. Our final
diarrhea. Then after recovery only breast milk was diagnosis was very early onset IBD (Chron’s disease) and
continued with rice suji and occasionally chicken based we discharged the patient with advice for periodic follow
diet was given. He had no history of cow’s milk ingestion up.
46
Fig.1 Colonoscopy showing erythematous mucosa, friable with shallow ulcer and few pseudopolyps in descending colon.
monogenic form, though he had no family history and his

genetic study was not done due to financial constraints.
Variable presentation may show in pediatric IBD. Usually
the onset is insidious, blood and mucus stained small
volume loose watery stool may be present. Children with
immune dysregulation polyendocrinopathy enteropathy X
linked (IPEX) syndrome may presented with severe
extensive volume of diarrhoea.16 In children with IL-10
signalling defect, chronic granulomatous disease (CGD),
and X-linked inhibitor of apoptosis protein (XIAP) may
presented with intestinal fistula.17 Children also may
presented with repeated infections with lesions of the skin,
nails, or hair.6 On physical examination, pallor and tender
Fig.-2: Histopathology with features of Chron’s colitis abdomen may be present. Children must be evaluated for
Perianal disease, folliculitis, arthritis, and gout. Some
monogenic variants of VEO-IBD can present with
DISCUSSION palpable spleen or lymphnode.18,19 Our patient presented
with blood and mucus mixed loose watery stool and he was
Inflammatory bowel disease (IBD) in children below 6
mildly pale, severely wasted.
years of age defined as very early-onset IBD (VEO-IBD).
Infantile onset IBD also presents before 2 years of age and The routine laboratory investigations for VEO-IBD
neonatal onset IBD present before <28 days of age. In include complete blood count (CBC) with ESR, important
pediatric IBD, around 6 to 15% of population presents at inflammatory markers. CBC picture may show low
below 6 years of age.4 The phenotype of VEO-IBD is hemoglobin, high platelet count. Neutrophils defects can
considered to be heterogeneous and while some children be associated with VEO-IBD, and low neutrophil as well as
have mild disease, others can present with aggressive and leukocytosis (seen in leukocyte adhesion deficiency) can be
severe disease rather than adult IBD.9-12 Due to more seen in some cases. There can be raised C-reactive protein.
aggressive phenotype, strong family history and involving Looking for immunological panel is important for
primary immunodeficiency gene, VEO-IBD is now immunodeficiency disorders. Colonoscopy may show
considered to be a monogenic disease.13-15 Our patient friable ulcer, pseudopolyps and histopathology confirms
presented in his infancy period and we consider he had the diagnosis with features of chronic inflammation in
47
bowel wall and changes associated with IBD. Besides, J, Kelsen J. Natural history of very early onset
monogenic form of VEO-IBD may show features of inflammatory bowel disease in north america: a
eosinophilic infiltrates, atrophied vilous, apoptosis, and retrospective cohort study. Inflammatory bowel
increased intraepithelial lymphocytes.7 Our patient had diseases. 2020 May 9.
typical lab features of IBD (pallor, thrombocytosis and 4. Uhlig HH, Schwerd T, Koletzko S, Shah N,
raised CRP). Other differentials- like allergic colitis, celiac Kammermeier J, Elkadri A, Ouahed J, Wilson DC,
disease, primary immunodeficiency disorder were excluded Travis SP, Turner D, Klein C. The diagnostic approach
in this case. Colonoscopy showed ulcer and pseudopolyps to monogenic very early onset inflammatory bowel
in descending colon with no rectal involvement. disease. Gastroenterology. 2014; 147(5): 990-1007.
Histopathology report showed features of Crohn’s colitis.
5. Uhlig HH. Monogenic diseases associated with
Like other IBD, the treatment options for VEO-IBD intestinal inflammation: implications for the
include both medical (anti-inflammatory agents, understanding of inflammatory bowel disease. Gut.
immunomodulators, biologics, antibiotics) and surgical 2013; 62(12): 1795-1805.
management (colectomy or ileal diversion). Hematopoietic
stem cell transplantation (HSCT) is beneficial for specific 6. Johnston RD, Logan RF. What is the peak age for
genetic defect.7 Our patient showed dramatic response onset of IBD?. Inflammatory bowel diseases. 2008
both clinically and biochemically after treatment with Oct 1;14(suppl_2): S4-5.
steroid and mesalazine. So, now immunomodulatory 7. Kelsen JR, Sullivan KE, Rabizadeh S, Singh N,
therapy or biological agents were not required in our Snapper S, Elkadri A, Grossman AB. North American
patient. Society for Pediatric Gastroenterology, Hepatology,
and Nutrition position paper on the evaluation and
He was discharged with advice for periodic follow up.
management for patients with very early-onset
CONCLUSIONS inflammatory bowel disease. Journal of pediatric
gastroenterology and nutrition. 2020; 70(3):
Monogenic VEO-IBD has high rates of morbidity and
389-403.
mortality, and it might require different treatment
strategies. So, starting the early pharmacologic treatment 8. Benchimol EI, Bernstein CN, Bitton A, et al. Trends
can be effective step. Early initiation vaccination therapy in epidemiology of pediatric inflammatory bowel
for children with VEO-IBD is necessary, due to the age of disease in Canada: distributed network analysis of
onset of disease. It is recommended to avoid immune multiple population-based provincial health
suppressive drugs for at least 1 month for corticosteroid administrative databases. Am J Gastroenterol 2017;
112: 1120–34.
administration and 3 months for azathioprine/6-MP and
biological medication.20, 21 9. Glocker E, Grimbacher B. Inflammatory bowel
disease: is it a primary immunodeficiency? Cell Mol
Life Sci 2012; 69: 41–8.
REFERENCES
10. Ruemmele FM, El Khoury MG, Talbotec C, et al.
1. Loftus EV. Clinical epidemiology of inflammatory
Characteristics of inflammatory bowel disease with
bowel disease: incidence, prevalence, and
onset during the first year of life. J Pediatr
environmental influences. Gastroenterology. 2004;
Gastroenterol Nutr 2006; 43: 603–9.
126(6): 1504-1517.
11. Benchimol EI, Mack DR, Nguyen GC, et al.
2. Kelsen JR, Conrad MA, Dawany N, Patel T, Shraim Incidence, outcomes, and health services burden of
R, Merz A, Maurer K, Sullivan KE, Devoto M. The very early onset inflammatory bowel disease.
unique disease course of children with very early Gastroenterology 2014;147:803.e7–13.e7.
onset-inflammatory bowel disease. Inflammatory
12. Aloi M, Lionetti P, Barabino A, et al., SIGENP IBD
bowel diseases. 2020; 26(6): 909-18.
Group. Phenotype and disease course of early-onset
3. Kerur B, Benchimol EI, Fiedler K, Stahl M, Hyams J, pediatric inflammatory bowel disease. Inflamm Bowel
Stephens M, Lu Y, Pfefferkorn M, Alkhouri R, Strople Dis 2014; 20: 597–605.
48
13. de Ridder L, Weersma RK, Dijkstra G, et al. Genetic inflammatory bowel disease. Genet Med. 2011; 13(3):
susceptibility has a more important role in 255-262.
pediatric-onset Crohn’s disease than in adult onset 18. Canna SW, Girard C, Malle L, et al. Life-threatening
Crohn’s disease. Inflamm Bowel Dis 2007; 13: NLRC4-associated hyperinflammation successfully
1083–92. treated with IL-18 inhibition. J Allergy Clin Immunol
14. Biank V, Broeckel U, Kugathasan S. Pediatric 2017; 139: 1698–701.
inflammatory bowel disease: clinical and molecular 19. Murthy A, Shao YW, Narala SR, et al. Notch
genetics. Inflamm Bowel Dis 2007; 13: 1430–8. activation by the metalloproteinase ADAM17
15. Begue B, Verdier J, Rieux-Laucat F, et al. Defective regulates myeloproliferation and atopic barrier
immunity by suppressing epithelial cytokine
IL10 signaling defining a subgroup of patients with
synthesis. Immunity 2012; 36: 105–19.
inflammatory bowel disease. Am J Gastroenterol
2011; 106: 1544–55. 20. Lu Y, Jacobson D, Bousvaros A. Immunizations in
patients with inflammatory bowel disease. Inflamm
16. Patey-Mariaud de Serre N, Canioni D, Ganousse S, et Bowel Dis 2009; 15: 1417–23.
al. Digestive histopathological presentation of IPEX
syndrome. Mod Pathol. 2009; 22(1): 95-102. 21. Rubin LG, Levin MJ, Ljungman P, et al., Infectious
Diseases Society of America. 2013 IDSA clinical
17. Worthey EA, Mayer AN, Syverson GD, et al. Making practice guideline for vaccination of the
a definitive diagnosis: successful clinical application of immunocompromised host. Clin Infect Dis 2014; 58:
whole exome sequencing in a child with intractable 309–18.
49
Obituary news May-2021
BMA would like to express deep condolence on deaths of the following notable physicians in recent past:
Sl. No. Name Date of Death

1 Dr. Jibesh Kumar Pramanik 06/01/2021
Assistant Professor, Respiratory Medicine
Shahid Ziaur Rahman Medical College Bogura
Ex. Student of Rajshahi Medical College (31th Batch)
2 Dr. Md. Abdur Rashid 07/01/2021

Anesthesiology Specialist
Ex. UH&FPO, Upazila Health Complex, Kahaloo, Bogra
Ex Student of Rajshahi Medical College (K-15 Batch)
3 Dr. Anwar Hossain 07/01/2021

Eye Specialist & Surgeon and Ex-consultant
National Institute of Ophthalmology and Hospital, Dhaka
Ex Student of Sher-E-Bangla Medical College, Barishal (4 Batch)
4 Dr. Kazi Md Naser Ahmed 26/01/2021

Medical Officer, Square Hospital, Dhaka
Ex Student of Sylhet MAG Osmani Medical College (6 Batch)
5 Dr. Mahmudur Rahman Khandaker 12/02/2021

Professor of Anesthesiology, Northern International Medical College, Dhaka
Ex, Assistant Professor of Anesthesiology, Dhaka Medical College Hospital
Ex Student of Rahshahi Medical College (1972-73)
6 Prof. Dr. Nazmul Haque 09/03/2021

Professor of Physiology, Northern International Medical College, Dhaka
Ex, Head of Department, Physiology, Shahid Suhrawardy Medical College, Dhaka
Ex Student of Chattogram Medical College (7 Batch)
7 Professor (Dr.) M Sultan Ul Alam 15/03/2021

Freedom Fighter,
Ex Head, Department of Community Medicine, Chattogram Medical College
Ex Student of Chattogram Medical College (8th Batch)
8 Dr. Abdul Hannan 27/03/2021

Associate Professor, Department of Surgery
Rajshahi Medical College
Ex Student of Rajshahi Medical College (31th Batch)
9 Prof. Dr. Nur -E -Alam Patowary 02/04/2021

Professor of Anesthesiology and Ex Head, Department of Anesthesiology,
Gonoshasthaya Somaj Vittik Medical College, Saver, Dhaka
Ex Student of Dhaka Medical College (26th Batch)
10 Professor Dr. Badrul Haque Titu 05/04/2021

Ex Professor of Neurology, Dhaka Medical College
Ex Student, Mymensingh Medical College (12 Batch)
50
Bangladesh Med J. 2019 Sept; 48(3)

11 Dr. Nurul Hasan Shoaib 06/04/2021
Ex Student of Sylhet MAG Osmani Medical College (27th Batch)
12 Professor Dr. Mohammad Obaidullah

Head, Department of Biochemistry, Rajshahi Medical College
Islami Bank Medical College, Rajshahi
Ex Student of Rajshahi Medical college (20th Batch) 08/04/2021
13 Dr. Abdul Latif 09/04/2021

Director, Chattogram Metropolitan Hospital
Ex Student, of Chattogram Medical College (17th Batch)
14 Dr. Gazi Saiful Alam Chowdhury Sapon 09/04/2021

Ex. Deputy Director, Rajshahi Medical college Hospital
Life Member, BMA
15 Dr. Mohammad Mozadded Mehdi 10/04/2021

Associate Professor and Sinior Consultant
Department of Cardiac Surgery
National Hard Foundation Hospital and Research Institute, Dhaka
Ex. Student of Dhaka Medical College (K 44 Batch)
16 Dr. Shariful Ahsan 11/04/2021

Medical Officer, Bangladesh Agricultural Research Council, Dhaka
17 Dr. Upandra Nath Sheel 13/04/2021

Rtd. Upazila Health and Family Planning Officer
Upazila Health Complex, Nagashree, Kurigram
Life Member, BMA
Ex. Student of Rangpur Medical College (4th Batch)
18 Dr. Rezaul Karim Badal 16/04/2021

Ex. Upazila Health and Family Planning Officer
Upazila Health Complex, Madhupur, Tangail
Ex Student of Mymensingh Medical College (10th Batch)
19 Dr. Mohammad Mujahid Hossain Ratan, Freedom Fighter 16/04/2021

Ex. Student of Dhaka Medical College (K-30 Batch
20 Dr. Mominul Alam 16/04/2021

Ex. Student of Dhaka Medical College (K-21 Batch)
21 Professor Dr. Abu Ahmed Asraf Ali 17/04/2021

Ex Principal, Shahid Ziaur Rahman Medical College Bogura
Life Member, BMA
22 Professor Dr. Abdul Majid, Freedom Fighter 20/04/2021

Ex. Professor, Department of Community Medicine
Holy Family Red Crescent Medical College, Dhaka
Life Member, BMA
Ex. Student of Sir Salimullah Medical College (5th Batch)
51
Bangladesh Med J. 2019 Sept; 48(3)

23 Professor Dr. Md. Fazlul Haque 22/04/2021
Director, Islamia Eye and Laser Center, Dhaka
Ex. Head, Department of Ophthalmology, Dhaka Medical College, Dhaka
Life Member, BMA
Ex Student of Sir Salimullah Medical College (2nd Batch)
24 Prof. Dr. Abul Khair Mohammad Shamsuzzaman Tushar 24/04/2021

Director, National Institute of Laboratory Medicine and Referral Centre, Dhaka
Life Member, BMA
Ex Student of Rajshahi Medical College (22nd Batch)
25 Professor Dr. Md. Humayun Kabir Mukul 25/04/2021

Head of Department, Orthopaedic Surgery
President Abdul Hamid Medical College, Kishoreganj
Ex. Department of Head, Orthopaedic Surgery, Mymensingh Medical College
Life Member, BMA
Ex Student of Mymensingh Medical College (14th Batch)
26 Dr. Ashis Kumar Bonik 25/04/2021

Emergency Medical Officer
Shahid Ahsanullah Master General Hospital, Tongi
Life Member, BMA
Ex Student of Shahid Monsur Ali Medical College (Passing year 2005)
27 Dr. Md. Mahbubul Islam 26/04/2021

Chief Cardiac Anesthesiologist and
Director, Management Committee, Labaid Hospital
Life Member, BMA
Ex Student of Sir Salimullah Medical College (4th Batch)
28 Professor Dr. ABM Shamsul Huda 26/04/2021

Ex. Principal and Head, Department of physiology and Biochemistry
Sir Salimullah Medical College
Ex Student of Dhaka Medical College (K-12 Batch)
29 Dr. Faridul Alam Reza Shokrana 27/04/2021

Ex. Joint Managing Director
Chattogram Managing Director
Life Member, BMA
Ex Student of Chattogram Medical College (8th Batch)
30 Dr. Md. Abdul Ohab Tarafdar 27/04/2021

Chest Specialist and Chairman,
Akota Hospital and Diagnostic Center pvt Ltd. Jashore
Ex Student of Sylhet MAG Osmani Medical College (10th Batch)
May Allah bless the departed souls.

Our heartiest commiseration to the deceased’s family, our prayers are with them during this difficult moment of their
life.
52
GPO registration number, Dhaka-1725 Vol. 50 No. 2 May 2021
Call for paper

To reach the doctors throughout the country and ensure their participation as author,
contents and presentation of the Bangladesh Medical Journal have been updated &
changed to some extent. In addition to original articles, review articles and case reports;
we are going to publish following sections regularly.
Letters to the editor

With a view to increase the bondage with the readers, we encourage to write letters to the
editor. Letters may include original research presented in a research letter format or case
reports or series. Alternatively, readers may express their ideas, opinions on important
national or international issues related to doctors, medical science or medical profession.
On being a doctor
Doctors are encouraged and advised to share their sweet, bitter, sad, memorable &
illuminating experiences as a professional doctor in the hospital and private chamber.
Medical news
Important recent updated inventions and ideas that may change the knowledge, attitude
& practice of a doctor and courses of the medical sciences, both at home and abroad; may
be written to us for publication in Bangladesh Medical Journal.
Medical jokes/poems
Meaningful jokes or poem writing related to medical profession and submitting to us by
soft copies are encouraged. There is no deadline of submission.
Please send your writings to the e-mail address of Bangladesh Medical Association Journal
E-mail: journal@bma.org.bd
Published by: Dr. Md. Ehteshamul Huq Choudhury on behalf of the Bangladesh Medical Association, BMA Bhaban,
15/2, Topkhana Road, Dhaka-1000, Bangladesh. Phone: +88-02-9568714, Fax: +88-02-9562527, +88-02-6566060,
e-mail:E-mail: journal@bma.org.bd, website: www.bma.org.bd Subscription: Local-Tk. 15 for single and Tk. 60
for annual. Overseas-$5 for single and $20 for annual.
Printed by: Asian Colour Printing, 130, D.I.T. Extension Road, Fakirerpool, Dhaka-1000, Bangladesh.
Tel: 49357726, 58313186, E-mail: asianclr@gmail.com. web: www.acp1980.com

BMA May 2021

Uploaded by

Copyright:

Available Formats

BMA May 2021

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

BMA May 2021

Uploaded by

Copyright:

Available Formats

Official Organ of Bangladesh Medical Association

Co-morbidities and family history among methamphetamine users 15

Patterns of post-endoscopic retrograde cholangiopancreatography (ERCP) complications 35

BMA Executive Committee for The Year 2017-2018

Information for Authors

Hypertension, insulin, and proinsulin in participants with Tables :

Effect of Extra-corporeal Shock-wave Therapy in the Management of Chronic Plantar Fasciitis

ABSTRACT treatment of plantar fasciitis and its therapeutic outcomes.60

Demographic variable: Background characteristics

(2) Modified Roles and Maudsley score Age

Table II : Educational status of participants of both groups

Table IV (a) MRM score of both groups

Table IV (b) MRM score of both groups

Group Mean ±SD P value

100-PSS(pain score); 0 week Group A 19.93 7.032 NS

Group B 20.20 6.183

100-PSS(pain score); 2nd week Group A 20.20 6.531 NS

Group B 20.67 6.774

100-PSS(pain score); 4th week Group A 27.27 6.782 NS

Group B 24.67 6.332

100-PSS(pain score); 8th week Group A 36.87 8.312 <0.05

Group B 33.40 8.013

Group Mean ±SD P value

100-PSS(function score); 0 week Group A 13.60 0.894 NS

Group B 13.80 1.064

100-PSS(function score); 2nd week Group A 14.00 1.390 NS

Group B 14.33 1.322

100-PSS(function score); 4th week Group A 18.87 2.726 NS

Group B 16.93 1.982

100-PSS(function score); 8th week Group A 21.47 2.968 <0.05

Group B 19.13 2.968

Abstract the children having early signs of autism, history of normal

Table I: Early signs of autism as screened by using ESAT tool (n=1000)

Table II: Gestational factors at a glance (n=26)

Variables Frequency Percentage Variables Frequency Percentage

Table-IV shows that, parameters of growth were higher in

Co-Morbidities and Family History Among Methamphetamine Users

Abstract most (94.8%) respondents, followed by cannabinoids (56.5%)

seizure of substances by law enforcement agencies in RESULTS

Physical co-morbidities Frequency Percentage

Table IV: Investigation findings of the patients in two groups

HbsAg-Anti-HBc 15 (13.0) 17 (14.7) 0.849ns ns= not significant

Table VII: Distribution of cases according to grade of DISCUSSION

Abstract erythematous plaques with thick silvery scale. Typical nail

There is no comprehensive study of trace elements

Table I: Demographic profile of study group (n=80)

Variables Case (n=40) Control (n=40) p- value

Reference Range 100.0% 92.5%

Variable Serum Zinc (µg/dL) Serum Copper (µg/dL) p- value

DISCUSSION infections which can lead to abnormal skin changes and

CONCLUSIONS 11. Sheikh G, Masood Q, Majeed S, Hassan I.

Abstract adhesive capsulitis of the shoulder among diabetic individuals

have varied widely in the literature depending on intended 54, 27%

MATERIALS AND METHOD Present Absent

Parameters Number Percentage

Patterns of Post-endoscopic Retrograde Cholangiopancreatography (ERCP) Complications

Abstract followed by proximal cholangiocarcinoma (13.7%),

Anticoagulant and antiplatelet medications were all Number of Percentage

Table II: Distribution of study subjects according to DISCUSSION