Socio-economic status and pregnancy complications and their impact on antenatal care services provided at home and Upazila health complex

The stage of pregnancy is crucial for women of reproductive age and their families. However, in low- and middle-income countries like Bangladesh, antenatal and postnatal care are not widely practiced due to various socio-economic factors, such as low education levels, income, age, pregnancy knowledge, and limited healthcare facilities. The objective of this study was to examine the factors associated with antenatal care in two locations in Bangladesh based on the data collected from the Bangladesh Demographic and Health Survey (BDHS) 2017-2018. We explored different variables as explanatory variables related to ANC service. The results showed that most of the respondents were from rural areas, with 77.02% receiving antenatal care at home. Women with secondary education were more likely to receive care at home than those without education. The Chi-square test indicated a positive correlation between antenatal care at home with several variables, whereas, in the case of Upazila health complexes, only three variables showed a positive association. Logistic regression analysis further showed some specific variables such as geographical division, religion, iron intake during pregnancy, and reporting pregnancy complications had a significant impact on ANC at home. In contrast, covariates such as residence, division, and wealth index were significant for antenatal care at Upazila health complexes. The division was a significant covariate in both cases. Interestingly, we observed that mothers who had been informed about the signs of pregnancy complications were 92% more likely to receive antenatal care at home than those who had not experienced pregnancy complications. Conversely, the results revealed that mothers who were unaware of pregnancy complications were 32% more likely to receive antenatal care at home than those who had been informed about complications. This suggests that when women are educated about pregnancy complications, they are more likely to receive more antenatal care. However, Bangladesh's situation is quite different due to a lack of proper education and knowledge of antenatal care services.

Can We Restart the First-Line Antibiotic as Empirical Choice When Enteric Fever is Suspected?

Enteric fever is a major health problem in Bangladesh. Antibiotic resistance especially against first-line antibiotics is a major concern in the management and thereby not practicing by physician as first choice thinking their resistance. This retrospective study was carried out in the Department of Microbiology, Bangladesh Medical College Hospital, Dhaka, Bangladesh from January of 2017 to December of 2019 to identify the year wise sensitivity pattern of first-line antibiotics like Amoxycillin, Cotrimoxazole and Chloramphenocol against Salmonella typhi and Salmonella paratyphi. All the blood samples sent for culture and sensitivity were evaluated to see the microbiom and their sensitivity pattern. Salmonella typhi and paratyphi were the major isolates in last 3 years which were 73.74% and 15.32% respectably. Sensitivity pattern of Amoxycillin, Cotrimoxazole and Chloramphenocol for Salmonella typhi is increased from 2017 to 2019 which were 66.0 to 83.0%, 80.0 to 83.0% and 84.0 to 85.0% respectively. Similar increasing pattern of sensitivity found in Salmonella paratyphi which was 82.5 to 89.2%, 76.2 to 95.4%, 98.7 to 98.5% respectively. They were also found highly sensitive (>90.0%) to 3rd generation cephalosporin. This study recommends the use of first-line antibiotics as empirical agent of choice in enteric fever as they are still highly sensitive against Salmonella typhi and Salmonella paratyphi.

Prognostic value of systolic mitral annular velocity measured with Doppler tissue imaging in patients with chronic heart failure caused by left ventricular systolic dysfunction

OBJECTIVE

To assess the prognostic value of various conventional and novel echocardiographic indices in patients with chronic heart failure (CHF) caused by left ventricular (LV) systolic dysfunction.

METHODS

185 patients with a mean (SD) age of 67 (11) years with CHF and LV ejection fraction < 45% despite optimal pharmacological treatment were prospectively enrolled. The patients underwent two dimensional echocardiography with tissue harmonic imaging to assess global LV systolic function and obtain volumetric data. Transmitral flow was assessed with conventional pulse wave Doppler. Systolic (Sm), early, and late diastolic mitral annular velocities were measured with the use of colour coded Doppler tissue imaging.

RESULTS

During a median follow up of 32 months (range 24-38 months in survivors), 34 patients died and one underwent heart transplantation. Sm velocity (hazard ratio (HR) 0.648, 95% confidence interval (CI) 0.463 to 0.907, p = 0.011), diastolic arterial pressure (HR 0.965, 95% CI 0.938 to 0.993, p = 0.015), serum creatinine (HR 1.006, 95% CI 1.001 to 1.011, p = 0.023), LV ejection fraction (HR 0.945, 95% CI 0.899 to 0.992, p = 0.024), age (HR 1.035, 95% CI 1.000 to 1.071, p = 0.052), LV end systolic volume index (HR 1.009, 95% CI 0.999 to 1.019, p = 0.067), and restrictive pattern of transmitral flow (HR 0.543, 95% CI 0.278 to 1.061, p = 0.074) predicted the outcome of death or transplantation on univariate analysis. On multivariate analysis, only Sm velocity (HR 0.648, 95% CI 0.460 to 0.912, p = 0.013) and diastolic arterial pressure (HR 0.966, 95% CI 0.938 to 0.994, p = 0.016) emerged as independent predictors of outcome.

CONCLUSIONS

In patients with CHF and LV systolic dysfunction despite optimal pharmacological treatment, the strongest independent echocardiographic predictor of prognosis was Sm velocity measured with quantitative colour coded Doppler tissue imaging.

What is the optimal medical management of ischemic heart failure?

Ischemic heart disease is an important and common contributor to the development of heart failure. Theoretically, all patients with heart failure may benefit from treatment designed to retard progressive ventricular dysfunction and arrhythmias. Patients with ischemic heart disease may also theoretically benefit from the relief of ischemia, the prevention of coronary occlusion, and revascularization. However, there is little evidence to show that the presence or absence of coronary disease modifies the benefits of effective treatments such as angiotensin-converting enzyme inhibitors and beta-blockers. Moreover, there is no evidence that treatment directed specifically at myocardial ischemia or coronary disease alters outcome in patients with heart failure. Treatments aimed at relieving painless myocardial ischemia have not been shown to alter prognosis. Lipid-lowering therapy is theoretically attractive for patients with heart failure and coronary disease; however, theoretical concerns also exist about the safety of such agents, and patients with heart failure have been excluded from large outcome studies very effectively. Some agents, such as aspirin, designed to reduce the risk of coronary occlusion seem ineffective or harmful in patients with heart failure, although warfarin may be safe and possibly effective. There is no evidence yet that revascularization improves prognosis in patients with heart failure, even in patients who are shown to have extensive myocardial hibernation. On current evidence, revascularization should be reserved for the relief of angina. Large-scale, randomized controlled trials are currently underway that are investigating the role of specific treatments targeted at coronary syndromes. The Carvedilol Hibernation Reversible Ischemia Trial: Marker of Success study is investigating the effects of carvedilol in a large cohort of patients with and without hibernating myocardium. The Warfarin and Antiplatelet Therapy in Chronic Heart Failure study is comparing the efficacy of aspirin, clopidogrel, and warfarin. The Heart Revascularization Trial-United Kingdom study is assessing the effect of revascularization on mortality in patients with heart failure and myocardial hibernation. Smaller scale studies are assessing the safety and efficacy of statin therapy in patients with heart failure. Only once the outcomes to these and other planned trials are known can the medical community know how best to treat their patients.

The role of signal averaged P wave duration and serum magnesium as a combined predictor of atrial fibrillation after elective coronary artery bypass surgery

OBJECTIVE

To investigate the role of low serum magnesium as a trigger for atrial fibrillation in patients with a substrate for the arrhythmia (assessed by signal averaged P wave duration).

DESIGN

A case-control study.

SETTING

A regional referral cardiac centre.

PATIENTS AND INTERVENTIONS

105 consecutive patients undergoing elective coronary artery bypass surgery had signal averaged P wave recordings before operation. Serum electrolytes were analysed preoperatively and on days 1, 2, and 5 after surgery.

MAIN OUTCOME MEASURES

Any episode of electrocardiographically recorded atrial fibrillation was taken as a study end point.

RESULTS

Of 102 patients discharged, 27 (26%) had documented episodes of atrial fibrillation at a mean of 2.7 days after surgery. A combination of P wave duration > 155 ms and serum magnesium on the first postoperative day of < 0.7 mmol/l had a sensitivity of 75% and specificity of 80% for predicting atrial fibrillation. Duration of hospital stay (7.9 v 6.8 days) was longer in the atrial fibrillation group (P < 0.01). Stepwise regression showed age, serum magnesium < 0.7 mmol/l on the first postoperative day (both P < 0.001), angiotensin converting enzyme inhibitor withdrawal (P < 0.02), and signal averaged P wave duration (P = 0.04) to be independent predictors.

CONCLUSIONS

The combination of signal averaged P wave duration and low serum magnesium on the first postoperative day identified the majority of patients with atrial fibrillation after coronary artery bypass surgery. Early identification and pharmacological treatment for selected patients may reduce the incidence of postoperative atrial fibrillation.