Bangladesh Medical Research Council Bulletin (Vol. 52, No. 01, 2026)

The practice of Clinical Medicine is a dynamically evolving paradigm. In its earliest era, medicine was intuitive – doctors relied on “experience” and heuristic assessment of signs and symptoms rather than scientific evidence.¹ Since the late 20^th century, this has rightly been replaced by evidence-based medicine (EBM), with clinical trials and meta-analyses considered the height of empirical evidence. EBM has undoubtedly transformed population-level patient outcomes by fostering “best medical practices” supported by systematic medical research. Nonetheless, this system has an inherent limitation evidence-based guidelines are formulated from mean results from a relatively homogeneous trial population, with the deliberate exclusion of heterogeneous characteristics.² Consequently, at the individual level in real-world settings, this often leads to heterogeneous outcomes such as poor responses or adverse events. This is due to inter-individual variation in genetics, lifestyle, environmental exposures, comorbidities or drug interactions.³ It has become increasingly evident that treatment should be personalized, i.e.,it should target the patient with the disease, rather than the disease in the patient.

Abstract

Background:Axial spondyloarthritis (axSpA) is often resistant to first-line non-steroidal anti-inflammatory drugs (NSAIDs), necessitating the use of advanced therapies. Janus kinase (JAK) inhibitors have become highly effective oral alternatives to biological agents. In resource-limited settings like Bangladesh, the availability of lower-cost tofacitinib provides a crucial therapeutic option, reducing financial and accessibility barriers associated with biologics. Effective patient management in these contexts requires tailored dosing strategies to carefully balance efficacy, safety, and affordability.

Objective:To assess the therapeutic efficacy and safety of tofacitinib in patients with NSAID-refractory axSpA, with a particular focus on the outcomes of a dose-escalation strategy for patients showing an inadequate response to standard dosing.

Methods:This prospective clinical trial (NCT03738956) enrolled 52 patients with NSAID-refractory axSpA. All participants initially received tofacitinib 5 mg twice daily (Phase A, months 0–3). At the end of month 3, treatment response was evaluated: patients achieving a clinically important improvement in ASDAS-CRP (“ASDAS-CRP e” 1.1) were maintained on 5 mg twice daily for the remainder of the study (Phase B, months 3–6). For those who failed to achieve this threshold, the tofacitinib dose was escalated to 10 mg twice daily. The primary efficacy endpoint was the ASAS20 response rate. Secondary assessments, conducted at baseline, 1, 3, and 6 months, included ASAS40/70, BASDAI, BASFI, ASDAS, MASES, CRP, ESR, spinal pain, and fatigue. Adverse events (AEs) and serious adverse events (SAEs) were actively monitored. Statistical significance was determined using two-sided tests, with p< 0.05 considered significant.

Results: In this study, 52 patients (mean age 32.9 years, 78.8% male) were included. Tofacitinib demonstrated rapid and sustained efficacy; by month 3, overall ASAS20, ASAS40, and ASAS70 response rates were 73.1%, 65.4%, and 30.8%, respectively. Patients maintained on 5 mg twice daily (n=42) showed continued significant improvement at month 6 (ASAS20: 95.2%; ASAS40: 88.1%; ASAS70: 50.0%; all p<0.05). Ten patients (19.2%) with inadequate response at month 3 underwent dose escalation to 10 mg twice daily, achieving modest subsequent improvements by month 6 (ASAS20: 30%; ASAS40: 30%; ASAS70: 20%). All composite disease measures (including BASDAI, BASFI, and ASDAS-CRP) improved significantly from baseline (p<0.05). Adverse events occurred in 63.5% of patients, with serious adverse events, including herpes zoster and tuberculosis, reported in 13.5%.

Conclusion: Standard dosing of tofacitinib showed rapid response, high efficacy, and sustained disease control in NSAID-refractory axial spondyloarthritis. Those with a poor response to the standard dose may benefit from dose escalation, but caution is required as serious adverse events are relatively common. Clinicians should prioritise vigilant safety monitoring and carefully weigh the risks and benefits before increasing the dose in non-responders.

Keywords:Axial Spondyloarthritis (axSpA); tofacitinib; ASAS20; ASAS40; ASAS70; JAK inhibitor

Abstract

Background:Acinetobacter species, particularly Acinetobacter baumannii, are among the most prevalent Gram negative pathogens responsible for hospital-acquired infections worldwide. These infections are widespread in Intensive Care Units (ICUs) and burn wards. Due to the organism’s ability to survive on surfaces for extended periods; its eradication from healthcare environments remains a significant challenge. In recent years, the alarming rise in antibiotic resistance among A. baumannii strains has become a major global health concern.

Objective: To explore the burden and antimicrobial resistance patterns of Multidrug-resistant (MDR) Acinetobacter baumannii isolates among burn patients admitted to a tertiary care burn hospital in Dhaka city.

Methods:This cross-sectional study was carried out on 200 samples over six months in the Department of Microbiology at the National Institute of Burn and Plastic Surgery, Dhaka, Bangladesh. Wound swab specimens were obtained from burn patients from the Intensive Care Unit (ICU) and High Dependency Unit (HDU) and general burn wards. Acinetobacter baumannii isolates were identified by conventional culture and biochemical methods. Antimicrobial susceptibility was done using the conventional disc diffusion method as well as the VITEK® 2 automated system due to the high burden of MDR organisms. Antimicrobial susceptibility testing was conducted in accordance with the Clinical and Laboratory Standards Institute (CLSI) guidelines-2025. Tigecycline was used, as most of the isolates were MDR pathogens. Based on predefined criteria, the isolates were categorized as MDR organisms.

Results:A total of 200 Acinetobacter spp. isolates were analyzed. The majority of patients were aged under 20 and the mean age was 23.3 ± 21.1 years, with a male-to-female ratio of 1.1:1. Overall, 98.5% of the isolates were classified as MDR, whereas only 1.5% were non-MDR. Resistance to cephalosporins and fluoroquinolones was markedly high. Carbapenem resistance to meropenem and imipenem was also high. Similarly, high resistance rates were observed for aminoglycosides, including gentamicin and amikacin. Relatively better susceptibility was noted for minocycline, tigecycline, colistin, and cefoperazone-sulbactam. The majority of susceptible isolates were MDR. Universal resistance to co-trimoxazole was observed. Overall, the findings demonstrate a high burden of multidrug resistance among Acinetobacter spp., with limited therapeutic options remaining effective.

Conclusion: The study reveals a high burden of MDR Acinetobacter spp. in burn patients, with limited sensitivity to most antibiotics. The findings highlight the urgent need for antimicrobial stewardship and strict infection control in burn units.

Keywords: Antimicrobial resistance, Acinetobacter baumannii, burn patient, multidrug-resistant bacteria.

Abstract

Background:Hyperlipidemia, a major modifiable risk factor for atherosclerosis and cardiovascular diseases, arises from abnormal lipid levels in the blood. Modern dietary habits, high saturated fats and refined sugars, contribute significantly to secondary hyperlipidemia. Evidence suggests that not only total cholesterol but also its distribution among lipoproteins influences disease risk. Aloe vera has been explored for its potential lipid lowering properties.

Objective: To evaluate the effects of aqueous extract of Aloe vera gel on serum lipid profile in high fatty diet induced hyperlipidemic rats.

Methods:This experimental animal study was conducted at the Department of Pharmacology and Therapeutics, Sir Salimullah Medical College (SSMC), Dhaka in collaboration with the Institute of Nutrition and Food Science (INFS) Dhaka University, over a 12-month period following ethical approval. Thirty healthy adult male Long Evans rats were randomly divided into five groups (n=6 each). Group A (standard control) received a normal laboratory diet with distilled water and Group B (hyperlipidemic control) received a high-fat diet. Group C received a high-fat diet for the first two weeks followed by aqueous extract of Aloe vera gel (300 mg/kg body weight, orally) along with a high-fat diet for the another four weeks. Group D received a high-fat diet for two weeks followed by atorvastatin (10 mg/kg body weight, orally) with a high-fat diet for four weeks. Group E received a high-fat diet for two weeks followed by a combination of atorvastatin (10 mg/kg body weight) and Aloe vera gel extract (200 mg/kg body weight) along with a high-fat diet for the another four weeks. After 42 days of intervension, all rats were anesthetized with chloroform on the morning of the 43rd day and following overnight fasting, blood samples were collected by cardiac puncture for estimation of the serum lipid profile. Data were analyzed using one-way ANOVA followed by Bonferroni test using SPSS version 26, with p<0.05 considered stastitically significant.

Results: Rats in the high-fat diet group developed significant hyperlipidemia compared to normal control (p<0.001), with elevated serum TC, TG, and LDL-C levels and reduced HDL-C levels. Intervention with Aloe vera gel extract significantly improved the lipid profile (p<0.001), showing marked reductions in TC, TG, and LDL-C and an increase in HDL-C. Atorvastatin produced a similar degree of improvement (p<0.001). The combination of Aloe vera gel extract with Atorvastatin showed the greatest lipid lowering effect, although the difference compared to individual intervension was not statistically significant.

Conclusion: Aloe vera gel extract significantly improved the lipid profile in high-fat-diet–induced hyperlipidemic rats. Its effects were comparable to atorvastatin for most parameters, except HDL. Combination therapy showed greater improvement than Aloe vera alone and produced effects comparable to atorvastatin, suggesting that Aloe vera may serve as a potential adjunct therapy for hyperlipidemia.

Keywords:Aloe vera gel, Aqueous extract, Hyperlipidemic rats, High-fat diet, Atorvastatin

Abstract

Background:Bisphenol A (BPA) is a ubiquitous environmental endocrine-disrupting chemical (EDC) widely found in plastics and food packaging. Growing epidemiological and experimental evidence suggests BPA exposure may contribute to metabolic dysfunction, particularly diabetes mellitus.

Objective: To investigate the correlation between serum Bisphenol A (BPA) concentrations levels and diabetic risk.

Methods:A case-control study was conducted involving 240 participants (120 individuals with type 2 diabetes mellitus (T2DM) and 120 age- and sex-matched controls). Serum BPA levels were measured using high performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS). Glycemic parameters, including fasting blood glucose, HbA1c, fasting insulin, and HOMA-IR, were assessed. Spearman correlation test was done to see the correlation. Multiple logistic regression analysis was performed after adjusting for potential confounders. Statistical significance threshold was p<0.05.

Results: Median serum BPA levels were significantly higher in diabetic participants compared to controls (3.82 g/L vs 1.64 g/L, p<0.001). After adjusting for confounders, participants in the highest BPA quartile demonstrated probable 3.74-fold increased odds of diabetes (OR 3.74, 95% CI: 1.89-7.42) compared to the lowest quartile. Serum BPA concentrations showed positive correlations with fasting glucose (r=0.48, p<0.001), HbA1c (r=0.51, p<0.001), and HOMA-IR (r=0.44, p<0.001). Dose-response relationships were observed between BPA exposure and markers of insulin resistance.

Conclusion: Elevated serum BPA levels are significantly associated with T2DM and impaired glycemic control. These findings support BPA’s potential diabetogenic effects and highlight the need for public health interventions to reduce environmental BPA exposure. Further prospective studies are warranted to establish causality and elucidate underlying mechanisms.

Keywords: Bisphenol A; Diabetes Mellitus; Endocrine Disruptors; Insulin Resistance; Environmental Exposure

Abstract

Background:Methotrexate (MTX) is the corner stone in management of rheumatoid arthritis (RA), but its limited use as oral formulation is frequently due to gastrointestinal intolerance, variable absorption and bioavailability. Subcutaneous (SC) MTX may offer better efficacy and tolerability..

Objective: To compare the efficacy and safety of subcutaneous (SC) injection versus oral methotrexate (MTX) in patients suffering from active rheumatoid arthritis (RA).

Methods:This open labeled randomized clinical trial was conducted on 90 patients at the department of rheumatology in Bangladesh medical university (BMU) during the period from January 2013 to October 2014. In phase 1, MTX was given 10 mg orally, weekly and the dose of MTX was increased to 15 mg/week after four weeks. All patients were followed up for 8 weeks from enrollment. Six patients were excluded from 2nd page of the study due to loss of follow up and adverse event In phase 2, patients were randomized in two groups. One group received 20 mg MTX subcutaneously weekly (n=40) and the other group received the same dose of MTX orally (n=44). After another 8 weeks the dose of MTX was increased to 25 mg/week. Final follow up was given at 16 weeks after randomization. ACR20, ACR50 and ACR70 response criteria was used to see the efficacy of MTX. Safety and adverse events were also recorded.

Results: At the end of phase 1, ACR 20 response was observed in 20% patients and a significant improvement was noticed across multiple disease activity parameters (p < 0.05) after 8 weeks. After phase 2 follow up(16 weeks), ACR 20 & ACR 50 response were 100% & 45% , respectively in subcutaneous group and 95.5% and 29.5%, respectively, in oral group, difference was statistically significant (P value of <0.01 & <0.05). None of the patient achieved ACR70 response. The measures of disease activity (except swollen joint count) like tender joint counts, pain VAS, patient and physician global scores, HAQ, ESR, and DAS28 were significantly improved in the SC group (p < 0.05). Gastrointestinal upset were more in oral group like nausea occurred in 65% (SC) vs. 87% (oral), anorexia in 45% vs. 73%, and dizziness in 43% vs. 82% (p < 0.01). One patient discontinued oral MTX due to intolerance.

Conclusion: Subcutaneous route was safe and effective than oral methotrexate. Subcutaneous MTX may be a preferable option in patients with inadequate response or intolerance to oral MTX in patient with active RA

Keywords: Efficacy & safety of methotrexate, oral methotrexate, subcutaneous methotrexate, rheumatoid arthritis

Abstract

Background:Ovarian cancer is often diagnosed at an advanced stage, resulting in poor prognosis despite modern management strategies. Estrogen receptor (ER) and progesterone receptor (PR) expression in epithelial ovarian cancer (EOC) may serve as prognostic biomarkers and guide potential hormonal therapy.

Objective: To determine the prevalence of ER and PR expression in epithelial ovarian cancer (EOC) and to assess their association with clinical and histopathological characteristics.

Methods:A cross-sectional observational study was conducted at the National Institute of Cancer Research & Hospital (NICRH), Dhaka, from July 2020 to June 2021. Forty women with histologically confirmed primary EOC were enrolled. Demographic, reproductive, and clinical data were collected. Histological grading and subtyping were performed, and ER/PR expression was assessed using immunohistochemistry. Associations of hormone receptor status with clinical and histopathological features were analyzed using Chi-squared and t-tests, with p < 0.05 considered significant.

Results: Among the study population, 30% of tumors were ER positive and 22.5% PR positive. Histologically, 65% were serous, 30% mucinous, and 5% clear cell carcinomas, with 80% being Grade-III. ER overexpression was significantly associated with high-grade tumors (Grade-III, p = 0.038) and marginally associated with advanced stage (Stage III, p = 0.051). PR positivity was significantly associated with serous histology (p = 0.044) and higher clinical stage (Stage III, 55.6%). No significant associations were observed between ER status and reproductive characteristics, whereas PR-positive patients were significantly older than PR-negative counterparts (p = 0.039).

Conclusion: ER overexpression in EOC is significantly associated with higher histological grade, while PR overexpression is associated with serous subtype and advanced FIGO stage. These findings suggest potential prognostic and therapeutic implications of hormone receptor status in EOC. Further studies with larger cohorts are recommended to confirm their role in guiding endocrine therapy.

Keywords: Epithelial ovarian cancer, estrogen receptor, progesterone receptor, immunohistochemistry, prognostic biomarker

Abstract

Background:Urinary tract infection caused by Enterococcus species is of great concern both in community and hospital settings due to their increasing resistance to multiple antimicrobial agents. Nitrofurantoin (NIT) is an important therapeutic option for urinary tract infection caused by Enterococcus species, whose mechanism of resistance remains to be explored.

Objective: To evaluate status of nitrofurantoin resistance in Enterococcus species by detection of efflux pump genes (emeA, efrA, efrB) and nitroreductase genes (ef0404, ef0648) and assessing the effect of efflux pump inhibitors (verapamil and chlorpromazine) on reducing the minimum inhibitory concentrations (MICs) of nitrofurantoin in resistant isolates.

Methods:Laboratory isolated Enterococcus species were identified from culture of urine specimen in Department of Microbiology and Immunology, Bangladesh Medical University (BMU). These isolates were subjected to nitrofurantoin susceptibility tests by both broth microdilution technique and automated method (VITEK®2 Compact). Enterococcal efflux pump genes (emeA, efrA and efrB) and nitroreductase genes (ef0404, ef0648)were detected by conventional PCR. Finally, the MICs of nitrofurantoin with and without efflux pump inhibitors (verapamil and chlorpromazine) were determined in resistant isolates by broth microdilution method.

Results: Among the 53 Enterococcus species isolated from urine, majority were E. faecalis (81.1%). Nitrofurantoin resistant isolates were 13.2% and mostly exhibited by the rarer species. At least one of the nitroreductase genes was present in all of the nitrofurantoin-susceptible enterococci isolates (ef0404, 80.4% and ef0648, 91.3%). Additionally, emeA and efrAB genes were present in 65.2% and 34.8% of the nitrofurantoin-susceptible isolates, respectively. The isolates resistant to nitrofurantoin did not contain any nitroreductase genes. Efflux pump genes were present in less than half (40%) of the resistant isolates. Effective reduction of MIC of nitrofurantoin among nitrofurantoin resistant enterococci isolates were observed in the combination of nitrofurantoin and chlorpromazine in comparison to nitrofurantoin and verapamil combination.

Conclusion: Deletion in the nitroreductases-encoding genes was the main reason for nitrofurantoin resistance in Enterococcus species rather than presence of efflux gene. The reduction of MIC of nitrofurantoin by chlorpromazine a efflux pump inhibitor advocate adjuvant role of it to overcome nitrofurantoin resistance.

Keywords: Enterococcus, efflux pump genes, nitroreductases genes, efflux pump inhibitor, nitrofurantoin, chlorpromazine.

Abstract

The aging population is a worldwide issue. The global population is aging. Due to the swiftly aging populace, geriatric medicine is an essential and growing sector with significant potential in Bangladesh. The main perspectives emphasize major shortcomings of the existing healthcare system, along with increasing acknowledgment and legislative efforts to address the specific needs of older adults. Geriatricians can significantly influence the shift in elder care towards a unified, individual-centered approach that emphasizes age-friendly services, preventive strategies, and functional abilities. A reliable, competency-based definition of a geriatrician needs to be established to effectively evaluate the existing workforce with the essential geriatric expertise to facilitate the paradigm shift. Geriatric medicine in Bangladesh is an essential and swiftly expanding area with significant possibilities because of the nation’s aging demographic. The main perspectives underscore major difficulties in the existing healthcare system, along with increased focus and government initiatives to address the specific requirements of the elderly. Geriatricians can significantly contribute to redirecting the care of older individuals toward a cohesive and person-focused approach that emphasizes functional ability, preventive measures, and services tailored to their age. The present circumstances require initiatives to establish a coherent competency-focused outline of a geriatrician to effectively evaluate the current workforce, where adequate geriatric training acts as essential resources to support the transformation. This review aims to address challenges in implementing geriatric care in Bangladesh.

Keywords: Geriatric medicine, Geriatrics, Geriatric issues, Geriatric challenges

Abstract

Background:Solitary subungual neurofibroma is an exceptionally rare benign tumor of the nerve sheath that most commonly presents as a slow-growing, painless subungual nodule. Owing to its uncommon location and nonspecific presentation, it is frequently misdiagnosed as a fungal or inflammatory nail disorder. Fifteen cases have been reported worldwide, highlighting the importance of awareness and accurate diagnosis

Case presentation: The patient, a 47-year-old Bangladeshi male, presented with a three-year history of a painless, progressively enlarging nodule beneath the nail of his right great toe. Clinical evaluation revealed nail deformity (onychodystrophy), lifting of the nail plate, and a firm mass beneath the nail, with no evidence of neurofibromatosis or any underlying systemic illness. Imaging and ultrasonography revealed a hypoechoic mass, and surgical excision under local anesthesia was performed. Histopathological analysis revealed a benign, unencapsulated spindle cell neoplasm with a shredded carrot collagenous appearance containing mast cells. Postoperative recovery was uneventful, with no recurrence after one year.

Conclusion: This case highlights the diagnostic challenges posed by solitary subungual neurofibromas because of their rarity and nonspecific presentation. Early recognition, histopathological confirmation, and complete surgical excision are key to favorable outcomes. Clinicians should keep neurofibroma in mind as a possible diagnosis for nail bed tumors, particularly when imaging results are unclear.

Keywords: Solitary subungual neurofibroma, nail neoplasm, hypoechoic mass, rare case, Bangladesh