Pacemaker patients\u27 perception of unsafe activities: a survey

Background: Cardiac pacing is a recognized and widely used treatment for Patients presenting with bradycardia. Physicians expect Patients to return to normal activities almost immediately post implantation. However, Patients themselves may perceive interference to pacemaker function by various routine activities and devices, and hence continue to lead restricted, disabled lives. The aim of this study is to determine if routine activities are perceived by pacemaker Patients to interfere with their device function. Methods: A descriptive cross sectional survey was carried out on consecutive Patients at the pacemaker clinic at a public hospital in Karachi, Pakistan. A 47-question tool was developed and tested. Patients\u27 perceptions of safety of performing various routine activities, along with sociodemographic data were recorded. Results: The final sample included 93 adult Patients (45% males). 41% were illiterate. 77.4% recalled receiving counselling at implantation, predominantly from the implanting physician and house staff. A considerable proportion of Patients considered many routine activities unsafe including driving automobiles (28%), passing through metal detectors (31%), bending over (37%), and sleeping on the side of the pacemaker (30%). Also considered unsafe were operation of household appliances-TV/VCR (television/video cassette recorders) (53%), irons (55%)) and electrical wall switches (56%). For nearly all variables neither literacy nor history of counselling improved incorrect perceptions. Conclusion: This study shows that our pacemaker Patients perceive many routine activities as unsafe, potentially leading to disabling life style modifications. The tremendous investment in pacemaker technology to improve Patient performance is not going to pay dividends if Patients continue to remain disabled due to incorrect perceptions. Further studies are required to determine the reasons for these misperceptions, and to determine if these problems also exist in, and hinder, other Patient populations

Cardiac electrophysiology studies and ablations for treatment of supraventricular arrhythmias--an initial experience from Karachi

OBJECTIVES: To review the clinical experience, complications and outcome of Cardiac Electrophysiology Studies and Catheter Radiofrequency Ablation in treatment of supraventricular tachycardias in Karachi. METHODS: A retrospective review of records of all patients who underwent an electrophysiological study and radiofrequency ablation at National Institute of Cardiovascular Diseases and Aga Khan University Hospital from 2005 to 2007 was performed. Patient\u27s demographics, disease and procedural data were collected and analyzed using SPSS.V.II. RESULTS: We enrolled 168 patients, 150 (89%) from National Institute of Cardiovascular Diseases and 18 (11%) from Aga Khan University Hospital. Sample had 86 (51%) male participants. The mean age was 43 +/- 15 years. Indications for procedure were recurrent supraventricular tachycardias (89.9%), Wolff Parkinson White Syndrome with atrial fibrillation (5.9%), syncope (2.4%), and wide QRS tachycardia (1.8%). Final diagnosis was Wolff Parkinson White Syndrome in 80 (48%) and Atriovetricular Nodal Reentrant Tachycardia in 88 (52%). The accessory pathway in Wolff Parkinson White Syndrome was located on left side in 61% of cases and on right side in 39% of cases. Overall acute success rate for Radio Frequency ablation was 90%. Success rate for ablation of accessory pathway in Wolff Parkinson White Syndrome was 85% while that for ablation of slow pathway in AV node re-entrant tachycardia was 95%. Complications occurred in one case. CONCLUSION: Electro Physiology Studies and Radiofrequency ablation proved to be a safe and effective method for diagnosis and treatment of supraventricular tachycardias in our patients

Predicting postoperative cardio-pulmonary complications by a test of stair climbing

OBJECTIVE: To assess whether a test of stair climbing ability could be used to predict the risk of developing postoperative cardiopulmonary complications in patients undergoing general anesthesia. DESIGN: Cohort study. PLACE AND DURATION OF STUDY: The Aga Khan University Hospital, Karachi. The duration of the study was from December 2003 to December 2004. PATIENTS AND METHODS: This study was carried out on consecutive, adult patients presenting for elective thoracic or abdominal surgery under general anesthesia. Pre-operatively, patients were asked to climb a standard staircase. Number of steps climbed was recorded. Those unable to climb stairs due to debilitating cardiac, pulmonary or rheumatologic disease were categorized as 0 stairs climbed. Outcome variables were postoperative cardiopulmonary complications or mortality. Period of follow-up was until hospital discharge. RESULTS: Seventy-eight patients were enrolled, 59 (75.6%) climbed 1 flight of stairs, 19 (24.3%) climbed \u3c 1 flight. All-cause cardiopulmonary complications rate was 26 %. The most frequent complication was lobar atelectasis, followed by bronchospasm and acute MI. The complication rate was 22.8% in those able to climb 1 flight and 40% in those patients who climbed \u3c 1 flight. The group that climbed \u3c 1 flight tended to have complications associated with poor reserves of the cardiopulmonary systems, i.e. pulmonary edema, exacerbation of underlying lung disease. The relative risk of developing complications, if unable to climb at least 1 flight of stairs, was calculated to be 1.8 (95% CI 0.7 - 4.6). CONCLUSION: Stair climbing can be a useful pre-operative tool to predict the risk of postoperative cardiopulmonary complication

Factors associated with the discontinuation of modern methods of contraception in the low income areas of Sukh Initiative Karachi: A community-based case control study

Introduction: Discontinuation of a contraceptive method soon after its initiation is becoming a public health problem in Low middle income countries and may result in unintended pregnancy and related unwanted consequences. A better understanding of factors behind discontinuation of a modern method would help in designing interventions to continue its use till desired spacing goals are achieved. |Objective: To determine factors associated with the discontinuation of modern contraceptive methods within six months of its use compared to continued use of modern method for at least six months in low-income areas of Karachi, Pakistan. Method: Community-based case-control study was conducted in low-income areas of Karachi. Cases were 137 users who discontinued a modern contraceptive method within 6 months of initiation and were not using any method at the time of interview, while controls were 276 continuous users of modern method for at least last six months from the time of interview. Information was collected by using a structured questionnaire. Applied logistic regression was used to identify the associated factors for discontinuation. Result: The mean ages of discontinued and continued users were 29.3±5.3 years and 29.2±5.4 years respectively. A larger proportion of the discontinued users had no formal education (43.8%) as compared to the continued users (27.9%). The factors associated with discontinuation of a modern method of contraception were belonging to Sindhi ethnicity [OR: 2.54, 95%CI 1.16-5.57], experiencing side effects [OR: 15.12; 95% CI 7.50-30.51], difficulty in accessing contraceptives by themselves [OR: 0.40, 95%CI 0.19-0.83] and difficulty in reaching clinics for management of the side effects [OR: 4.10, 95%CI 2.38-7.05]. Moreover, women having support from the husband for contraceptive use were less likely to discontinue the method [OR: 0.58, 95% CI 0.34-0.98]. Conclusion: Sindhi ethnicity and side effects of modern methods of contraception were identified as major factors for discontinuation in low-income populations. Similarly, women who had difficulty in travelling to reach clinics for treatment also contributed to discontinuation. Furthermore, women using long acting methods and those supported by their husbands were less likely to discontinue the contraceptive methods. Findings emphasize a need to focus on Sindhi ethnicity and trainings of service providers on management of side effects and provision of high quality of services

Quality of life after stroke in Pakistan

Background: There is very little information about the quality of life (QOL) of stroke survivors in LMIC countries with underdeveloped non communicable health infrastructures, who bear two thirds of the global stroke burden. Methodology: We used a sequential mix methods approach. First, a quantitative analytical cross-sectional study was conducted on 700 participants, who constituted 350 stroke survivor and their caregiver dyads. QOL of stroke survivor was assessed via Stroke Specific Quality of Life Scale (SSQOLS) whereas QOL of caregivers was assessed through RAND-36. In addition; we assessed complications, psychosocial and functional disability of stroke survivors. Following this quantitative survey, caregivers were qualitatively interviewed to uncover contextually relevant themes that would evade quantitative surveys. Multiple linear regression technique was applied to report adjusted β-coefficients with 95% C.I. Results: The QOL study was conducted from January 2014 till June 2014, in two large private and public centers. At each center, 175 dyads were interviewed to ensure representativeness. Median age of stroke survivors was 59(17) years, 68% were male, 60% reported depression and 70% suffered post-stroke complications. The mean SSQOLS score was 164.18 ± 32.30. In the final model severe functional disability [adjβ -33.77(-52.44, -15.22)], depression [adjβ- 23.74(-30.61,-16.82)], hospital admissions [adjβ-5.51(-9.23,-1.92)] and severe neurologic pain [adjβ -12.41(-20.10,-4.77)] negatively impacted QOL of stroke survivors (P \u3c 0.01). For caregivers, mean age was 39.18 ± 13.44 years, 51% were female and 34% reported high stress levels. Complementary qualitative study revealed that primary caregivers were depressed, frustrated, isolated and also disappointed by health services. Conclusion: The QOL of Stroke survivors as reported by SSQOLS score was better than compared to those reported from other LMIC settings. However, Qualitative triangulation revealed that younger caregivers felt isolated, depressed, overwhelmed and were providing care at great personal cost. There is a need to develop cost effective holistic home support interventions to improve lives of the survivor dyad as a unit

Clinical and echocardiographic characteristics of patients with significant pericardial effusion requiring pericardiocentesis

Objective: Clinical and echocardiographic features of significant pericardial effusion (PE) have been reported from the west. Currently there is lack of published data from this part of the world, we reviewed all consecutive cases of significant PE requiring echocardiographic assisted pericardiocentesis to analyze the clinical and echocardiographic features of these patients.Methods: Forty four consecutive patients who underwent echocardiography assisted pericardiocentesis at the Aga Khan University Hospital (AKUH) between January 1988 and May 2001 re included in this review.Results: Most common presenting symptoms were dyspnea (89%) and fever (36%). Elevated JVP and pulsus paradoxus were documented in 59% and 41% of patients respectively. Sinus tachycardia (75%) and low voltage (34%) were the most common ECG findings. Malignancy (45-51%) and tuberculosis (27%) were among the most frequent causes of PE. One patient died during echocardiography-assisted pericardiocentesis.CONCLUSION: The symptoms and physical findings of haemodynamically significant PE are frequently nonspecific. Transthoracic echocardiography is the gold standard for rapid and confirmatory diagnosis of PE and cardiac tamponade. The most common cause of PE was malignancy followed by tuberculosis. Pericardiocentesis under echocardiographic guidance is a safe and effective treatment for significant PE

High HIV incidence among persons who inject drugs in Pakistan: greater risk with needle sharing and injecting frequently among the homeless.

BACKGROUND: The incidence of HIV among persons who inject drugs (PWIDU) has fallen in many nations, likely due to successes of clean needle/syringe exchange and substance abuse treatment and service programs. However in Pakistan, prevalence rates for PWID have risen dramatically. In several cities, prevalence exceeded 20% by 2009 compared to a 2003 baseline of just 0.5%. However, no cohort study of PWID has ever been conducted. METHODS: We enrolled a cohort of 636 HIV seronegative PWID registered with three drop-in centers that focus on risk reduction and basic social services in Karachi. Recruitment began in 2009 (March to June) and PWID were followed for two years. We measured incidence rates and risk factors associated with HIV seroconversion. RESULTS: Incidence of HIV was 12.4 per 100 person-years (95% exact Poisson confidence interval [CI]: 10.3-14.9). We followed 474 of 636 HIV seronegative persons (74.5%) for two years, an annual loss to follow-up of \u3c13 per 100 person years. In multivariable Cox regression analysis, HIV seroconversion was associated with non-Muslim religion (Adjusted risk ratio [ARR] = 1.7, 95%CI:1.4, 2.7, p = 0.03), sharing of syringes (AR  = 2.3, 95%CI:1.5, 3.3, p\u3c0.0001), being homeless (ARR = 1.7, 95%CI:1.1, 2.5, p = 0.009), and daily injection of drugs (ARR = 1.1, 95%CI:1.0, 1.3, p = 0.04). CONCLUSIONS: Even though all members of the cohort of PWID were attending risk reduction programs, the HIV incidence rate was very high in Karachi from 2009-2011. The project budget was low, yet we were able to retain three-quarters of the population over two years. Absence of opiate substitution therapy and incomplete needle/syringe exchange coverage undermines success in HIV risk reduction

Increases in Heart Rate Variability Signal Improved Outcomes in Rapid Response Team Consultations: A Cohort Study

Background. Reduced heart rate variability (HRV) indicates dominance of the sympathetic system and a state of “physiologic stress.” We postulated that, in patients with critical illness, increases in HRV might signal successful resuscitation and improved prognosis. Methods. We carried out a prospective observational study of HRV on all patients referred to the rapid response team (RRT) and correlated with serial vital signs, lactate clearance, ICU admission, and mortality. Results. Ninety-one patients were studied. Significantly higher HRV was observed in patients who achieved physiological stability and did not need ICU admission: ASDNN 19 versus 34.5, p=0.032; rMSSD 13.5 versus 25, p=0.046; mean VLF 9.4 versus 17, p=0.021; mean LF 5.8 versus 12.4, p=0.018; and mean HF 4.7 versus 10.5, p=0.017. ROC curves confirmed the change in very low frequencies at 2 hours as a strong predictor for ICU admission with an AUC of 0.772 (95% CI 0.633, 0.911, p=0.001) and a cutoff value of −0.65 associated with a sensitivity of 78.6% and a specificity of 61%. Conclusions. Reduced HRV, specifically VLF, appears closely related to greater severity of critical illness, identifies unsuccessful resuscitation, and can be used to identify consultations that need early ICU admission