Effect of L-type calcium channel blocker (amlodipine) on myocardial iron deposition in patients with thalassaemia with moderate-to-severe myocardial iron deposition: protocol for a randomised, controlled trial

Introduction: Sideroblastic cardiomyopathy secondary to repeated blood transfusions is a feared complication in thalassaemia. Control of myocardial iron is thus becoming the cornerstone of thalassaemia management. Recent evidence suggests a role for L-type Ca2+ channels in mediating iron uptake by the heart. Blocking the cellular iron uptake through these channels may add to the benefit of therapy to standard chelation in reducing myocardial iron. We aim to determine the efficacy of amlodipine (a calcium channel blocker) as an adjunct to standard aggressive chelation in retarding myocardial iron deposition in thalassaemics with or without cardiomyopathy.Outcomes: The primary outcome is to compare the efficacy of amlodipine+chelation (intervention) versus standard chelation (control) in retarding myocardial iron deposition. Secondary outcomes include the effect of amlodipine therapy on systolic and diastolic function, strain and strain rate and liver iron content.Methods and analysis: This is a single-centre, parallel-group, prospective randomised control trial. Twenty patients will be randomised in a 1:1 allocation ratio into the intervention and control arms. In addition to conventional echocardiography, MRI T2* values for assessment of cardiac and liver iron load will be obtained at baseline and at 6 and 12 months. Cardiac T2* will be reported as the geometric mean and per cent coefficient of variation, and an increase in cardiac T2* values from baseline will be used as an end point to compare the efficacy of therapy. A p Value of Study setting: Department of Pediatric and Child Health, Aga Khan University Hospital, Karachi, Pakistan.Ethics and dissemination: This study has been approved by the Ethics Review Committee and Clinical Trials Unit at The Aga Khan University with respect to scientific content and compliance with applicable research and human subjects regulations. Findings will be reported through scientific publications and research conferences and project summary papers for participants

Predictors of diarrheal mortality and patterns of caregiver health seeking behavior in in Karachi, Pakistan

Background: Pakistan is unfortunately among the five countries that contributed to the most deaths due to diarrhea and pneumonia in 2010. To explore factors associated with diarrheal deaths we assessed care-seeking behavior and other predictors of diarrhea-related mortality in children in selected low-income peri-urban communities of Karachi, Pakistan.Methods: A mixed methods study (qualitative and quantitative) using matched case-control design and focus group discussions with parents of children with moderate to severe diarrhea (MSD) was undertaken. Cases were children Demographic, clinical, and care-related behavioral predictors of mortality were assessed. Conditional logistic regression was performed, matched adjusted odds ratios (mOR) are reported.Results: Parents of 77 cases and 154 controls were interviewed. Cases were less likely to receive appropriate care compared to controls (mOR=0.2, 95% confidence interval (CI) 0.05-0.91). Refusal for hospital admission (OR=8.9, 95% CI 2.6-30.8), and delays in reaching the health facility (OR=3.6, 95% CI 1.0-12.9) were significant independent predictors of mortality. We found strong beliefs in traditional and spiritual healing in the population; use of both modern and traditional/spiritual treatments concurrently was common.Conclusion: Appropriate care seeking behavior predicts survival in children with diarrhea in Pakistan. There is a complex belief system relating to traditional and standard therapies. Health education for appropriate health care seeking should be implemented in order to achieve a substantial decline in diarrheal disease mortality in Pakistan

A framework for improving parent satisfaction with the inpatient pediatric admission process: Experience from a low-resource setting

The objective for this initiative was to reduce parental anxiety and thus improve their satisfaction related to hospital admission by ensuring that the child’s management plan and basic amenities were communicated to the parents within the first hour of arrival at the Children’s Hospital inpatient unit. The intervention for this project was developed based on the Theory of Change framework. Effectiveness of the intervention was assessed by comparing change in parent-reported anxiety scores and improvement in patient satisfaction scores at 24 hours post-admission as an indicator of experience. The frequency of delivery of each individual message was also tracked and compared at baseline and post-intervention. The results showed a significant reduction in parental anxiety levels within the first 24 hours of admission (3.5 to 3.2, P = .01). The parent satisfaction score was significantly improved from baseline to post-intervention (4.00 vs 4.82 respectively; P \u3c .001). Comparison between the baseline and post-intervention demonstrated a statistically significant (P \u3c .001) increase in frequency of messages delivered. This initiative highlighted that reengineering the current system using existing resources to standardize admission communication along with an adequate monitoring and feedback plan can help reduce parental anxiety, thus improving parent satisfaction with the services

Echocardiography‐ versus intracardiac electrocardiogram‐based optimization of cardiac resynchronization therapy: A systematic review

Abstract Objective This systematic review aimed to evaluate the performance of echocardiography‐based programming in comparison with the intracardiac electrocardiogram (IEGM)‐based method for the optimization of cardiac resynchronization therapy (CRT). Methods A literature review was conducted using digital databases to systematically identify the studies reporting CRT optimization through echocardiography compared with IEGM. Detailed patient‐level study characteristics including the type of study, sample size, therapy, the New York Heart Classification (NYHA) status, lead placement, and other parameters were abstracted. Finally, postprogramming outcomes were extracted for each article. Results In a total of 11 studies, 919 patients were recruited for the final analysis. Overall, 692 (75.29%) were males. The mean duration of the QRS complex in our study population ranged from 145.2 ± 21.8 ms to 183 ± 19.9 ms. There was an equal improvement in the NYHA class between the two methods while the left ventricular ejection fraction (LVEF) demonstrated an improvement by IEGM. Many studies supported IEGM to increase the 6‐minute walk test and left ventricular outflow tract velocity time interval (LVOT VTI) when compared to echocardiography. The mean time for echocardiography‐based optimization was 60.15 min while that of IEGM‐based optimization was 6.65 min. Conclusion IEGM is an alternative method for CRT optimization in improving the NYHA class, LVEF, and LVOT VTI, and is less time‐consuming when compared to the echocardiography‐based methods