Evaluating the effectiveness of text messaging and phone call reminders to minimize no show at pediatric outpatient clinics in Pakistan: protocol for a mixed-methods study

Background: Missing health care appointments without canceling in advance results in a no show, a vacant appointment slot that cannot be offered to others. No show can be reduced by reminding patients about their appointment in advance. In this regard, mobile health (mHealth) strategy is to use text messaging (short message service, SMS), which is available on all cellular phones, including cheap low-end handsets. Nonattendance for appointments in health care results in wasted resources and disturbs the planned work schedules.Objectives: The purpose of this study is to evaluate the efficacy of the current text messaging (SMS) and call-based reminder system and further explore how to improve the attendance at the pediatric outpatient clinics. The primary objectives are to (1) determine the efficacy of the current clinic appointment reminder service at pediatric outpatient clinics at Aga Khan University Hospital, (2) assess the mobile phone access and usage among caregivers visiting pediatrics consultant clinics, and (3) explore the perception and barriers of parents regarding the current clinic appointment reminder service at the pediatric outpatient clinics at Aga Khan University Hospital.Methods: The study uses a mixed-method design that consists of 3 components: (1) retrospective study (component A) which aims to determine the efficacy of text messaging (SMS) and phone call–based reminder service on patient’s clinic attendance during January to June 2017 (N=58,517); (2) quantitative (component B) in which a baseline survey will be conducted to assess the mobile phone access and usage among parents/caregivers of children visiting pediatrics consultant clinics (n=300); and (3) qualitative (component C) includes in-depth interviews and focus group discussion with parents/caregivers of children visiting the pediatric consultancy clinic and with health care providers and administrative staff. Main constructs will be to explore perceptions and barriers related to existing clinic appointment reminder service. Ethics approval has been obtained from the Ethical Review Committee, Aga Khan University, Pakistan (4770-Ped-ERC-17).Results: Results will be disseminated to pediatric quality public health and mHealth communities through scientific meetings and through publications, nationally and internationally.Conclusions: This study will provide insight regarding efficacy of using mHealth-based reminder services for patient’s appointments in low- and middle-income countries setup. The finding of this study will be used to recommend further enhanced mHealth-based solutions to improve patient appointments and decrease no show

Antiphospholipid Syndrome and Stroke

Thromboses of the cerebral arterial and venous systems are a common manifestation of antiphospholipid syndrome (APS) often leading to ischemic and hemorrhagic stroke. APS increases stroke risk via many mechanisms, including hypercoagulability and inflammation. These mechanisms, among others, must be considered by physicians when evaluating and treating such patients to achieve optimal short- and long-term outcomes. In this chapter, we will discuss the epidemiology of APS as it relates to neurological disease focusing on stroke, APS stroke mechanisms, suggested clinical evaluations, acute treatment strategies, and long-term secondary stroke prevention strategies. Current consensus statements and the most recent literature will be summarized

Trends in Thrombolysis and Thrombectomy Use in Patients With Ischemic Stroke and Cancer

Background To determine how intravenous thrombolysis (IV‐tPA) and mechanical thrombectomy (MT) use has changed in patients with acute ischemic stroke (AIS) with cancer (AIS‐C) compared with patients with AIS and noncancer (AIS‐NC) in the United States since publication of pivotal MT trials. Methods All primary AIS‐NC and AIS‐C admissions (weighted N=5 748 357) were identified from the 2007 to 2019 Nationwide Inpatient Sample. Joinpoint and multivariable‐adjusted models with interaction terms were used to compare the rate of change in IV‐tPA and MT use between AIS‐C and AIS‐NC. Results From 2007 to 2019, 4.4% of AIS admissions had active cancer. Overall IV‐tPA use in AIS‐C (6.4%) was lower than that of AIS‐NC (8.5%) (P<0.001) but use differed by cancer subtype (hematologic, 7.2%; metastatic, 4.2%). IV‐tPA use increased over time in all cancers, but analysis of status‐by‐time interaction revealed that the pace of increase was slower in metastatic compared with AIS‐NC admissions (rate ratio, 0.98; P=0.015) per year. In contrast, MT use in AIS‐C (2.2%) was greater than that of AIS‐NC (1.9%), but use was highest in metastatic (2.5%) and lowest in hematologic cancers (1.6%) (P values for all pairwise comparisons <0.001). MT use increased at a faster pace in metastatic AIS‐C (rate ratio, 1.06; P=0.001)/year compared with AIS‐NC. In‐hospital all‐cause mortality in AIS‐NC was 4.2% compared with 8.2% in AIS‐C (P<0.001). Mortality declined over time in all cancer groups, but the pace of decline was faster in solid and metastatic AIS‐C compared with AIS‐NC (P values <0.01). Conclusions Use of IV‐tPA and MT has increased in AIS‐C over the past decade. Contrary to prior studies, the current frequency and pace of increase in MT use is greater in metastatic AIS‐C compared with AIS‐NC. Future studies are needed to determine whether AIS‐C are more predisposed to large‐vessel occlusion

Management of bleeding gastric varices: a single session of histoacryl injection may be sufficient

Objective: Gastric variceal bleeding is one of the most feared complications of portal hypertension and hence merits investigation for its optimal therapy. We aimed to evaluate the efficacy and long-term outcome(s) of patients treated with a single session of histoacryl sclerotherapy for active gastric variceal bleeding.Methods: The medical records of patients who presented with active gastric variceal bleeding between 1998 and 2011 in a tertiary care setting were evaluated retrospectively and the eventual outcome(s) (initial hemostasis, rebleeding, and mortality rate) was assessed at least 1 year after the index bleed.Results: Ninety-seven patients were included. The mean age of the patients was 51.0 ± 12.5 years; 62% were men. Hepatitis C was the most common etiology, found in 63 (65%) patients. The majority of the patients were classified as Child-Pugh grade B and C: 44 (46%) and 29 (31%) patients, respectively. A total of 40 (41%) patients were IGV1, 35 (36%) patients were GOV 2, 20 (21%) patients were GOV 1, and 2 (2%) patients were IGV2. A single session of histoacryl was successful in controlling bleeding in 83 (86%) patients. Seven (7%) patients died during the hospital stay. Rebleeding was observed in 24 (27%) patients during the 1-year follow-up, of whom 12 (50%) were managed successfully with repeated histoacryl injection. The overall mortality rate at 6 weeks, 6 months, and 1 year was 14 (14%), 19 (20%) and 26 (27%) patients, respectively. Child-Pugh classification was a significant prognostic factor of survival (P\u3c0.001).CONCLUSION: A single session of histoacryl sclerotherapy is effective in the majority of patients with active gastric variceal bleeding. Rebleeding was observed in one-fourth of patients, half of whom were controlled successfully by repeated histoacryl sclerotherapy

Challenges identified in the management of patients with inherited metabolic disorders – A five year experience from Pakistan

Background: Pakistan is the sixth most populous country in the World. High rates of consanguinity and inter caste marriages have resulted in a substantial burden of inherited metabolic disorders (IMDs). Despite this load, there is a dearth of both medical genetic and clinical metabolic services in Pakistan. There are inadequate numbers of appropriately trained clinicians, ill-equipped laboratories, lack of scientists and technologists equipped with skills to deal with the challenging laboratory investigations involved in IMD and a health care infra-structure unable to support a service. Aim: We present the first five year experience of the first established metabolic unit at a tertiary care hospital in Pakistan and present the case for screening of parents, parents’ siblings and antenatal diagnostic testing in subsequent pregnancies in order that families can make informed choices in preventing recurrence. Subjects and methods: This retrospective observational study comprising of patients’ chart review was conducted in the Department of Paediatrics, AKUH Karachi in Pakistan for patients who presented to the Clinical Genetics unit from January 2008 to December 2012 seeking diagnosis and treatment for the underlying IMD. Results: We evaluated 426 children, of which, 333 (78%) had consanguineous parents. Most patients, 151 (35%). evaluated for IMD were between 1 year and 5 years of age. Developmental delay, seizures, hypotonia, microcephaly, neuroregression, dystonia, ataxia and encephalopathy were the most common reasons for referrals. Only 155 (36%) patients underwent metabolic biochemical testing. Among the investigated group of patients, diagnoses were established for 85 (55%) patients equivalent to only 19.8% of the total. Conclusion: Neonatal screening for IMDs and their treatment in the current situation is an unaffordable practical option in Pakistan. Screening parents, siblings and subsequent pregnancies, however, is likely to provide a cost effective and acceptable alternative in reducing the burden and enabling early, effective detection of affected progeny before the stage when neurometabolic changes become irreversible in developing countries like Pakistan with very limited resources