BACKGROUND In Pakistan, the prevalence of stunting in children under five years has remained above global critical levels over the two decades, with the current stunting rate being 40.2% in 2018. Children living in rural areas and in the poorest households suffer the most from stunting across the country - 43.2% in rural areas and 51.4% in the lowest wealth quintile. As a continuing public health concern, it is essential that stunting prevention is a national priority in order to ensure human capital development, especially among the poorest households. OBJECTIVE The primary objective of this study is to determine the effect of specialized nutritious food (SNF), cash transfers (CBTs) and social and behavior change communication (SBCC) on reducing stunting in children 6-23 months. METHODS A five-arm cluster randomized controlled trial will be conducted in district Rahim Yar Khan, Punjab, Pakistan. The intervention packages will be: 1) Cash only; 2) Cash with SNF; 3) Cash with SBCC; and 4) Cash with SBCC and SNF. The control arm will receive routine standard-of-care. We will enroll children at 6 months of age and follow on a monthly basis up to 24 months of age. A total of 2000 children, 400 in each arm will be enrolled to detect a 20% reduction in the prevalence of stunting among children at 24 months of age. Length, weight, food intake, compliance to interventions, morbidities and other relevant data will be collected at enrollment and on a monthly basis over the period of 18 months. The process evaluation will assess acceptability of the interventions and potential barriers to implementation through focus group discussions and in-depth interviews with the target population and relevant stakeholders. Furthermore, a cost analysis will be conducted to assess the cost effectiveness of each intervention package. RESULTS All recruitment and follow-up data are complete. Data analyses are yet to be completed. This study will explore the effectiveness of intervention packages comprised of cash transfers from BISP, with or without additional SNF and/or SBCC to prevent childhood stunting. CONCLUSIONS The findings of this trial will provide robust evidence as to which intervention package(s) can have significant effect on linear growth of children and to design effective intervention package(s) to prevent stunting in children at 24 months of age. CLINICALTRIAL ClinicalTrials.gov NCT03299218; https://clinicaltrials.gov/ct2/show/NCT03299218

Background In Pakistan, the prevalence of stunting in children younger than 5 years has remained above global critical levels over the past two decades, with the stunting rate being 40.2% in 2018. Children living in rural areas and in the poorest households suffer the most from stunting across the country—43.2% in rural areas and 51.4% in the lowest wealth quintile. As a continuing public health concern, it is essential that stunting prevention is a national priority in order to ensure human capital development, especially among the poorest households. Objective The primary objective of this study is to determine the effect of a medium quantity of a lipid-based nutrient supplement (LNS) combined with unconditional cash transfers and social and behavior change communication (SBCC) on reduction of stunting in children aged 6 to 23 months. Methods A 5-arm cluster randomized controlled trial will be conducted in the district of Rahim Yar Khan in Punjab, Pakistan. The intervention packages will be (1) cash only, (2) cash with LNS, (3) cash with SBCC, and (4) cash with SBCC and LNS. The control arm will receive routine standard of care. We will enroll children at 6 months of age and follow up on a monthly basis up to 24 months of age. A total of 2000 children, 400 in each arm, will be enrolled to detect a 20% reduction in the prevalence of stunting among children aged 24 months. Length, weight, food intake, compliance to interventions, morbidities, and other relevant data will be collected at enrollment and on a monthly basis over the period of 18 months. The process evaluation will assess acceptability of the interventions and potential barriers to implementation through focus group discussions and in-depth interviews with the target population and relevant stakeholders. Furthermore, a cost analysis will be conducted to assess the cost-effectiveness of each intervention package. Results The study protocol was approved by the Ethics Review Committee of Aga Khan University in Pakistan on January 4, 2017. Data collection began in May 2017 and was completed in July 2019. Data analyses are yet to be completed. This study will explore the effectiveness of intervention packages comprised of cash transfers from Benazir Income Support Programme with or without additional LNS and SBCC in preventing childhood stunting. We expect the results to be published in peer-reviewed journals by autumn of 2020. Conclusions The findings of this trial will provide robust evidence as to which intervention packages can have significant effects on linear growth of children and design effective intervention packages to prevent stunting in children aged 6 to 23 months. Trial Registration ClinicalTrials.gov NCT03299218; https://clinicaltrials.gov/ct2/show/NCT03299218 International Registered Report Identifier (IRRID) DERR1-10.2196/19001

IntroductionImprovement in health-related quality of life (HRQoL) has been reported in patients with congenital heart disease treated with interventional cardiac catheterization; however, there is a significant dearth of literature from low/middle-income countries (LMICs) about this aspect. Multiple factors like sociodemographic and cultural differences, variable procedural outcomes due to lack of technical expertise and limited resources and inconsistent postprocedure follow-up may affect HRQoL in LMICs. This protocol paper aims to describe the study methodology to determine the HRQoL and its predictors in patients who have undergone interventional cardiac catheterization. Conclusions from this protocol study will help prepare a holistic approach to delivering care to patients in low-resource settings.Methods and analysisA mixed-methods study design will be used. The quantitative arm will compare the HRQoL of these postcardiac interventional catheterization patients with their age-matched healthy siblings to identify the HRQoL predictors, whereas the qualitative arm will further explore the experiences of these patients and parents. A minimum number of 108 patients of age 2 years and above, at least 6 months postinterventional catheterization follow-up and ability to understand Urdu/English will be enrolled. PedsQL 4.0 Generic Core Scales, PedsQL Cognitive Functioning Scale and PedsQL 3.0 Cardiac Module will be used. The Student’s t-test will analyse the difference in the means of HRQoL between patients and siblings. Multiple regression will identify HRQoL predictors. A subsample of enrolled patients and parents will be interviewed and analysed using directed content analysis (a qualitative component of the study).Ethics and disseminationEthics approval has been obtained from Ethics Review Committee of The Aga Khan University, Pakistan (ERC #2020-3456-11808). Study findings will be published in peer-reviewed journals and presented at conferences.

Pulmonary artery sling is a rare congenital vascular anomaly in which the left pulmonary artery arises from the posterior aspect of right pulmonary artery and courses to the left behind the tracheal bifurcation and in front of the esophagus to reach the left lung hilum and forms a sling around the trachea. We are reporting a case of a two-month-old infant with biliary atresia referred for screening echocardiogram before surgical procedure. The patient had no history of respiratory distress or dysphagia. Echocardiography revealed aberrant left pulmonary artery arising from the right pulmonary artery with no pulmonary stenosis probably pulmonary artery sling. Diagnosis was confirmed on cardiac computed tomography angiography. On minor class of risk stratification patient was allowed to proceed for surgical procedure for biliary atresia as standard risk of anesthesia.