Background Pakistan is the sixth most populous nation in the world and has an estimated 4 million stroke survivors. Most survivors are taken care of by community-based caregivers, and there are no inpatient rehabilitation facilities. Objective The objective of this study was to evaluate the effectiveness and safety of locally designed 5-min movies rolled out in order of relevance that are thematically delivered in a 3-month program to deliver poststroke education to stroke survivor and caregiver dyads returning to the community. Methods This study was a randomized controlled, outcome assessor–blinded, parallel group, single-center superiority trial in which participants (stroke survivor-caregiver dyads) with first-ever stroke (both ischemic and hemorrhagic) incidence were randomized within 48 hours of their stroke into either the video-based education intervention group or the control group. The video-based education intervention group had health education delivered through short videos that were shown to the participants and their caregivers at the time of admission, before discharge, and the first and third months of follow-up after discharge. The control group had standardized care including predischarge education and counseling according to defined protocols. All participants enrolled in the video education intervention and control groups were followed for 12 months after discharge for outcome assessment in the outpatient stroke clinics. The primary outcome measures were the proportion of participants achieving control of blood pressure, blood sugar, and blood cholesterol in the video intervention versus the control group. Several predefined secondary outcomes were included in this study, of which we report the mortality and functional disability in this paper. Analysis was by performed using the intention-to-treat principle. Results A total of 310 stroke survivors and their caregiver dyads (participant dyads) were recruited over a duration of 6 months. In total, 155 participant dyads were randomized into the intervention and control groups, each. The primary outcome of control of three major risk factors revealed that at 12 months, there was a greater percentage of participants with a systolic BP<125 mm Hg (18/54, 33% vs 11/52, 21%; P=.16), diastolic BP<85 mm Hg (44/54, 81% vs 37/52, 71%; P=.21), HbA1c level<7% (36/55, 65% vs 30/40, 75%; P=.32), and low-density lipoprotein level<100 mg/dL (36/51, 70% vs 30/45, 67%; P=.68) in the intervention group than in the control group. The secondary outcome reported is the mortality among the stroke survivors because the number of stroke-related complications was higher in the control group than in the intervention group (13/155, 8.4% vs 2/155, 1.3%), and this difference was statistically significant (P<.001). Conclusions The Movies4Stroke trial failed to achieve its primary specified outcome. However, secondary outcomes that directly related to survival skills of stroke survivors demonstrated the effectiveness of the video-based intervention on improving stroke-related mortality and survival without disability. Trial Registration ClinicalTrials.gov NCT02202330; https://www.clinicaltrials.gov/ct2/show/NCT02202330

The study supports a model system in resource constrained settings that allows routine capture of individual level data through GPS enabled mobile phone providing actionable information and geospatial maps to local public health managers, policy makers and study staff monitoring immunization coverage.

Background ST elevation myocardial infarction (STEMI) is an acute cardiac manifestation that requires immediate revascularization preferably through primary percutaneous coronary intervention (PCI). This study aims to describe gender stratified outcomes and epidemiological profile of STEMI patients undergoing treatment at a tertiary care hospital in Karachi, Pakistan. Methods A 5-year, retrospective analysis of hospital records was undertaken on confirmed STEMI patients admitted between 2010 and 2014, undergoing primary PCI. Information was retrieved on demographic variables, risk factors, total ischemia time, door to balloon time, angiographic findings, and treatment strategy and in-hospital outcomes. Results A total of 603 patients were available for analysis. Mean age of the participants was 58 ± 11 years, with 78.6% being males. The most common risk factors were hypertension (48.1%), diabetes (37%), and smoking (22.2%). Gender stratified analysis revealed poorer clinical presentation and prolonged ischemia time among women when compared to men (410 vs. 310 min, respectively). Total in-hospital mortality was 9.6% and was higher in women (19.3%), patients with non-anterior infarction (12%), Killip class >2 (39%), advanced age (14.6%), and multi-vessel disease (12%). Conclusion Our study describes the common risk factors and treatment outcomes for STEMI patients undergoing primary PCI at a tertiary care hospital in Karachi. In-hospital mortality and total ischemia time were higher among women compared to men in our study. Moreover, the risk profile, treatment related complications, and outcomes were poorer in women compared to men. We suggest further research to investigate the effect of prolonged ischemia time on long-term clinical outcomes.

Background and Aims There is little information on the incremental prognostic importance of frailty beyond conventional prognostic variables in heart failure (HF) populations from different country income levels. Methods A total of 3429 adults with HF (age 61 ± 14 years, 33% women) from 27 high-, middle- and low-income countries were prospectively studied. Baseline frailty was evaluated by the Fried index, incorporating handgrip strength, gait speed, physical activity, unintended weight loss, and self-reported exhaustion. Mean left ventricular ejection fraction was 39 ± 14% and 26% had New York Heart Association Class III/IV symptoms. Participants were followed for a median (25th to 75th percentile) of 3.1 (2.0–4.3) years. Cox proportional hazard models for death and HF hospitalization adjusted for country income level; age; sex; education; HF aetiology; left ventricular ejection fraction; diabetes; tobacco and alcohol use; New York Heart Association functional class; HF medication use; blood pressure; and haemoglobin, sodium, and creatinine concentrations were performed. The incremental discriminatory value of frailty over and above the MAGGIC risk score was evaluated by the area under the receiver-operating characteristic curve. Results At baseline, 18% of participants were robust, 61% pre-frail, and 21% frail. During follow-up, 565 (16%) participants died and 471 (14%) were hospitalized for HF. Respective adjusted hazard ratios (95% confidence interval) for death among the pre-frail and frail were 1.59 (1.12–2.26) and 2.92 (1.99–4.27). Respective adjusted hazard ratios (95% confidence interval) for HF hospitalization were 1.32 (0.93–1.87) and 1.97 (1.33–2.91). Findings were consistent among different country income levels and by most subgroups. Adding frailty to the MAGGIC risk score improved the discrimination of future death and HF hospitalization. Conclusions Frailty confers substantial incremental prognostic information to prognostic variables for predicting death and HF hospitalization. The relationship between frailty and these outcomes is consistent across countries at all income levels.

BackgroundRecent Life Changes Questionnaire (RLCQ) developed by Richard Rahe has enabled quantification of stress by analyzing life events. The overall aim of the study was to create a reliable version of the Rahe’s RLCQ for measuring stress in individuals living in developing countries and assess its validity. This paper discusses criterion validation of the adapted RLCQ in urban communities in Pakistan.MethodsThis is a criterion validation study. Four urban communities of Karachi, Pakistan were selected for the study in which households were randomly chosen. Two data collectors were assigned to administer the adapted RLCQ to eligible participants after obtaining written informed consent. Following this interaction, two psychologists interviewed the same participants with a diagnostic gold standard of Mini International Neuropsychiatric Interview (MINI) which is utilized in usual practice within Pakistan to confirm the presence of stress related mental disorders such as Depression, Anxiety, Dysthymia, Suicide, Phobia, OCD, Panic Disorder, PTSD, Drug abuse and dependence, Alcohol abuse and dependence, Eating Disorders and Antisocial Personality Disorder to validate the accuracy of the adapted RLCQ. We generated the ROC curves for the adapted RLCQ with suggested cut-offs, and analyzed the sensitivity and specificity of the adapted RLCQ.ResultsThe area under the receiver operating characteristic curve (ROC) of common mental disorders such as depression and anxiety was 0.64, where sensitivity was 66%, specificity was 56% and the corresponding cut off from the adapted RLCQ was 750. Individuals scoring ≥750 were classified as high stress and vice versa. In contrast, the area under the ROC curve for serious mental disorder and adverse outcomes such as suicide, bipolar and dysthymia was 0.75, where sensitivity was 72% and specificity was 60% at the cut off of 800 on the adapted RLCQ. Individuals scoring ≥800 were classified as high stress and vice versa. The rate of agreement between the two psychologists was 94.32% (Kappa = 0.84).ConclusionThe adapted and validated RLCQ characterizes common mental disorders such as depression and anxiety with moderate accuracy and severe mental disorders such as suicide, bipolar and dysthymia with high accuracy.Trial registrationClinicaltrials.gov NCT02356263. Registered January 28, 2015. (Observational Study Only).