Innovative continuum of care to promote exclusive breast feeding in Pakistan: protocol of a pilot randomised controlled trial.

BACKGROUND: Breastmilk being the ideal nutrition from birth to 2 years and beyond has many health benefits for both newborn and mothers. This study will assess the feasibility and acceptability of a continuum of care programme, which is a health facility and community based till 6 months post partum to encourage ideal breastfeeding practices. METHODS AND ANALYSIS: A pilot randomised control trial having two-parallel arms of intervention and control groups was conducted in gynaecology and obstetrics department of Aziz Bhatti Shaheed Teaching Hospital with a community outreach component of 6 months. 50 women between 28 and 32 weeks of gestation fulfilling inclusion criteria will be allocated in 1:1 randomly into intervention and control groups through computer-generated random number generator software. 25 participants in intervention group will receive counselling and training on breast feeding during antenatal visits along with a family member of support by a trained female doctor within the hospital, at birth by a trained nurse and at home for 6 months by a trained lady health worker. It will be supported by reading materials and videos through a mobile phone WhatsApp application. The 25 participants in control group will receive the support already provided within the hospital and at home. The primary outcomes feasibility and acceptability will be determined at 6 months post partum from participants and providers by a semistructured questionnaire. The secondary outcomes are rates of infant early initiation and exclusive breast feeding at 2 weeks, 1, 3 and 6 months, Infant Feeding Attitude at 1 month and Breastfeeding Self-Efficacy at 3 months. Quantitative and qualitative data will be analysed via SPSS software V.20 and thematic analysis, respectively. CONCLUSION: This pilot randomised controlled trial (RCT) will guide the interventions for the definite RCT. ETHICS AND DISSEMINATION: Approved by institutional ethical committee, informed consent from all participants and results will be disseminated in peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT05951868.

S3 detection as a diagnostic and prognostic aid in emergency department patients with acute dyspnea.

STUDY OBJECTIVE: Dyspneic emergency department (ED) patients present a diagnostic dilemma. Recent technologic advances have made it possible to capture information about pathologic heart sounds at ECG recording. This study evaluates the effect of an S3 captured by acoustic cardiography on emergency physician diagnostic accuracy and confidence in their diagnosis of acute decompensated heart failure, as well as the patient's prognosis. METHODS: Dyspneic ED patients older than 40 years who were not dialysis dependent were prospectively enrolled in this multinational study. Treating emergency physicians, initially blinded to all laboratory and acoustic cardiography results, estimated acute decompensated heart failure probability from 0% to 100% on a visual analog scale. The emergency physician repeated the visual analog scale after acoustic cardiography results were provided. Physician diagnostic accuracy for and confidence in acute decompensated heart failure were evaluated against a reference standard diagnosis, as determined by 2 independent cardiologists blinded to acoustic cardiography. Patients were followed through 90 days to determine the relationship of the S3 to adverse events. RESULTS: Nine hundred ninety-five patients with acoustic cardiography results were enrolled from March to October 2006 at 7 US and 2 international sites. Median age was 63 years, 55% were men, and 44% were white. The reference diagnosis was acute decompensated heart failure in 41.5%. After initial history and physical examination, the treating physician's initial sensitivity, specificity, and accuracy for acute decompensated heart failure as a possible diagnosis were 89.0% (95% confidence interval [CI] 85.5% to 91.8%), 58.2% (95% CI 54.0% to 62.2%), and 71.0% (95% CI 68.4% to 73.8%), respectively. Acoustic cardiography had an accuracy of 68% (95% CI 65.4% to 71.3%), sensitivity of 40.2% (95% CI 35.5% to 45.1%), and specificity of 88.5% (95% CI 85.5% to 90.9%). Emergency physician confidence and diagnostic accuracy were influenced by adding information about the presence or absence of S3. In a multivariable model, the S3 added no independent prognostic information for 30-day (odds ratio 1.20; 95% CI 0.67 to 2.14) or 90-day events (odds ratio 1.22; 95% CI 0.78 to 1.90). CONCLUSION: In patients presenting with acute dyspnea, the acoustic cardiography S3 was specific for acute decompensated heart failure and affected physician confidence but did not improve diagnostic accuracy for acute decompensated heart failure, largely because of its low sensitivity. Further, the acoustic cardiography S3 provided no significant independent prognostic information.

Clinical significance of left atrial volume in clinical outcomes of heart transplant recipients.

BACKGROUND: Left atrial volume (LAV) is surgically kept enlarged in heart transplant (HT) recipients. On the other hand, LAV has been known an independent predictor of various cardiovascular diseases and is associated with exercise capacity of HT recipients. Thus, we evaluated the hypothesis that LAV is still associated with clinical outcomes in HT recipients whose left atria are artificially enlarged. METHODS: Clinical outcomes over 5 years after HT were retrospectively evaluated in 35 HT recipients who had a LAV measurement with echocardiography at 1 year after HT at the University of Cincinnati Medical Center. The LAV was derived from a stacked disc method using apical 4 and 2 chamber views. RESULTS: The average LAV normalized to body surface area was 38.3 ± 9.9 ml/m(2) (mean ± SD) at 1 year after HT. Two deaths and one drop-out occurred during 5-year follow up. A total of 552 cardiac symptom-related hospitalizations occurred in the recipients. The average time to first hospitalization was 166 ± 279 days and average number of hospitalizations of each recipient was 15 ± 16. The indexed LAV failed to correlate with the time to first hospitalization and number of hospitalizations of each recipient (Spearman's p-value; 0.141 and 0.519 respectively). When the patients were divided to groups of large LAV (n = 17) and small LAV (n = 18) using the cut off value of the mean LAV, no significant difference was noted in mortality, hospitalization, and new onset of atrial fibrillation between the groups. CONCLUSIONS: Although our study is limited by a retrospective study design and relatively small number of patients, our results implicate that LAV is not significantly associated with clinical outcomes in HT recipients over 5 years after HT.

Does left atrial volume affect exercise capacity of heart transplant recipients?

BACKGROUND: Heart transplant (HT) recipients demonstrate limited exercise capacity compared to normal patients, very likely for multiple reasons. In this study we hypothesized that left atrial volume (LAV), which is known to predict exercise capacity in patients with various cardiac pathologies including heart failure and hypertrophic cardiomyopathy is associated with limited exercise capacity of HT recipients. METHODS: We analyzed 50 patients [age 57 ±2 (SEM), 12 females] who had a post-HT echocardiography and cardiopulmonary exercise test (CPX) within 9 weeks time at clinic follow up. The change in LAV (ΔLAV) was also computed as the difference in LAV from the preceding one-year to the study echocardiogram. Correlations among the measured parameters were assessed with a Pearson's correlation analysis. RESULTS: LAV (n = 50) and ΔLAV (n = 40) indexed to body surface area were 40.6 ± 11.5 ml·m-2 and 1.9 ± 8.5 ml·m-2·year-1, data are mean ± SD, respectively. Indexed LAV and ΔLAV were both significantly correlated with the ventilatory efficiency, assessed by the VE/VCO2 slope (r = 0.300, p = 0.038; r = 0.484, p = 0.002, respectively). LAV showed a significant correlation with peak oxygen consumption (r = -0.328, p = 0.020). CONCLUSIONS: Although our study is limited by a retrospective study design and relatively small number of patients, our findings suggest that enlarged LAV and increasing change in LAV is associated with the diminished exercise capacity in HT recipients and warrants further investigation to better elucidate this relationship.