Protocol for a pragmatic cluster randomised controlled trial to evaluate the effectiveness of digital health interventions in improving non-communicable disease management during the pandemic in rural Pakistan

BACKGROUND

The COVID-19 pandemic has revealed gaps in global health systems, especially in the low- and middle-income countries (LMICs). Evidence shows that patients with non-communicable diseases (NCDs) are at higher risk of contracting COVID-19 and suffering direct and indirect health consequences. Considering the future challenges such as environmental disasters and pandemics to the LMICs health systems, digital health interventions (DHI) are well poised to strengthen health care resilience. This study aims to implement and evaluate a comprehensive package of DHIs of integrated COVID-NCD care to manage NCDs in primary care facilities in rural Pakistan.

METHODS

The study is designed as a pragmatic, parallel two-arm, multi-centre, mix-methods cluster randomised controlled trial. We will randomise 30 primary care facilities in three districts of Punjab, where basic hypertension and diabetes diagnosis and treatment are provided, with a ratio of 1:1 between intervention and control. In each facility, we will recruit 50 patients who have uncontrolled hypertension. The intervention arm will receive training on an integrated COVID-NCD guideline, and will use a smartphone app-based telemedicine platform where patients can communicate with health providers and peer-supporters, along with a remote training and supervision system. Usual care will be provided in the control arm. Patients will be followed up for 10 months. Our primary indicator is systolic blood pressure measured at 10 months. A process evaluation guided by implementation science frameworks will be conducted to explore implementation questions. A cost-effectiveness evaluation will be conducted to inform future scale up in Pakistan and other LMICs.

DISCUSSION

Our study is one of the first randomised controlled trials to evaluate the effectiveness of DHIs to manage NCDs to strengthen health system resilience in LMICs. We will also evaluate the implementation process and cost-effectiveness to inform future scale-up in similar resource constrained settings.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier-NCT05699369.

Meniscal Extrusion in the Knee: Should only 3 mm Extrusion be Considered Significant? An Assessment by MRI and Arthroscopy

Aim. The aim of this study was to assess whether significant meniscal extrusion of more than 3 mm or of even lesser degrees of extrusion could be considered significant. We also aimed to determine the morphology of tears that are most likely to be associated with significant extrusion.

Study design and material. The study was done retrospectively on a group of 202 patients (157 males and 45 females) who had been seen in our hospital between 2007 and 2011 with meniscal tears (in one knee only) diagnosed by MRI and confirmed on arthroscopy. Extrusion of 3 mm or more (usually considered significant) was seen in 102 cases and less than 3 mm in 100. Extrusion was measured on the coronal MR images rather than on saggital images because of ease and reproducibility. The tears were confirmed by arthroscopy and correlated with the extent of extrusion on MRI.

Results: Out of the total of 202 cases, 102 cases (50.5%) had extrusion of 3 mm or more on MRI. Of these, the medial meniscal posterior horn tears accounted for 63 cases (64.26%), 21 cases were medial meniscal body tears (21.42%), five medial meniscal root tears (5.1%), nine lateral meniscal body tears (9.18%) and four lateral meniscal posterior horn tears(4.08%). Forty-four cases had extrusion of 3-4 mm, 26 had extrusion of 4-5mm, 17 cases had extrusion of 5-6mm, ten had extrusion of 6-7mm and five had extrusion of 7 mm or more. One hundred cases fell in the < 3mm extrusion category, of which 80 (39.6%) were in the 2-3 mm extrusion group and 20 (9.9%) in the 1-2 mm extrusion group. They comprised of 61 cases of medial meniscal posterior horn tears, 23 cases of medial meniscal body tears, six medial meniscal root tears, eight lateral meniscal body tears and two lateral meniscal posterior horn tears. The highest proportion of meniscal tears was seen in the 2-3 mm category comprising nearly 40% of the entire study group. The majority of tears were medial meniscal posterior horn tears.

Conclusion: Menisci that extruded 2-3 mm from the tibial margin formed a major proportion of menisci treated for tears by repair or menisectomy. We should consider extrusion of more than 2mm as significant. Most tears had extrusion of 2-4 mm.

Open anterior hip dislocation in a young adult with exposed femoral head and no neurovascular damage

ABSTRACT

Anterior hip dislocation is common in younger adults and is the result of severe, high energy trauma such as high-velocity motor vehicle accidents or falls from great heights. A similar mechanism of injury would cause a femur neck fracture in older patients. Of these, open anterior hip dislocations are extremely rare and are usually associated with other soft tissue and bony injuries. We report a case of an open anterior hip dislocation with normal neurovascular status in a third world setting.

KEY WORDS

trauma, open anterior, dislocation, hip, femoral head, osteonecrosis.