Predicting outcomes in acute coronary syndrome using biochemical markers.

OBJECTIVES: To assess risk prediction in patients with acute coronary syndrome (ACS) during the hospital stay, at 6 weeks and at 6 months period using high sensitivity C-reactive protein (hs-CRP), serum creatinine, cardiac troponin I, creatine kinase total, and MB levels. METHODS: It was a prospective observational study. The primary outcome was taken as all-cause mortality. Patients with ACS were enrolled and followed up at 6 weeks and 6 months duration from the index event. Mortality and cause of death were recorded. The hs-CRP was estimated on admission, at 6 weeks, and at 6 months. The estimated glomerular filtration rate (eGFR) was calculated using the abbreviated modification of diet in renal disease (MDRD) formula at admission, at 6 weeks, and 6 months. RESULTS: There were a total of 108 cases of ACS in the duration of 6 months who completed the follow-up. The hs-CRP level of >5mg/dl was highly significant for predicting mortality during hospital stay and at 6 weeks (p<0.001). There was 11% of in-hospital mortality (p<0.001). At 6 months, the overall mortality was 28% (p<0.001). There was a statistical significance with low eGFR (median eGFR 45ml/min/1.73m(2)) levels during the admission. CONCLUSION: hs-CRP levels above 5mg/dl and the eGFR levels ≤30ml/min/1.73m(2) were significant in predicting mortality of the patients with ACS. This may provide simple assessment tools for predicting outcome in ACS in resource-poor settings if validated further.

Echocardiographic evaluation of diastolic function in asymptomatic type 2 diabetes.

INTRODUCTION: Diabetes mellitus is an established risk factor for congestive cardiac failure in which the diastolic function is impaired earlier than the systolic function and majority of these patients maybe asymptomatic without signs of overt heart failure. METHODS: A cross sectional hospital based study was done which included 100 asymptomatic patients with type 2 diabetes without evidence of coronary artery disease, congestive heart failure, thyroid or overt renal disease. LVDD was evaluated by Doppler echocardiography, which included the valsalva maneuver to unmask the pseudonormal pattern of left ventricular filling. The prevalence of LVDD and the associated risk factors were assessed. RESULTS: LVDD was found in 71 subjects (71%), of whom 60 had impaired relaxation and 11 had a pseudonormal pattern of ventricular filling. Systolic function was normal in all subjects, and there was no correlation between LVDD and indexes of metabolic control. It was also found that age > or =45 years was associated with an almost three times higher risk for the development of diastolic dysfunction in type 2 diabetes. Females were at a two times higher risk of developing diastolic dysfunction than when compared to men. Duration of diabetes > or = two years was associated with a two times higher risk for developing diastolic dysfunction. CONCLUSIONS: LVDD is much more common than previously reported in subjects with well-controlled type 2 diabetes who are free of clinically detectable heart disease. The high prevalence of this phenomenon in this high-risk population suggests that screening for LVDD in type 2 diabetes should include procedures such as the valsalva maneuver to unmask a pseudonormal pattern of ventricular filling.

Delayed presentation of acute coronary syndrome: a challenge in its early management.

INTRODUCTION: The time of presentation of acute coronary syndrome from the onset of chest pain determines the treatment modality and prognosis. Delayed presentation is associated with a poor outcome. In the present study, we tried to find out the causes of late presentation of ACS in a tertiary care center in the eastern part of Nepal. METHODS: It was a cross-sectional descriptive study that included 100 consecutive patients with ACS presenting to our institute over a period of 8 months. They were studied for their demographic profile, delay in presentation, the management done at the local centers and their final diagnosis. RESULTS: We found that patients living within Dharan City reached BPKIHS within 20 hours of the onset of chest pain while those from outside the city who came directly reached within 63 hours. Other patients reached their respective local centers (health posts, district hospitals and private clinics) within 39 hours. The commonest cause of delay was vehicular problem followed by unnecessary delay at the local centers. The work up for chest pain was inadequate in these centers. Late presentation to our institute significantly affected the optimal management. CONCLUSIONS: We found that significant number of patients with ACS from eastern Nepal presented late in our tertiary care center. In order to improve ACS outcome in this region, we advise equipping the local centers with electrocardiogram machines, improvement in ambulance services and a greater emphasis on coronary artery disease awareness programs as well as initiating preventive measures.

Omphalocele with dextrotardia-A rare association.

Omphalocele is frequently associated with many other congenital malformations. In cardiac anomalies, association of omphalocele with dextrocardia has been rarely noticed before. We present here a child with dextrocardia and omphalocele alongwith a brief review of the literature on this rare association.

Population pressure and land resources in Nepal: a revisit, twenty years later.

PIP: This study analyzes the changes in the relationship between population and land resources in Nepal from 1971 to 1991. During this period, the country's total population increased by 7 million people while it's national per capita holding of cultivated land dropped significantly from 0.17 to 0.13 hectares. However, it was noted that there is a greater balance in the regional distribution of population and land resources in 1991 as compared to 1971. A shift in the redistribution of population can be accounted to the migration of the people from the Hills to Tarai. The large agricultural area in Tarai contributes to its underpopulated status compared with the Hills in relation to the total agricultural production. The increase in rural population is the direct result of poverty, and the inability of the Nepal government to grant lands to the Hill migrants resulted to land encroachment. The problem of Nepal is not simply the number of people living in an area nor the interregional migration, but the number of people who have and who have no access to land and forest resources.^ieng

Ecopolitical battles at the Tarai frontier of Nepal: an emerging human and environmental crisis.

"In Nepal, the drama of human and environmental ills is increasingly being played out in the form of peasants' ecopolitical battles over common land access and control, such as in the Tarai frontier, a region bordering the Gangetic Plain of India. This is a complex battle, pitting peasants' day-to-day survival against environmental security on one front, and against the Nepalese State and its dominant class interests on the other. This article critically dissects this raging battle to gain a clear understanding of its complexities as well as its diverse roots."

Population and poverty in dependent states: Latin America considered.

"Malthusians maintain that rapid population growth aggravates poverty, while Marxists contend that social formations determine its nature and extent. Each perspective is incomplete, however, since it ignores the insights of the other. Latin American states, characterized by dependent capitalism formations and dominated by ruling elites, are generally incapable of solving the problems of population and poverty. Since population growth under dependent capitalism weakens labor's bargaining position against capital, reduced population growth is emphasized as a labor empowerment strategy the poor can implement on their own to improve their socioeconomic conditions."

Land and landlessness among rural-to-rural migrants in Nepal's Terai region.

"Nepal has been experiencing a permanent rural-to-rural migration of households from the central hill zone to the Terai region. Migrant households, due to the structure of the Terai economy, are impelled to acquire control of land for subsistence agriculture by squatting, purchasing, or receiving a grant. A household's ability to maximize subsistence opportunities is partly a function of the means by which land is acquired and whether land is acquired at all. Factors which determine the chances of acquiring land reflect the role of institutional rigidities such as the distribution of wealth and the caste structure, state-imposed land reform policies, and such household characteristics as family size and risk aversion. A multinomial logit model is used to empirically assess the importance of these elements in the outcomes of migrant households' resource acquisition decisions."

Population growth and development in the Third World: the neocolonial context.

PIP: Less developed countries (LDCs) that were colonies of other nations continued operating under the same social and political structures set up by the former ruling nations. The small minority of elites in the LDCs held on to the power acquired during colonial times. In order to preserve their political and financial status after independence, they maintained their close linkages to the capitalist nations and their multinational corporations (MNCs). The elites did not generally have popular support, however. These capitalist nations and their commercial interests continue to dictate most LDCs development process which supports the financial interests of the MNCs and the local elites and not those of the majority, the poor. The poor realize that they are trapped and unable to break away from the economic and political structures, therefore, to assure some form of security, they have many children which exacerbates their poverty. Yet population control policies based on Malthusian theory and those that rely on such undimensional, technical approaches as family planning alone cannot cure the multidimensional social problems of high population growth and poverty. Neither the Malthusian nor Marxist theories totally explain the situation in the LDCs or even provide workable solutions. Research on population and development in LDCs needs to address both the Malthusian concern for the problems posed by high growth rates and the Marxist critique of class struggle in development trends. To eliminate the trap of poverty and dependent economies, each country must design its own remedies based on its history, culture, and geography and alter the prevailing social, economic, and political power structures in favor of the poor. 6 propositions that must be modified to each nation's particular problems and needs are presented to guide LDCs in formulating or reformulating policies to alleviate the problems of population and poverty.^ieng

Issues in population pressure, land resettlement, and development: the case of Nepal.

PIP: This analysis considers the question of whether resettlement schemes really relieve population pressure or help achieve a better regional balance between population and resource distribution in a manner consistent with Nepal's national objective of agricultural growth with social justice. The 1st part of the analysis discusses population pressure, followed by the conceptualization of ecodemographic relations and sociodemographic relations. The 2nd part of the analysis considers Nepal's agrarian economy along with a case-study examination of its contemporary resettlement project in Chitwan district. Finally, information is presented from a field survey conducted in Chitwan in 1979, which support the assertions that: the sociodemographic relations -- not population pressure as such -- are the primary roots of agrarian development problems in a country like Nepal; and resettlement schemes, when implemented without due consideration of the pervasive sociodemographic relations, are a deficient technical fix to imbalances in ecodemographic relations. Nepal provides a typical example of ecodemographic imbalances in the regional distribution of population and resources. Although the Hill and Mountain regions make up almost 60% of Nepal's total population, they share less than 30% of the total land under cultivation. The Tarai region, which is the northern extension of the Gangetic Plain in India, occupies over 70% of the cultivated land and supports only slightly over 40% of the population. As the case study illustrates, development strategies such as land resettlement are invariably formulated and implemented as a technical solution within the framework of ecodemographic relations. Little attention is directed to addressing the social dimension of these programs, i.e., the structual problems directly associated with the existing sociodemographic relations. Development, or land resettlement in the present case, is not simply a technical issue concerned with land reclamation and its management. It is also a social issue, because the sociodemographic relations determine significantly the direction (or directions) that resettlement programs take. When development policies make little effort to tackle the underlying forces of these relations, resettlement schemes result in the reconstitution of class divisions and disparity in the ownership of resources in newly resettled areas.^ieng

A preliminary report on population pressure and land resources in Nepal.

PIP: Population problems in relation to national development have touched Nepal as well as underdeveloped countries. This article uses the Sen Gupta mathematical model which provides an objective basis for deriving a population pressure index based on the relationship between population and available national resources. The population pressure index was computed for each of the 75 districts of Nepal and then a map of population pressure was compared with that of simple population density. Simple population density does not realistically indicate the degree of population pressure on land resources. Nepal is predominantly a rural-agrarian country. While farming is the most predominant economic activity, farming methods are still backward and primitive, resulting in a low level of productivity. It is mainly a subsistence agriculture. The most important contribution that this model makes to this spatial economic analysis is its use of production figures as the nucleus of a population pressure index. Spatial patterns indicate that almost all the mountain and Hill districts are overpopulated with very high population pressure indices. The population in these districts exceeds the carrying capacity of the presently available land resources. Underpopulation was apparent in the Tarai District. Results of the spatial analysis indicate that there are regional disparities with regard to spatial distribution of human and land resources. This very spatial disparity is 1 of the main problems of Nepal's economy. The analysis also indicates that simple population density does not provide an adequate index of population pressure. Population pressure is not the same thing as simple population density. Clearly, however, there are areas where population exerts a mounting pressure on land resources in certain areas. Population pressure in Nepal is actually a local problem affecting a significant portion of the population with little or no access to the means of production. A small proportion of the population controls the majority of land, a situation which leads to population pressure among the population with little or no control over the means of production.^ieng