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.

Omphalocele with Dextrocardia - A Rare Association

Omphalocele is frequently associated with many other congenital malformations. In cardiacanomalies, association of omphalocele with dextrocardia has been rarely noticed before. We presenthere a child with dextrocardia and omphalocele alongwith a brief review of the literature on this rareassociation.Key Words: congenital malformations, dextrocardia, omphalocele

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.

A comparative study of outcome of preterm neonate with and without history of preterm premature rupture of membrane

The aim of the study was to find out the neonatal outcome of infants born with history of preterm premature rupture of membrane (PPROM) and to compare with infants born without history of PPROM. It was a retrospective study that included 187 preterm newborn with history of PPROM admitted in neonatal intensive care unit of the third affiliated hospital of Zhengzhou University from January 2008 to December 2008. Another 150 preterm newborns from same department during same period were taken as control. Patient demographics, patient's problem, investigation, management and outcome were recorded from medical record department and compared. Chi square and t test were used for statistical analysis. There was no statistical difference of gestational age, mode of delivery, birth weight and gender between case and control group. Respiratory system related problems like birth asphyxia, respiratory distress syndrome, apnea and pneumonia were common in both group but not statistical significant (p>0.05). However, need of oxygen supply and mechanical ventilation was significantly more (p<0.05) in case group. Neonatal death was more in case group (5.3%) than in control group (0.7%) and was statistically significant (p<0.001). The morbidity of preterm neonate does not entirely depend on history of PPROM than prematurity itself. However severity of disease and death is more with history of PPROM.

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.

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.KEY WORDS:acute coronary syndrome, chest pain, delayed presentation, electrocardiogram

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."