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The small retailer has a difficult time competing with large mass merchandisers, category killers, and retail chains. Price discounting is not an option, because the small retailer can never beat the price of large retail operations. Therefore, small retailers must look to other means of differentiation. This paper proposes a customer value concept that is based on the premise that customers are of varying value to a retail operation. Dividing a retailer's customer base into four buckets, marketing strategies are suggested for each group that will optimize a small retailer's marketing investment. The success of this type of marketing approach is based on an understanding of brand value, repeat purchase behavior of customers, and customer relationship management (CRM) technology. [ABSTRACT FROM AUTHOR]

Objective: Empathic concern (EC) for others may be related to COVID-19 pandemic responses. Participants and methods: The purpose of this survey study was to examine differences in pandemic responses in 1,778 college students rated as low (LE) versus high (HE) on the EC subscale of the Interpersonal Reactivity Index. Results: HE participants reported greater concerns in numerous pandemic-related domains, including acquiring COVID-19; access to COVID-19 treatment; number of COVID-19 cases, hospitalizations, and deaths reported; staying employed; and being isolated for long periods of time. Generalized anxiety symptoms, depressive symptoms, and perceived stress scores were significantly higher for individuals in the HE group compared to the LE group. The HE group reported being significantly more adherent to health and safety recommendations than the LE group. Conclusions: Empathic concern for others is important for promoting college student prosocial behavior but is associated with anxiety and depression symptomatology during times of traumatic stress.

Objective: This study examined acculturation with positive alcohol expectancies (PAE) and alcohol use intentions among college-bound Latinas using a bidimensional (ie U.S. acculturation/enculturation) and bidomain (ie behaviors/values) acculturation framework. Participants: A total of 298 Latina young adults between 18 and 20 years old were included in this analysis. Methods: Data were collected the summer before participants began college for the first time. We used an online survey to assess acculturation, PAE, and alcohol use expectancies. Results: Path analyses showed that U.S. acculturation values were related to more PAE and alcohol use intentions. U.S. acculturation behaviors were related to more alcohol use intentions, and the pathway was moderated by PAE. There was also an interaction between U.S. acculturation and enculturation behaviors predicting alcohol use intentions. Conclusion: This study sheds light on how acculturating Latina young women think about alcohol use prior to beginning college, which is an opportune window for targeted prevention programs.

Background: This study examined changes in reported alcohol use among women during the early stages of the COVID-19 pandemic and the relations to adverse changes in employment (e.g. job loss, furlough, reduced pay). Further, this study assessed how the relation between changes in alcohol use and experiencing an adverse change in employment was moderated by four theoretically relevant dimensions of conformity to masculine norms (CMNI, i.e. risk-taking, winning, self-reliance, and primacy of work)., Methods: The sample for the present study is a subset of a survey that was conducted in the spring of 2020 among U.S. adults and includes 509 participants who met the inclusion criteria. We assessed pandemic-related employment change status, changes in reported frequency and quantity of alcohol consumed, and four CMNI dimensions. Relations between these variables were assessed with a multinomial logistic regression path model., Results: Experiencing an adverse change in employment early in the pandemic was related to increased alcohol use when moderated by the CMNI dimension primacy of work. For people higher on primacy of work, an adverse change in employment was associated with a higher likelihood of reporting an increase in frequency, but not quantity, of drinking (rather than a decrease or no change). Not experiencing an adverse change in employment early in the pandemic was associated with an increased likelihood of reporting an increase for quantity but not frequency., Conclusion: The results highlight the importance of considering how work-oriented women may be at risk for increasing alcohol use when confronted with changes in work status.

Background: The present study aimed to quantify the burden of structural heart disease in Nepali children., Methods: We performed a school-based cross-sectional echocardiographic screening study with cluster random sampling among children 5-16 years of age., Results: Between December 2012 and January 2019, 6573 children (mean age 10.6 ± 2.9 years) from 41 randomly selected schools underwent echocardiographic screening. Structural heart disease was detected in 14.0 per 1000 children (95% CI 11.3-17.1) and was congenital in 3.3 per 1000 (95% CI 2.1-5.1) and rheumatic in 10.6 per 1000 (95% CI 8.3-13.4). Rates of rheumatic heart disease were higher among children attending public as compared to private schools (OR 2.8, 95% CI 1.6-5.2, p = 0.0001)., Conclusion: Rheumatic heart disease accounted for three out of four cases of structural heart disease and was more common among children attending public as compared to private schools.

We report the case of an 18-year-old female admitted to the hospital for severe hemodynamic instability and fatal outcome within 6 hours following admission. Significant electrocardiographic modifications were noted and are presented with diagnostic options. ( Level of Difficulty: Intermediate. )., Competing Interests: The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2021 The Authors.)

Introduction: Systematic echocardiographic screening of children in regions with an endemic pattern of rheumatic heart disease allows for the early detection of valvular lesions suggestive of subclinical rheumatic heart disease. The natural course of latent rheumatic heart disease is, however, incompletely understood at this time., Methods: We performed a prospective cohort study of children detected to have echocardiographic evidence of definite or borderline rheumatic heart disease according to the World Heart Federation Criteria., Results: Among 53 children found to have definite (36) or borderline (17) rheumatic heart disease, 44 (83%) children underwent follow-up at a median of 1.9 years (IQR 1.1-4.5). The median age of the children was 11 years (IQR 9-14) and 34 (64.2%) were girls. Among children with definite rheumatic heart disease, 21 (58.3%) were adherent to secondary antibiotic prophylaxis, 7 (19.4%) were not, information on adherence was missing in 2 (5.6%) children and 6 (16.7%) were lost to follow-up. Regression of disease was observed in 10 children (27.8%), whereas 20 children (55.6%) had stable disease. Among children adherent to secondary prophylaxis, seven (33.3%) showed regression of disease. Among children with borderline disease, seven (41.2%) showed regression of disease, three (17.6%) progression of disease, four (23.5%) remained stable and three (17.6%) were lost to follow-up. On univariate analysis, we identified no predictors of disease regression, and no predictors for lost to follow-up or non-adherence with secondary antibiotic prophylaxis., Conclusion: Definite rheumatic heart disease showed regression in one in four children. Borderline disease was spontaneously reversible in less than half of the children and progressed to definite rheumatic heart disease in one in five children., Trial Registration Number: NCT01550068., Competing Interests: Competing interests: TP has received research grants to the institution from Biotronik, Boston Scientific and Edwards Lifesciences, speaker fees from Biotronik and Boston Scientific, serves as a consultant for HighLife SAS, and is a proctor for Medtronic and Boston Scientific., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Importance: Echocardiographic screening allows for early detection of subclinical stages of rheumatic heart disease among children in endemic regions., Objective: To investigate the effectiveness of systematic echocardiographic screening in combination with secondary antibiotic prophylaxis on the prevalence of rheumatic heart disease., Design, Setting, and Participants: This cluster randomized clinical trial included students 9 to 16 years of age attending public and private schools in urban and rural areas of the Sunsari district in Nepal that had been randomly selected on November 17, 2012. Echocardiographic follow-up was performed between January 7, 2016, and January 3, 2019., Interventions: In the experimental group, children underwent systematic echocardiographic screening followed by secondary antibiotic prophylaxis in case they had echocardiographic evidence of latent rheumatic heart disease. In the control group, children underwent no echocardiographic screening., Main Outcomes and Measures: Prevalence of the composite of definite or borderline rheumatic heart disease according to the World Heart Federation criteria in experimental and control schools as assessed 4 years after intervention., Results: A total of 35 schools were randomized to the experimental group (n = 19) or the control group (n = 16). After a median of 4.3 years (interquartile range [IQR], 4.0-4.5 years), 17 of 19 schools in the experimental group (2648 children; median age at follow-up, 12.1 years; IQR, 10.3-12.5 years; 1308 [49.4%] male) and 15 of 16 schools in the control group (1325 children; median age at follow-up, 10.6 years; IQR, 10.0-12.5 years; 682 [51.5%] male) underwent echocardiographic follow-up. The prevalence of definite or borderline rheumatic heart disease was 10.8 per 1000 children (95% CI, 4.7-24.7) in the control group and 3.8 per 1000 children (95% CI, 1.5-9.8) in the experimental group (odds ratio, 0.34; 95% CI, 0.11-1.07; P = .06). The prevalence in the experimental group at baseline had been 12.9 per 1000 children (95% CI, 9.2-18.1). In the experimental group, the odds ratio of definite or borderline rheumatic heart disease at follow-up vs baseline was 0.29 (95% CI, 0.13-0.65; P = .008)., Conclusions and Relevance: School-based echocardiographic screening in combination with secondary antibiotic prophylaxis in children with evidence of latent rheumatic heart disease may be an effective strategy to reduce the prevalence of definite or borderline rheumatic heart disease in endemic regions., Trial Registration: ClinicalTrials.gov Identifier: NCT01550068.

Importance: Although rheumatic heart disease has been nearly eradicated in high-income countries, 3 in 4 children grow up in parts of the world where it is still endemic., Objectives: To determine the prevalence of clinically silent and manifest rheumatic heart disease as a function of age, sex, and socioeconomic status and to estimate age-specific incidence., Design, Setting, and Participants: In this school-based cross-sectional study with cluster sampling, 26 schools in the Sunsari district in Eastern Nepal with 5467 eligible children 5 to 15 years of age were randomly selected from 595 registered schools. After exclusion of 289 children, 5178 children were enrolled in the present study from December 12, 2012, through September 12, 2014. Data analysis was performed from October 1, 2014, to April 15, 2015., Exposures: Demographic and socioeconomic characteristics were acquired in a standardized interview by means of a questionnaire customized to the age of the children. A focused medical history was followed by a brief physical examination. Cardiac auscultation and transthoracic echocardiography were performed by 2 independent physicians., Main Outcomes and Measures: Rheumatic heart disease according to the World Heart Federation criteria., Results: The median age of the 5178 children enrolled in the study was 10 years (interquartile range, 8-13 years), and 2503 (48.3%) were female. The prevalence of borderline or definite rheumatic heart disease was 10.2 (95% CI, 7.5-13.0) per 1000 children and increased with advancing age from 5.5 (95% CI, 3.5-7.5) per 1000 children 5 years of age to 16.0 (95% CI, 14.9-17.0) in children 15 years of age, whereas the mean incidence remained stable at 1.1 per 1000 children per year. Children with rheumatic heart disease were older than children without rheumatic heart disease (median age [interquartile range], 11 [9-14] years vs 10 [8-13] years; P = .03), more commonly female (34 [64.2%] vs 2469 [48.2%]; P = .02), and more frequently went to governmental schools (40 [75.5%] vs 2792 [54.5%]; P = .002). Silent disease (n = 44) was 5 times more common than manifest disease (n = 9)., Conclusions and Relevance: Rheumatic heart disease affects 1 in 100 schoolchildren in Eastern Nepal, is primarily clinically silent, and may be more common among girls. The overall prevalence and the ratio of manifest to subclinical disease increase with advancing age, whereas the incidence remains stable at 1.1 per 1000 children per year. Early detection of silent disease may help prevent progression to severe valvular damage.

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., (Copyright © 2015 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.)

Background: Rheumatic heart disease accounts for up to 250 000 premature deaths every year worldwide and can be regarded as a physical manifestation of poverty and social inequality. We aimed to estimate the prevalence of rheumatic heart disease in endemic countries as assessed by different screening modalities and as a function of age., Methods: We searched Medline, Embase, the Latin American and Caribbean System on Health Sciences Information, African Journals Online, and the Cochrane Database of Systematic Reviews for population-based studies published between Jan 1, 1993, and June 30, 2014, that reported on prevalence of rheumatic heart disease among children and adolescents (≥ 5 years to <18 years). We assessed prevalence of clinically silent and clinically manifest rheumatic heart disease in random effects meta-analyses according to screening modality and geographical region. We assessed the association between social inequality and rheumatic heart disease with the Gini coefficient. We used Poisson regression to analyse the effect of age on prevalence of rheumatic heart disease and estimated the incidence of rheumatic heart disease from prevalence data., Findings: We included 37 populations in the systematic review and meta-analysis. The pooled prevalence of rheumatic heart disease detected by cardiac auscultation was 2·9 per 1000 people (95% CI 1·7-5·0) and by echocardiography it was 12·9 per 1000 people (8·9-18·6), with substantial heterogeneity between individual reports for both screening modalities (I² = 99·0% and 94·9%, respectively). We noted an association between social inequality expressed by the Gini coefficient and prevalence of rheumatic heart disease (p = 0·0002). The prevalence of clinically silent rheumatic heart disease (21·1 per 1000 people, 95% CI 14·1-31·4) was about seven to eight times higher than that of clinically manifest disease (2·7 per 1000 people, 1·6-4·4). Prevalence progressively increased with advancing age, from 4·7 per 1000 people (95% CI 0·0-11·2) at age 5 years to 21·0 per 1000 people (6·8-35·1) at 16 years. The estimated incidence was 1·6 per 1000 people (0·8-2·3) and remained constant across age categories (range 2·5, 95% CI 1·3-3·7 in 5-year-old children to 1·7, 0·0-5·1 in 15-year-old adolescents). We noted no sex-related differences in prevalence (p = 0·829)., (Copyright © 2014 Rothenbühler et al. Open Access article distributed under the terms of CC BY. Published by .. All rights reserved.)

Objective: To investigate the prevalence, characteristics and maternal and perinatal outcomes of pregnancies complicated by heart disease., Design: Prospective single-centre registry., Setting: Tertiary care teaching hospital in eastern Nepal., Patients: Pregnant women presenting to the antenatal clinic and/or labour room between 1 March 2012 and 31 March 2013., Main Outcome Measures: Prevalence, characteristics, and maternal and perinatal outcomes of pregnancies complicated by heart disease., Results: Fifty-three out of 9463 pregnancies (0.6%) were complicated by cardiac disease. Proportions of acquired, congenital and arrhythmic heart disease amounted to 89%, 9% and 2%, respectively. Rheumatic heart disease (RHD) was the most frequent cardiac disease complicating pregnancy (n=47). Among 45 women with RHD continuing pregnancy until delivery, 30 (67%) were primigravidae. The predominant valvular pathology was mitral stenosis (62%), followed by mitral regurgitation (21%) and aortic regurgitation (13%). Twenty women (44%) underwent elective or emergency caesarean section. Maternal and fetal/perinatal mortality of pregnancies complicated by RHD amounted to 4% and 16%, respectively. New York Heart Association (NYHA) functional class III or class IV (HR 6.0, 95% CI 1.2 to 29.1, p=0.026), pulmonary hypertension (HR 9.1, 95% CI 1.6 to 51.5, p=0.012) and severe mitral stenosis (HR 7.0, 95% CI 1.4 to 34.4, p=0.017) were identified as predictors of maternal or fetal/perinatal mortality in an univariate analysis., Conclusions: Rheumatic mitral stenosis was the most frequent heart disease complicating pregnancy in a consecutive cohort from a teaching hospital in Nepal. Exercise intolerance, pulmonary hypertension and severe mitral stenosis were identified as predictors of maternal or fetal/perinatal mortality.

We present the case of an atypical presentation of myelofibrosis presenting with acute inferior-wall ST-elevation myocardial infarction. Besides cigarette smoking, the patient had no known traditional cardiovascular risk factors like diabetes, hypertension, or a sedentary lifestyle. He, however, had a hypercoagulable state due to a myeloproliferative neoplasm. This demonstrates that the typical presentation of a common emergency condition may involve more complex underlying illness, which when identified, may change the approach to the management of the patient for a more optimal outcome.

Globally, there is a shortage of health workers in rural areas. Effective health systems depend on having sufficient, accessible health workers with the right skills. In countries like Nepal, highly skilled health workers often prefer to work overseas or in urban centres, and therefore, in the short term, it may be pragmatic to focus on ensuring support and skills development of mid level or paramedical health workers. Information technology has the potential to support these health workers. We describe a pilot intervention undertaken in Gulmi District, whereby all mid level health workers in the district have been provided with a free phone number to call three General Practitioner Doctors (GPs) in the District Hospital. The intervention aims to increase appropriate referral, and increase connectivity between the District centre and peripheral health facilities. We hope that our intervention will provide support to rural health workers, and, if implemented as part of a package of interventions, may increase retention. We present some initial findings from discussions with health workers and analysis of call-log data, and describe our next phase evaluation and possible scale-up.

Background: The burden of rheumatic heart disease (RHD) continues to be a major contributor to morbidity and premature death in poor and developing countries. We investigated patterns of valvular involvement in patients with RHD as observed in a large tertiary care hospital in eastern Nepal., Methods: We retrospectively reviewed transthoracic echocardiography reports from patients diagnosed with RHD between June 1999 and February 2011., Results: Among 10 860 transthoracic echocardiography studies, 1055 female and 658 male patients were diagnosed with RHD, 25.7% of the patients being below 20 years of age. Mitral regurgitation was the most common valvular lesion across all age groups irrespective of sex (n = 1321, 77.1%). Female patients were significantly older as compared to male patients at the time of presentation (32.8 ± 15.2 versus 28.5 ± 15.4 years; P < 0.001) and more commonly presented with mitral stenosis as compared to male patients (62.8 versus 51.5%; P < 0.001), with a peak between the age of 30 and 49 years. Conversely, aortic regurgitation was more common in men as compared to women (55.6 versus 48.9%; P = 0.007). Involvement of both the mitral and the aortic valve was observed in 49.8% of the patients and was more common in men as compared to women (52.7 versus 47.8%; P = 0.047)., Conclusion: In this consecutive cohort of patients with RHD in Nepal differential patterns of valvular involvement are observed across sex and age categories.

Objectives: To evaluate a protocol for a population-based programme targeting the prevention of rheumatic heart disease (RHD) progression by early echocardiographic diagnosis of valvular lesions and timely implementation of secondary prevention., Design: Observational survey with a subsequent prospective cohort study., Setting: Private boarding school in the urban area of the Sunsari district situated on the foothills of the Lower Himalayan Range in Eastern Nepal., Participants: Fifty-four unselected school-going children 5-15 years of age, 24 girls and 30 boys., Primary Outcome Measure: Logistic feasibility of a large-scale population-based screening study using the echocardiographic criteria formulated by the World Heart Federation, with longitudinal follow-up of children with definite or borderline RHD in a prospective cohort study., Results: Standardised interview, physical examination and screening echocardiography were performed in a three-staged process and took approximately 6 min per child. Socio-economic status was assessed using surrogate markers such as the occupation of the primary caregiver, numbers of rooms at home, car, television, cell phone and internet connection. Physical examination was focused on cardiac auscultation and signs of acute rheumatic fever and targeted echocardiography was performed by an independent examiner without knowledge of the clinical findings. Two children with evidence of borderline RHD were re-examined at B.P. Koirala Institute of Health Sciences and the indication for secondary antibiotic prevention was discussed with the parents and the children. At 6 months of follow-up, echocardiographic findings were stable in both children. Implementation of secondary antibiotic prevention was challenged by impaired awareness of subclinical RHD among parents and inadequate cooperation with family physicians., Conclusions: This pilot study shows that the methods outlined in the protocol can be translated into a large-scale population-based study. We learned that education and collaboration with teachers, parents and family physicians/paediatricians will be of key importance in order to establish a sustainable programme.

The authors report on the use of 5 French diagnostic catheters to deliver a stent-on-a-wire system during a double vessel coronary intervention., (Copyright © 2011 Wiley Periodicals, Inc.)

Introduction: Rheumatic heart disease (RHD) remains a major contributor to morbidity and mortality in developing countries. The reported prevalence rates of RHD are highly variable and mainly attributable to differences in the sensitivity of either clinical screening to detect advanced heart disease or echocardiographic evaluation where disease is diagnosed earlier across a continuous spectrum. The clinical significance of diagnosis of subclinical RHD by echocardiographic screening and early implementation of secondary prevention has not been clearly established., Methods and Analysis: The authors designed a cross-sectional survey to determine the prevalence of RHD in children from private and public schools between the age of 5 and 15 years in urban and rural areas of Eastern Nepal using both cardiac auscultation and echocardiographic evaluation. Children with RHD will be treated with secondary prevention and enrolled in a prospective cohort study. The authors will compare the prevalence rates by cardiac auscultation and echocardiography, determine risk factors associated with diagnosis and progression of RHD, investigate social and economic barriers for receiving adequate cardiac care and assess clinical outcomes with regular medical surveillance as a function of stage of disease at the time of diagnosis. Prospective clinical studies investigating the impact of secondary prevention for subclinical RHD on long-term clinical outcome will be of central relevance for future health resource utilisation in developing countries., Ethics and Dissemination: The study was considered ethically uncritical and was given an exempt status by the ethics committee at University of Bern, Switzerland. The study has been submitted to the National Nepal Health Research Council and was registered with http://www.ClinicalTrials.gov (NCT01550068). The study findings will be reported in peer-reviewed publications. CLINICALTRIALS.GOV IDENTIFIER: NCT01550068.

Background. This study was carried out to establish the prevalence of cardiovascular risks such as hypertension, obesity, and diabetes in Eastern Nepal. This study also establishes the prevalence of metabolic syndrome (MS) and its relationships to these cardiovascular risk factors and lifestyle. Methods. 14,425 subjects aged 20-100 (mean 41.4 ± 15.1) were screened with a physical examination and blood tests. Both the International Diabetic Federation (IDF) and National Cholesterol Education Programme's (NCEP) definitions for MS were used and compared. Results. 34% of the participants had hypertension, and 6.3% were diabetic. 28% were overweight, and 32% were obese. 22.5% of the participants had metabolic syndrome based on IDF criteria and 20.7% according to the NCEP definition. Prevalence was higher in the less educated, people working at home, and females. There was no significant correlation between the participants' lifestyle factors and the prevalence of MS. Conclusion. The high incidence of dyslipidemia and abdominal obesity could be the major contributors to MS in Nepal. Education also appears to be related to the prevalence of MS. This study confirms the need to initiate appropriate treatment options for a condition which is highly prevalent in Eastern Nepal.

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.

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.

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.

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.

"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.", (excerpt)

"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.", (excerpt)

"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.", (excerpt)