BackgroundThere has been a paradigm shift in the definition of timing of early invasive strategy (EIS) for patients admitted with non‐ST‐elevation myocardial infarction (NSTEMI) in the last decade. Data on trends of EIS for NSTEMI and associated in‐hospital outcomes are limited. Our aim is to analyze temporal trends in the incidence, utilization of early invasive strategy, and in‐hospital outcomes of NSTEMI in the United States.Methods and ResultsWe analyzed the 2002–2011 Nationwide Inpatient Sample databases to identify all patients ≥40 years of age with the principal diagnosis of acute myocardial infarction (AMI) and NSTEMI. Logistic regression was used for overall, age‐, sex‐, and race/ethnicity‐stratified trend analysis. From 2002 to 2011, we identified 6 512 372 patients with AMI. Of these, 3 981 119 (61.1%) had NSTEMI. The proportion of patients with NSTEMI increased from 52.8% in 2002 to 68.6% in 2011 (adjusted odds ratio [OR; per year], 1.055; 95% confidence interval [CI], 1.054 to 1.056) in the overall cohort. Similar trends were observed in age‐, sex‐, and race/ethnicity‐stratified groups. From 2002 to 2011, utilization of EIS at day 0 increased from 14.9% to 21.8% (Ptrend<0.001) and utilization of EIS at day 0 or 1 increased from 27.8% to 41.4% (Ptrend<0.001). Risk‐adjusted in‐hospital mortality in the overall cohort decreased during the study period (adjusted OR [per year], 0.976; 95% CI, 0.974 to 0.978).ConclusionsThere have been temporal increases in the proportion of NSTEMI and, consistent with guidelines, greater utilization of EIS. This has been accompanied by temporal decreases in in‐hospital mortality and length of stay.

Background:Cutaneous tuberculosis (TB) is essentially an invasion of the skin by Mycobacterium tuberculosis, the same bacteria that causes pulmonary tuberculosis.Aim:This study was conducted to study the common types of cutaneous TB and to find the management pattern in a tertiary teaching hospital in Pokhara, Nepal.Materials and Methods:All the cases of cutaneous TB were biopsied and furthermore investigated by performing Mantoux test, sputum examination, fine needle aspiration cytology, chest X-ray and ELISA.Results:In this study, we found that tuberculosis verrucous cutis (48%) had a higher incidence than other types of cutaneous TB. More males were affected than were females (1.2:1). Commonly affected sites were the limb and the buttock (48%). The most commonly affected age group was 16–25 years (40%). All cases (except two) were more than 15 mm in size in the Mantoux test. The histopathological picture was typical in all except three cases. All patients were treated with antitubercular treatment as per the national guidelines.Conclusion:The most common type of cutaneous TB was tuberculosis verrucous cutis and the most commonly affected sites were the limb and the buttock. As cutaneous TB sometimes reflects the presence of pulmonary tuberculosis, its incidence should not be ignored.

Background/Aim:Alcohol is the most common substance abused in Nepal. Liver disease caused by alcohol abuse, including its end stage, cirrhosis, is a major health care problem, which is difficult to treat.Objectives:To study the demographic profile, laboratory parameters, complications and their prognostic implications among patients of alcoholic liver disease (ALD).Materials and Methods:Records of all patients of ALD admitted from January 1' 2005 to December 31' 2006 were studied and followed up to December 31, 2007. A total of 181 patients were analyzed. Their clinical profile and laboratory parameters were noted and analyzed using SPSS-10.0 software.Results:Among the 181 patients, 80.7% were male, 30.9% were army/ex-army and 65.2% were documented smokers. The mean age of presentation was 52.08 years. Jaundice (57.5%) was the most common presentation followed by hepatomegaly (51.4%). Hypoalbuminemia (50.3) followed by ascites (48.1) were common complications. Death occurred in 19.1% of the patients, the most common cause being hepatic encephalopathy (72.2%) followed by variceal bleeding and hepatorenal syndrome. Jaundice, ascites and hepatic encephalopathy at presentation and female sex were significantly associated with increased mortality along with discriminant score >32, aspartate aminotransferase (AST): Alanine aminotranferase (ALT) ≥ 2, ultrasonography (USG)-proven cirrhosis, rise in prothrombin time ≥5 s, total bilirubin ≥ 4mg/dL and ESR ≥34.Conclusion:ALD was predominantly seen among the productive age group with a high morbidity and mortality. Jaundice, ascites, hepatic encephalopathy at presentation and female sex are poor prognostic indicators along with discriminant score > 32, AST:ALT ≥ 2, USG-proven cirrhosis, coagulopathy, hyperbilirubenemia and high ESR.

Aim:  To reveal the commonly occurring important types of rheumatological disorders, as well as various clinico‐epidemiological aspects, concurrent medical illnesses, and the ancillary medications used, along with their side‐effects. Method:  A total of 365 patients with various rheumatological disorders were studied at the Rheumatology Department of Manipal Teaching Hospital, Pokhara, Nepal from September 2001 to September 2004. The diagnosis was based on the criteria of the American College of Rheumatology (1988). A pro forma was prepared for 30 common rheumatological disorders, listing patient identification, clinical characteristics, disease duration, objective and subjective assessment of the progress of the diseases, monitoring the response of treatment and side‐effects of medications. Patients aged 15–75 years, men and women suffering from various musculoskeletal disorders, fulfilling the ACR criteria, were studied. Each patient was followed up at 1–3 monthly interval and data recorded systematically to monitor the progress of joint function and evaluating the effects of medications. Results:  Out of the 365 patients recorded, only 337 fulfilled the criteria laid down by ACR. Most common rheumatological disorders in order of frequency were soft tissue rheumatism (40.0%), inflammatory arthritis (21.36%) and bone and cartilage diseases (21.06%). Connective tissue disorders were only 4.74%. Seronegative spondyloarthritis group was only 2.67% and least common disease was gout at 3.85%. Rheumatoid arthritis was the most common inflammatory arthritis observed in 20.17% of total cases. Fibromyalgia was the most common soft tissue rheumatism seen in 19.88%. Osteoarthritis of knee, hand and hip were the most common degenerative disorder of the bone and cartilage, constituting 10.38%. Lumbago, lumbar spondylolisthesis and spinal canal stenosis together comprised 14.24% of patients with low back pain. Cervical spondylosis and all types of shoulder joint pain syndromes comprised 5.93% and 5.34%, respectively. Patients were mostly in the age group 20–60 years. The most common type of drug used in all rheumatic conditions was non‐steroidal anti‐inflammatory drugs in 81.6% of cases followed by steroids in 26.7%, disease‐modifying and cytotoxic drugs in 18.6% and 17.2% of cases, respectively. Chronic obstructive airway disease and hypertension constituted the major concurrent illness in 23.63% and 18.78%, respectively. Conclusion:  This unique type of clinico‐epidemiological study on rheumatological disorders, the first in Nepal, will provide a rich database for future investigations into rheumatology and would plan for all levels of prevention and therapy in the future.

Designing, implementing, and applying agent-based models (ABMs) requires a structured approach, part of which is a comprehensive analysis of the output to input variability in the form of uncertainty and sensitivity analysis (SA). The objective of this paper is to assist in choosing, for a given ABM, the most appropriate methods of SA. We argue that no single SA method fits all ABMs and that di erent methods of SA should be used based on the overarching purpose of the model. For example, abstract exploratory models that focus on deeper understanding of the target system and its properties are fed with only the most critical data representing patterns or stylized facts. For them, simple SA methods may be su icient in capturing the dependencies between the output-input spaces. In contrast, applied models used in scenario and policy-analysis are usually more complex and data-rich because a higher level of realism is required. Here the choice of a more sophisticated SA may be critical in establishing the robustness of the results before the model (or its results) can be passed on to end-users. Accordingly, we present a roadmap that guides ABM developers through the process of performing SA that best fits the purpose of their ABM. This roadmap covers a wide range of ABM applications and advocates for the routine use of global methods that capture input interactions and are, therefore, mandatory if scientists want to recognize all sensitivities. As part of this roadmap, we report on frontier SA methods JASSS, () , http://jasss.soc.surrey.ac.uk/ / / .html Doi:. /jasss. emerging in recent years: a) handling temporal and spatial outputs, b) using the whole output distribution of a result rather than its variance, c) looking at topological relationships between input data points rather than their values, and d) looking into the ABM black box âĂŞ-finding behavioral primitives and using them to study complex system characteristics like regime shi s, tipping points, and condensation versus dissipation of collective system behavior.

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Background:The global prevalence of dengue has increased dramatically in recent decades, with currently 50 million clinical cases and up to 5 million hospitalisations annually. Caused by one of five closely related but antigenically distinct virus serotypes (DEN-1 to DEN-5), dengue is an emerging mosquito-borne viral disease and an important public health problem in Nepal.Objectives: This study was designed to determine the occurrence of dengue in clinically suspected patients in Narayani Zone, Central Nepal.

Background:Ischemic mitral regurgitation is a frequent complication of acute coronary syndrome. It primarily occurs in patients with a prior myocardial infarction but also may be seen with acute ischemia, a setting in which the MR typically resolves after the ischemia resolves. The vast majority of patients have “functional” ischemic MR. In these individuals, the papillary muscles, chordae, and valve leaflets are normal. However, the leaflets do not coapt and restricted leaflet motion is frequently noted on echocardiography. Ischemic mitral regurgitation indicates a poor prognosis after acute myocardial infarction. This study addresses the clinical characteristics of patients of acute coronary syndrome with mild functional ischemic mitral regurgitation and its impact on immediate in-hospital cardiovascular outcomes and death.Patients and Methods:From March 2006 through May 2007, patients who underwent 2-dimensional (2D) color doppler echocardiographic quantification of ischemic mitral regurgitation within 10 days of admission for acute coronary syndrome (ACS) in Manipal Teaching Hospital, a tertiary hospital in the western region of Nepal were noted. The demographic details, conventional risk factors of coronary artery disease, clinical and laboratory findings, treatment course and in-hospital outcomes of all the patients with mild functional ischemic MR following ACS in that time duration were recorded in a designated Performa. A total of 94 patients enrolled in the study were divided into two groups: Group I with mild functional ischemic MR and Group II without MR on 2D echocardigraphic assessment. Patient characteristics, risk factors, ejection fraction, and cardiovascular outcome and death among the two groups were compared and analyzed using software package SPSS 17.0 version.Results:Group I constituted 64.89% of the study population and Group II comprised of 35.11%. The patients in Group I was more likely to be elderly diabetic (P<0.05), and smokers with hypertension (P < 0.05). Mild functional ischemic MR was more common in patients with STEMI as compared to those with unstable angina and NSTEMI (55.7%, 36.1%, and 8.2%; P < 0.05).The mean ejection fraction in the first group was 54.84% in contrast to 58.92% observed in group II (P < 0.05).The type of wall involvement inferred from EKG analysis was homogeneously distributed in both the groups. Finally, there was no difference in immediate in-hospital (within 10 days) mortality or cardiovascular outcomes (heart failure, ventricular tachycardia/fibrillation, hypotension, and cardiogenic shock) between these two groups.Conclusion:Ischemic mitral regurgitation following acute coronary syndromeare more likely in elderly diabetics and hypertensive smokers. It is a more common finding in STEMI. Although mild MR following ACS does reduce ejection fraction, the immediate (within 10 days) in-hospital mortality and cardiovascular outcomes are not significantly altered.