Effect of mycophenolate mofetil on the white blood cell count and the frequency of infection in systemic lupus erythematosus.

Leukopenia is a common manifestation of SLE. Addition of immunosuppressive therapy in a SLE patient who is already leukopenic is a clinical concern. It could worsen leukopenia, increase the risk of infection, or both. The aim of this study was to analyze the immediate effect of mycophenolate mofetil on the white blood cell count and the rate of infection in SLE patients. Two hundred and forty-four patients within the Hopkins Lupus Cohort who were newly started on mycophenolate mofetil were included in the study. The white blood cell count and interval infection history on the day mycophenolate mofetil was started were compared with the white blood cell count and interval infection history at the next visit. The study was based on 244 patients who began taking mycophenolate mofetil in the cohort. The study population included 47 % African Americans, 44 % Caucasians, and 9 % other ethnicities. There was a slight but not statistically significant increase in the white blood cell count (6.63 vs. 7.01), after starting mycophenolate mofetil. Patients with a baseline white blood cell count \u3c3000/mm(3) did have a statistically significant increase in the white blood cell count after starting mycophenolate mofetil (2.57 vs. 5.13, P = 0.0047). We also found a statistically significant increase in the risk of bacterial infection (but not viral infection) after starting mycophenolate mofetil (4 vs. 9 %, P = 0.0036). Leukopenia does not worsen with mycophenolate mofetil. However, mycophenolate mofetil appears to slightly increase the rate of bacterial (but not viral) infection

Rice production in Chitwan district of Nepal: An analysis from economic and environmental perspectives

Rice (Oryza sativa L.) is the major staple food in the Nepalese context. Chitwan district of Nepal was purposively selected to analyze the rice production from the socio-economic and environmental perspective. A total of 100 rice growing farmers, 50 organic and 50 inorganic were selected as the sample for the purpose of the study using the simple random method of sampling. Primary data were collected through a pre-tested semi-structure interview schedule and key informant interviews; secondary data were collected reviewing related publications. Descriptive statistics, multiple regression and chi-square test were used for data analysis. The multiple regression revealed that the four explanatory variables included in the model: age of the household head, primary occupation of the household head, number of family members involved in agriculture and subsidy in inputs for rice farming were found to have positive and statistically significant effect on rice yield (P<0.01). Moreover, chi-square test revealed that the farming practices that contributes to climate change mitigation such as: minimum tillage practice (P<0.05), crop diversification (P<0.01), green manuring (P<0.01), agro forestry practice (P<0.05), incorporating crop residues (P<0.1), weed management practice (P<0.01) and pest management practice (P<0.01)were found to be well adopted by the organic rice farmers, in contrast, the farming practices of inorganic rice farmers were statistically and significantly different in this respect. Government should make such policy that could grave the attention of the Nepalese people towards organic agriculture; moreover, encouraging them to make it their primary occupation

Climate change and maize agriculture among Chepang communities of Nepal: A review

This paper reviews recent literature concerning effects of climate change on agriculture and its agricultural adaptation strategies, climate change impacts on Chepang communities and their maize farming. Climate change is perhaps the most serious environmental threat to agricultural productivity. Change in temperature and precipitation specially has greater influence on crop growth and productivity and most of these effect are found to be adverse. Climate change has been great global threat with global temperature rise by 0.83 °C and global sea level rise by 0.19 m. Poor countries of the world are more vulnerable to changing climate due to different technological, institutional and resource constraints. In context of Nepal, practices like tree plantation, lowering numbers of livestock, shifting to off farm activities, sloping agricultural land technology (SALT) and shifting cultivation are most common coping strategies. Chepang, one of the most backward indigenous ethnic groups of Nepal are also found to perceive change in the climate. Perception and adaptation strategies followed by different farmers of world including Chepang is mainly found to be effected by household head’s age, size of farm, family size, assessment to credit, information and extension service, training received and transportation. Maize is second most important crop in Nepal in which increase in temperature is favorable in Mountain and its yield is negatively influenced by increase in summer rain and maximum temperature. Local knowledge of indigenous people provides new insights into the phenomenon that has not yet been scientifically researched. So, government should combine this perceptive with scientific climate scenario and should conduct activities in term of adoption strategies and policies to insist targeted and marginalized farmers

A Case of Severe Hypoxia Caused by Phenazopyridine-Induced Methemoglobinemia: A near Fatal Event from Over-the-Counter Medication Use

Methemoglobinemia is a rare blood disorder characterized by the oxidation of heme iron from ferrous (Fe2+) to ferric (Fe3+) state, which increases oxygen affinity and impairs oxygen release to the tissue causing hypoxia. It can be congenital or acquired; however, most cases are acquired and caused by exogenous substances such as medications, chemicals, and environmental substances. Phenazopyridine is an over-the-counter urinary analgesic medication commonly used for symptomatic relief of dysuria and has been reported to cause methemoglobinemia. However, only a handful of cases of phenazopyridine-induced methemoglobinemia have been reported. We present a case of an 89-year-old female who presented with severe hypoxia, shortness of breath, headache, nausea, and dizziness caused by phenazopyridine-induced methemoglobinemia. She was found to have a methemoglobin level of 21.5% and was treated with methylene blue, leading to a rapid improvement of her symptoms. She was taking one over-the-counter phenazopyridine 200 mg tablet three times daily for two weeks for her chronic dysuria. This case highlights the need to have a high index of suspicion of phenazopyridine-induced methemoglobinemia in a patient presenting with unexplained shortness of breath with a history of phenazopyridine use as it could lead to severe methemoglobinemia with hypoxia that could potentially be fatal if not promptly diagnosed

Improving Blood Transfusion Practices in a Community Hospital Setting: Our Experience with Real-Time Clinical Decision Support

There is good evidence that 50% or more of red blood cell (RBC) transfusions are unnecessary. To curtail inappropriate RBC transfusions at our hospital, real-time clinical decision support was implemented in our electronic medical record (EMR) that alerts clinicians to the patient’s most recent pretransfusion hemoglobin value upon order entry and provides Best Practice Advisory. This is a soft pop-up alert which is activated when the hemoglobin exceeds 7 g/dL. The ordering clinician can either honor (by cancelling the order) or override the alert. We studied the impact of the alert on blood utilization during a 3-month period (November 2016 to January 2017). For patients who were transfused despite the alert, a retrospective review of the medical chart was performed to determine whether or not the transfusion was clinically indicated. During the study period, 178 of the 895 RBC transfusion orders (20%) triggered the alert. After excluding duplicates, 144 orders were included in our analysis. Most of these orders (124/144, 86%) were carried out despite the alert. According to our chart review, 48% of the alert transfusions could be considered inappropriate, with hemodynamically stable, asymptomatic anemia being the leading indication. Of clinical services, orthopedic surgery had the highest rate of overriding the alert with no clinical justification (70%). The number of RBC transfusions dropped from 313.5 units per month (preintervention period) to 293.2 units per month (postintervention period)—a 6.5% decrease. Real-time clinical decision support may reduce the number of inappropriate RBC transfusions in a community hospital setting, though in our study, the decrease in blood utilization (6.5%) did not reach statistical significance

Economics of Organic Vs Inorganic Rice Production: a Case of Chitwan District of Nepal

Xiii Rice (Oryza sativa L.) is the major staple food crop of Nepal. A research was conducted in December, 2019 to examine the economic viability of organic rice farming and factors affecting its adoption. Fulbari area of Chitwan district of Nepal was purposively selected for this study on consultation with Agriculture Knowledge Centre, Chitwan and review of past works which showed good practice of organic rice farming. A total of 100 farm households, 50 organic and 50 inorganic were selected using simple random sampling. Primary data were collected through a pre-tested semi-structured interview schedule, while secondary data were collected from related publications. The probit regression analysis showed that the six variables were statistically significant for the decision to adopt organic rice farming, they are: number of schooling years of the household head (p= 0.014), annual household income from agriculture (p= 0.012), membership of any agricultural organization (p= 0.000), subsidy in other inputs in addition to seed and fertilizers (p= 0.000), area of rice cultivated land (p= 0.007) and awareness on climate change (0.086). The benefit cost ratio of organic rice production (2.2) was higher as compared to inorganic (1.9) which showed that the profitability in organic rice production was higher than in inorganic. Furthermore, indexing identified- lengthy certification process (0.85) as the first major hindrance in adoption of organic rice farming followed by lack of proper organic market (0.68), high cost of organic seed and fertilizer (0.56), lack of knowledge and trainings on organic farming (0.48) and lack of government support such as grants and premium price (0.44) as the second, third, fourth and fifth hindrances respectively. The government should promote organic rice farming, prioritizing the small scale and marginal farmers by giving subsidies and premium, facilitating in certification and marketing, and providing knowledge about climate change

RS3PE revisited: a systematic review and meta-analysis of 331 cases.

OBJECTIVES: Remitting seronegative symmetrical synovitis with pitting oedema (RS(3)PE) syndrome is a rare inflammatory arthritis, characterised by symmetrical distal synovitis, pitting oedema of the hands and feet, absence of rheumatoid factor, and favourable response to glucocorticoids. The aim of our study is to further delineate the clinical and laboratory features, and response to treatment. METHODS: We performed a systematic electronic search of Medline, PubMed, EMBASE, ACR and EULAR databases for case reports, case series, and related articles of RS(3)PE. Statistical analysis was done comparing categorical variables with Chi-square tests and frequencies of means via t-tests. Binary logistic regression analysis was performed to identify predictors of erosions, recurrence, malignancy and rheumatologic disorders. RESULTS: 331 cases of RS(3)PE were identified from 121 articles. RS(3)PE was found in older patients (71±10.42 years) predominantly in males (n= 211, 63.36%), was symmetrical (n=297/311, 95.50%) involved the hands (n=294/311, 94.53%) A concurrent rheumatologic condition was reported in 22 cases (6.65%), and malignancy in 54 cases (16.31%). Radiographic joint erosions were found in 5.5%. Most patients responded to medium-dose glucocorticoids (16.12±9.5 mg/day). Patients with concurrent malignancy requiring non-significantly higher doses of prednisone (18.12 vs. 15.76 mg, p 0.304) and higher likelihood of recurrence of disease (OR 4.04, 95% CI 1.10-14.88, p=0.03). CONCLUSIONS: The symptoms and unique findings that make up RS(3)PE appear to represent a steroid-responsive disease that may be a harbinger of an underlying malignancy. More study is needed to understand the molecular origins of RS(3)PE in order to determine whether it is a separate disease process. Patients with concurrent cancer tend to have more severe presentations and higher rates of recurrence

Distribution of important medicinal plant species in Nepal under past, present, and future climatic conditions

Climate change is causing shifts in the habitat, distribution, ecology, and phenology of Himalayan plants. These changes are predicted to continue, jeopardizing the survival of medicinal plant species and local livelihoods that rely on them. We analyzed the present and future diversity and distribution of medicinal plant species influenced by different climate change scenarios, and calculated the climatic niche of the species using ensemble species distribution modeling (eSDM). We compiled 1041 (N) geospatial data of seven high-value medicinal plant species of Nepal: Aconitum spicatum (n = 100), Allium wallichii (n = 151), Bergenia ciliata (n = 48), Nardostachys jatamansi (n = 121), Neopicrorhiza scrophulariiflora (n = 94), Paris polyphylla (n = 310) and Valeriana jatamansi (n = 217) including over 85 % from field surveys and the rest from literature and online database. We used bioclimatic variables from Models for Interdisciplinary Research on Climate (MIROC) of version MIROC6, and selected Shared Socioeconomic Pathways (SSP)2-4.5 and SSP5-8.5 for the year of 2050 and 2070 for modeling. We found elevation, mean diurnal and annual temperature ranges (BIO2 and BIO7), and precipitation of warmest and coldest quarters (BIO18 and BIO19) to be the most high weight cofactors for projecting the future potential distribution of high-value medicinal plants in Nepal. Results showed that the suitable range of distribution for high-value medicinal plants would increase and concentrate in mountainous areas of central Nepal, but decline in (sub)tropical and temperate areas, suggesting both in-situ and ex-situ conservation practices, respectively