Phytotoxic effects of invasive Ageratina adenophora on two native subtropical shrubs in Nepal.

The response of native plants to allelopathic interference of invasive species may differ from species to species. In this study, the phytotoxic effects of Ageratina adenophora were tested on two native shrubs (Osbeckia stellata and Elsholtzia blanda) of Nepal. Both the shrubs were grown in pots under treatments of A. adenophora fresh leaves and root leachates, and litter. Then, the seedling length and biomass were compared among the treatments. The results show that A. adenophora litter has stimulatory effects but the leachates from fresh leaves and root are phytotoxic to the growth and development of native shrubs. Infrared Spectroscopy (IR) analysis confirmed the presence of O-H (Hydroxyl), N-H (Amines), C≡C (Alkynes), and C-H stretching (Aromatic) or C-O-C stretching (Ethers) in the leachates representing harmful allelochemicals. The invaded soil by A. adenophora had low pH and a high amount of organic matter, total nitrogen, phosphorus, and potassium than the uninvaded soil. The results indicate that the native O. stellata and E. blanda are harmed by A. adenophora in nature by leaching of allelochemicals and probably by reducing the soil pH. Overall, this study has provided valuable insights regarding the effects of A. adenophora invasion on native shrubs and revealing the potential mechanism of its invasiveness.

Out of pocket Expenditure on Health Service Delivery at a Tertiary Care Women's Hospital: A Descriptive Cross-sectional Study.

INTRODUCTION: Institutional delivery in Nepal is increasing in the past decades and has been the priority program of the government of Nepal. However, due to the hidden costs related to institutional deliveries, the financial burden remains unacceptably high for poor households. The study aimed to find out the major out of pocket expenditure on health service delivery at a tertiary care hospital in Kathmandu, Nepal. METHODS: A descriptive cross-sectional study was carried out at a tertiary care hospital from December 2018 to May 2019. Ethical approval was taken from Nepal Health Research Council (ref. no. 2087) and permission was taken from the hospital. Informed consent was taken from the participants. Convenient sampling was done. A semi-structured questionnaire was used as a tool for the interview. Data was entered into Epidata and analyzed using the Statistical Package of the Social Sciences version 23. Descriptive analysis was done using mean, median, standard deviation, inter-quartile range, frequency, and percentage. RESULTS: The median out of pocket expenditure of the participants to maternal delivery was NRs. 11720 (7610-20263). The median expenditure was found highest for food and drinking NRs. 2500 (1500-5550) and transportation NRs. 2150 (1400-4543) respectively. CONCLUSIONS: Indirect expenditures were found to be higher than direct medical expenditures. Accessibility of the birthing centers and health insurance may reduce the costs related to maternal deliveries.

Hypoglycemia in Hospitalized Hemodialysis Patients With Diabetes: An Observational Study.

INTRODUCTION: Hypoglycemia and hyperglycemia affect outcomes in hospitalized patient. Patients with diabetes and end stage renal disease are prone to hypoglycemia and few studies have evaluated glucometrics to identify the incidence and risk factors for hypoglycemia in this population. METHODS: We designed an observational retrospective review of 150 insulin requiring inpatients with diabetes receiving hemodialysis. We collected demographics, baseline characteristics, and glucometric data focusing on episodes of hypoglycemia with glucose cutoffs <70, <54, and <40 mg/dl. Detailed glucose and insulin data for 24 hours before and after hemodialysis was analyzed for each patient in context of a hypoglycemic episode. T-tests, one-way ANOVA, and chi-square tests were used for statistical analysis. RESULTS: At least one glucose value less than 70 mg/dl was observed in 51% of hemodialysis patients, less than 54 mg/dl in 28%, and less than 40 mg/dl in 11%. Patients with hypoglycemia had a higher HbA1c, standard deviation of glucose ( P = .0009) and higher total daily dose (TDD) of insulin by weight (0.34 units/kg vs 0.23 units/kg, P = .003). We observed a linear increasing risk for hypoglycemia with increasing TDD, with nearly 65% of hypoglycemic episodes occurring with TDD >0.20 units/kg. A majority (61%) of all hypoglycemic episodes occurred in the 24 hours prior to a hemodialysis session. Type 1 diabetes was independently associated with hypoglycemia. CONCLUSIONS: Hospitalized diabetes patients undergoing hemodialysis were found to have high rates of hypoglycemia. Our results support using a lower TDD of insulin in this population (<0.23 units/kg/day) and recommend special caution in those with type 1 diabetes.

PATHOPHYSIOLOGY AND MANAGEMENT OF HYPOGLYCEMIAIN END-STAGE RENAL DISEASE PATIENTS: A REVIEW.

OBJECTIVE: This review focuses on hypoglycemia in patients with end-stage renal disease (ESRD). It discusses the pathophysiology of glucose metabolism in the kidney, the impact of dialysis on glucose and insulin metabolism, and the challenges of glucose monitoring in ESRD. The clinical relevance of these changes is reviewed in relation to altered blood glucose targets and modification of antidiabetes therapy to prevent hypoglycemia. Based on current data and guidelines, recommendations for the outpatient and inpatient setting are provided for diabetes management in ESRD. METHODS: PubMed, OVID, and Google Scholar were searched to identify related articles through May 2016 using the following keywords: "glucose metabolism," "kidney," "diabetes," "hypoglycemia," "ESRD," and "insulin" in various combinations for this review. RESULTS: In ESRD, a combination of impaired insulin clearance, changes in glucose metabolism, and the dialysis process make patients vulnerable to low blood glucose levels. Hypoglycemia accounts for up to 3.6% of all ESRD-related admissions. At admission or during hospitalization, hypoglycemia in ESRD has a poor prognosis, with mortality rates reported at 30%. Several guidelines suggest a modified hemoglobin A1c (A1c) goal of 7 to 8.5% (53 to 69 mmol/mol) and an average blood glucose goal of 150 to 200 mg/dL. Noninsulin antidiabetes agents like dipeptidyl peptidase 4 inhibitors, repaglinide, and glipizide in appropriate doses and reduction of insulin doses up to 50% may help decrease hypoglycemia. CONCLUSION: Patients with ESRD are at high risk for hypoglycemia. Increased awareness by providers regarding these risks and appropriate diabetes regimen adjustments can help minimize hypoglycemic events. ABBREVIATIONS: ADA = antidiabetes agent BG = blood glucose CKD = chronic kidney disease DPP-4 = dipeptidyl peptidase 4 eGFR = estimated glomerular filtration rate ESRD = end-stage renal disease GFR = glomerular filtration rate HD = hemodialysis NPH = neutral protamine Hagedorn PD = peritoneal dialysis SA = short acting SU = sulfonylurea.

The potential role of incretin therapy in the hospital setting.

Hyperglycemia has been associated with increased morbidity and mortality in hospitalized patients. Insulin has traditionally been the drug of choice for managing hyperglycemia in this setting, but carries a significant risk of hypoglycemia. Incretin-based therapies, including glucagon-like peptide-1, glucagon-like peptide-1 receptor agonists and dipeptidyl peptidase-4 inhibitors, have potential use in the hospital. These agents have a relatively low risk of hypoglycemia, favorable short-term side effect profile, and can be used alone or in combination with insulin. Several small studies have supported the safety and efficacy of incretin therapies in the inpatient setting with the majority of data coming from the intensive care setting. Large-scale clinical studies are needed to further evaluate the potential role of incretins in the management of inpatient hyperglycemia.

The Institute of Medicine, the Food and Drug Administration, and the calcium conundrum.

In the present article we aim to bring forward the apparent disconnect between two US government-sponsored entities - the Institute of Medicine (IOM) and the Food and Drug Administration (FDA) - regarding the safe upper limit of Ca intake. In light of the 2011 US Congress-appointed IOM report indicating an upper limit of elemental Ca intake of 2000-2500 mg/d in adults (based on age group), it is perplexing that the FDA has not yet required a change on the labelling of over-the-counter Ca-containing antacids, some of which indicate an upper limit of elemental Ca intake of 2800-3000 mg/d. Even more concerning is that Ca intake is rarely from supplementation in isolation. National Health and Nutrition Examination Survey (NHANES) data from 2003-2006 indicate that mean dietary Ca intakes for males ranged from 871 to 1266 mg/d and for females from 748 to 968 mg/d depending on the age group. The estimated total Ca (diet + supplements) intake exceeded the upper limit in 5 % of the population older than 50 years. Furthermore, NHANES data from 1999-2000 indicate that when Ca is taken as part of an antacid preparation, patients often fail to report this as Ca intake. Thus, individuals taking the maximum allowable dose of supplemental Ca as antacids are at high risk for complications associated with excess Ca intake. Our hope is that by describing Ca homeostasis and highlighting the risks and dangers of Ca overload, the FDA will align its recommendation with the IOM and solve the current Ca conundrum in the USA for the sake of patient safety.