Pediatric kidney transplantation in the developing world: challenges and solutions.

The prevalence of pediatric RRT and transplantation are low in developing countries, 6-12 and <1 to 5 per million child population (pmcp), respectively. This is due to low GDP/capita of <$10 000, government expenditure on health of <2.6-9% of GDP and paucity of facilities. The reported incidence of pediatric CKD and ESRD is <1.0-8 and 3.4-35 pmcp, respectively. RRT and transplantation are offered mostly in private centers in cities where HD costs $20-100/session and transplants $10 000-20 000. High costs and long distance to centers results in treatment refusal in up to 35% of the cases. In this backdrop 75-85% of children with ESRD are disfranchised from RRT and transplantation. Our center initiated an integrated dialysis-transplant program funded by a community-government partnership where RRT and transplantation was provided "free of cost" with life long follow-up and medication. Access to free RRT at doorsteps and transplantation lead to societal acceptance of transplantation as the therapy of choice for ESRD. This enabled us to perform 475 pediatric transplants in 25 years with 1- and 5-year graft survival of 96% and 81%, respectively. Our model shows that pediatric transplantation is possible in developing countries when freely available and accessible to all who need it in the public sector.

Data analytics and knowledge management approach for COVID-19 prediction and control.

The Coronavirus Disease (COVID-19) caused by SARS-CoV-2, continues to be a global threat. The major global concern among scientists and researchers is to develop innovative digital solutions for prediction and control of infection and to discover drugs for its cure. In this paper we developed a strategic technical solution for surveillance and control of COVID-19 in Delhi-National Capital Region (NCR). This work aims to elucidate the Delhi COVID-19 Data Management Framework, the backend mechanism of integrated Command and Control Center (iCCC) with plugged-in modules for various administrative, medical and field operations. Based on the time-series data extracted from iCCC repository, the forecasting of COVID-19 spread has been carried out for Delhi using the Auto-Regressive Integrated Moving Average (ARIMA) model as it can effectively predict the logistics requirements, active cases, positive patients, and death rate. The intelligence generated through this research has paved the way for the Government of National Capital Territory Delhi to strategize COVID-19 related policies formulation and implementation on real time basis. The outcome of this innovative work has led to the drastic reduction in COVID-19 positive cases and deaths in Delhi-NCR.

iQMS: IoT-based QMS framework for tracking of quarantined subjects.

The outbreak of Coronavirus Disease as a pandemic has resulted in a huge saddle on health infrastructure. Preventive measures such as quarantine, social distancing, isolation, and community containment play a pivotal role to contain the spread of exponentially growing COVID cases. This huge burden permitted authorities for institutional/home quarantine for the suspected persons. The biggest challenge for institutional/home quarantine is to monitor and track the movement of quarantined persons. These suspected cases pose a serious threat in outbreak and transmission of the disease. In this paper, an intelligent-Quarantine Monitoring System (iQMS) has been presented which comprises of a wearable IoT-based wristband, bundled with an android mobile app to track and report the absconding quarantined subjects in near real-time. The iQMS incorporates a cloud-based solution with IoT sensors using a global positioning system (GPS) based tracker for geo-fencing breach. The proposed system will facilitate the authorities in remote monitoring and tracking of identified subjects.

A renal transplantation model for developing countries.

The estimated incidence of end-stage renal disease (ESRD) in Pakistan is 100 per million population. Paucity and high costs of renal replacement therapy allows only 10% to get dialysis and 4-5% transplants. Our center, a government organization, started a dialysis and transplant program in 1980s where all services were provided free of charge to all patients. It was based on the concept of community government partnership funded by both partners. The guiding principles were equity, transparency, accountability and development of all facilities under one roof. This partnership has sustained itself for 30 years with an annual budget of $25 million in 2009. Daily 600 patients are dialyzed and weekly 10-12 receive transplants. One- and 5-year graft survival of 3000 transplants is 92% and 85%, respectively. The institute became a focus of transplantation in Pakistan and played a vital role in the campaign against transplant tourism and in promulgation of transplant law of 2007, and also helped to increase altruistic transplants in the country. This model emphasizes that in developing countries specialized centers in government sector are necessary for transplantation to progress and community support can make it available to the common man.

Living related renal transplants with lifelong follow-up. A model for the developing world.

AIMS: To describe the dynamic of a model of public government partnership for dialysis and transplantation in developing countries. MATERIALS: A model was established on the philosophy of public-government partnership to provide an integrated dialysis and transplant service "Free with dignity" with lifelong follow-up care and medications. The government provided 50% of funds and the public was motivated to donate the rest. This included affluent individuals, corporations, business houses and the general public. RESULTS: This model has been sustained for the last two decades. In 2008, 655,000 patients were treated at SIUT. Over 600 patients are dialyzed each day with a total of 165,411 dialysis sessions/year. Thus far 2,249 transplants have been performed, 431 in 2008. One- and 5-year graft survival rates were 92% and 85%, respectively. The laboratory performed 4.1 million tests and radiological investigations numbered 164,217. Over $ 6 million were spent on medications. Free services offered by the model have motivated the government to increase its funding from $ 2.1 million in 1998 to $ 10 million in 2008 and the public has matched these figures with total donations exceeding $ 20 million. CONCLUSIONS: For transplantation to be successful in developing countries, it has to be made available to the common people who constitute 90% of the population. Our model of public-government partnership has made dialysis and transplantation available to the disenfranchised with lifelong follow-up and medications. Transplantation has become relevant to them, resulting in societal acceptance of transplantation as a preferred mode of therapy. This has motivated society to support both living related and deceased donor programs.

Human organ and tissue transplantation in Pakistan: when a regulation makes a difference.

Organ transplantation must be viewed in relation to the prevailing cultural, religious and economic conditions of a nation. Over the past two decades, Pakistan has emerged as one of the largest centres for commercial renal transplantation. Government efforts, supported by professional associations, civil society organizations and the media, along with World Health Organization technical assistance, have led to the development of legislation regulating this practice and curbing organ trade in conformity with international guidelines. Although only two years have passed since the enactment of the law, there is evidence that conditions have significantly improved, raising hopes for ethical and safe organ transplantation in Pakistan. This study reviews the salient features of the legislation and lists the foreseeable evolving challenges and opportunities.

Health status and renal function evaluation of kidney vendors: a report from Pakistan.

Unrelated kidney transplants have lead to commerce and kidney vending in Pakistan. This study on 104 vendors reports demographics, history, physical and systemic examination, ultrasound findings, renal and liver function and GFR by Cockcroft-Gault. Results were compared with 184 age, sex and nephrectomy duration matched living-related donors controls. Comparison of vendors versus controls showed mean age of 30.55 +/- 8.1 versus 30.65 +/- 7.85 (p = 0.91) years, M:F of 4.5:1 versus 4.2:1 and nephrectomy period of 33.89 +/- 30 versus 32.01 +/- 29.71 (p = 0.60) months respectively. Of the vendors 67% were bonded laborers earning <50 $/month as compared to controls where 68% were skilled laborers and self-employed earning >100 $/month. History of vendors revealed jaundice in 8%, stone disease in 2% and urinary tract symptoms in 4.8%. Postnephrectomy findings between vendors versus donors showed BMI of 21.02 +/- 2.8 versus 23.02 +/- 4.2 (p = 0.0001), hypertension in 17% versus 9.2% (p = 0.04), serum creatinine (mg/dL) of 1.17+/-0.21 versus 1.02 +/- 0.27 (p = 0.0001), GFR (mL/min) of 70.94 +/- 14.2 versus 95.4 +/- 20.44 (p = 0.0001), urine protein/creatinine of 0.150 +/- 0.109 versus 0.10 +/- 0.10 (p = 0.0001), hepatitis C positivity in 27% versus 1.0% (p = 0.0001) and hepatitis B positive 5.7% versus 0.5% (p = 0.04), respectively. In conclusion, vendors had compromised renal function suggesting inferior selection and high risk for developing chronic kidney disease in long term.

Maternal risk factors associated with low birth weight in Karachi: a case-control study.

To evaluate maternal risk factors associated with low birth weight (LBW) among women aged 15-35 years, we carried out a hospital-based, case-control study on 262 cases (mothers of neonates weighing < or = 2.5 kg) and 262 controls (mothers of neonates weighing > 2.5 kg). Odds of delivering a low-birth-weight baby decreased with increase in maternal haemoglobin [odds ratio (OR): 0.701; 95% confidence interval (CI): 0.62-0.79]. Odds were greater among mothers not using iron supplements during pregnancy (OR: 2.88; 95% CI: 1.83-4.54). Mothers of LBW babies had lower haemoglobin levels before delivery.

Anthropometric indices of middle socio-economic class school children in Karachi compared with NCHS standards--a pilot study.

OBJECTIVE: To measure height and weight of school going children (2-18 years of age) in Karachi. By means of these parameters we were able to document where the Pakistani paediatric population plot on NCHS growth centile charts. METHODS: A population based cross-sectional study (in government and private schools, Karachi), in which height and weight were taken using standardized techniques. Two thousand two hundred forty five healthy school-going children 2 to 16 years of age (calculated from date of birth); sex, height and weight were documented. After the survey was completed, height and weight of the children were plotted on NCHS centiles curves. RESULTS: P5, P25 and P50 centiles for height and weight of the Pakistani girls and boys was much below that of NCHS. However, P95 for boys and girls weight and height did not differ markedly in the Pakistani and NCHS centiles. CONCLUSION: Height and weight of these children is below the NCHS centile for height and weight. Children plotting near the P95 NCHS, indicates that obesity may be a serious concern in our population. However, further studies are required for support. This pilot study indicates the need for development of centile charts for Pakistani paediatric population.

A comparative study of fine needle aspiration cytology versus non-aspiration technique in thyroid lesions.

The present study was done to explore the diagnostic yield by the non-aspiration technique as compared with fine needle aspiration cytology (FNAC) of lesions in the thyroid gland. This method of non-aspiration fine needle cytology, which utilizes no active suction or aspiration, was performed on 150 patients presenting with enlargement of the thyroid gland. Smears were then cytologically assessed as unsuitable, diagnostically adequate or diagnostically superior, without knowledge of the sampling method employed. Diagnostically superior specimens were obtained significantly more frequently by the non-aspiration technique in 136 benign lesions and 14 neoplasms. Thus, the non-aspiration technique combined with FNAC can result in obtaining good quality cellular material in thyroid lesions.

An Indian eye to personalized medicine.

Acknowledging the successful sequencing of the human genome and the valuable insights it has rendered, genetic drafting of non-human organisms can further enhance the understanding of modern biology. The price of sequencing technology has plummeted with time, and there is a noticeable enhancement in its implementation and recurrent usage. Sequenced genome information can be contained in a microarray chip, and then processed by a computer system for inferring analytics and predictions. Specifically, smart cards have been significantly applicable to assimilate and retrieve complex data, with ease and implicit mobility. Herein, we propose "The G-Card", a development with respect to the prevalent smart card, and an extension to the Electronic Health Record (EHR), that will hold the genome sequence of an individual, so that the medical practitioner can better investigate irregularities in a patient's health and hence recommend a precise prognosis.

High-energy microwave thermotherapy in patients in urinary retention.

PURPOSE: To study the outcome of high-energy transurethral microwave thermotherapy (TUMT) in patients with obstructive benign prostatic hyperplasia (BPH). PATIENT AND METHODS: Between September 1995 and March 1998, patients presenting with urinary retention secondary to BPH were recruited into the study. Their mean age was 67.2 years (range 50-85 years). The mean catheterization time prior to treatment was 3 months (range 15 days-1 year). Among the 200 patients treated during this period, 30 were high anesthesia risk (American Society of Anesthesiologists Class III/IV). The patients were treated in a single 1-hour session using high-energy (Prostatron 2.5) software, the range of energy transmitted being 111.9 to 214.2 kJ (mean 196.3 kJ). Symptoms were scored according to the International Prostatic Symptom Score (IPSS). The mean prostate volume subjected to TUMT was 59 cc (range 40-149.7 cc). The patients were followed every 3 months with measurements of peak flow rate, postvoiding residual urine volume estimation, and IPSS. RESULTS: Of the 200 patients, 33 were lost to follow-up, 155 were responsive (catheter free with physiologically acceptable peak flow rate), and 12 (7%) were nonresponsive. Only 4 patients (2%) experienced deterioration in their flow rates during the follow-up period of 2 years. They underwent transurethral resection. High-energy thermotherapy resulted in irritative voiding complaints in 80% of patients for 2 to 4 weeks. CONCLUSION: The initial results were encouraging, and the 2-year follow-up has shown appreciable sustainability in the treatment outcome, particularly in patients at high anesthesia risk.

Predictive residual vector quantization [image coding].

This paper presents a new vector quantization technique called predictive residual vector quantization (PRVQ). It combines the concepts of predictive vector quantization (PVQ) and residual vector quantization (RVQ) to implement a high performance VQ scheme with low search complexity. The proposed PRVQ consists of a vector predictor, designed by a multilayer perceptron, and an RVQ that is designed by a multilayer competitive neural network. A major task in our proposed PRVQ design is the joint optimization of the vector predictor and the RVQ codebooks. In order to achieve this, a new design based on the neural network learning algorithm is introduced. This technique is basically a nonlinear constrained optimization where each constituent component of the PRVQ scheme is optimized by minimizing an appropriate stage error function with a constraint on the overall error. This technique makes use of a Lagrangian formulation and iteratively solves a Lagrangian error function to obtain a locally optimal solution. This approach is then compared to a jointly designed and a closed-loop design approach. In the jointly designed approach, the predictor and quantizers are jointly optimized by minimizing only the overall error. In the closed-loop design, however, a predictor is first implemented; then the stage quantizers are optimized for this predictor in a stage-by-stage fashion. Simulation results show that the proposed PRVQ scheme outperforms the equivalent RVQ (operating at the same bit rate) and the unconstrained VQ by 2 and 1.7 dB, respectively. Furthermore, the proposed PRVQ outperforms the PVQ in the rate-distortion sense with significantly lower codebook search complexity.

Next-state functions for finite-state vector quantization.

The finite-state vector quantization scheme called dynamic finite-state vector quantization (DFSVQ) is investigated with regard to its subcodebook construction. In the DFSVQ, each input block is encoded by a small codebook called the subcodebook which is created from a much larger codebook called supercodebook. Each subcodebook is constructed by selecting, using a reordering procedure, a set of appropriate code-vectors from the supercodebook. The performance of the DFSVQ depends on this reordering procedure; therefore, several reordering procedures are introduced and their performance are evaluated. The reordering procedures investigated, are based on the conditional histogram of the code-vectors, index prediction, vector prediction, nearest neighbor design, and the frequency usage of the code-vectors. The performance of the reordering procedures are evaluated by comparing their hit ratios (the number of blocks encoded by the subcodebook) and their computational complexity. Experimental results are presented and it is found that the reordering procedure based on the vector prediction performs the best when compared with the other reordering procedures.

Nonlinear vector prediction using feed-forward neural networks.

The performance of a classical linear vector predictor is limited by its ability to exploit only the linear correlation between the blocks. However, a nonlinear predictor exploits the higher order correlations among the neighboring blocks, and can predict edge blocks with increased accuracy. We have investigated several neural network architectures that can be used to implement a nonlinear vector predictor, including the multilayer perceptron (MLP), the functional link (FL) network, and the radial basis function (RBF) network. Our experimental results show that a neural network predictor can predict the blocks containing edges with a higher accuracy than a linear predictor.

Advances in residual vector quantization: a review.

Advances in residual vector quantization (RVQ) are surveyed. Definitions of joint encoder optimality and joint decoder optimality are discussed. Design techniques for RVQs with large numbers of stages and generally different encoder and decoder codebooks are elaborated and extended. Fixed-rate RVQs, and variable-rate RVQs that employ entropy coding are examined. Predictive and finite state RVQs designed and integrated into neural-network based source coding structures are revisited. Successive approximation RVQs that achieve embedded and refinable coding are reviewed. A new type of successive approximation RVQ that varies the instantaneous block rate by using different numbers of stages on different blocks is introduced and applied to image waveforms, and a scalar version of the new residual quantizer is applied to image subbands in an embedded wavelet transform coding system.

A modular neural network vector predictor for predictive image coding.

In this paper, we present a modular neural network vector predictor that improves the predictive component of a predictive vector quantization (PVQ) scheme. The proposed vector prediction technique consists of five dedicated predictors (experts), where each expert predictor is optimized for a particular class of input vectors. An input vector is classified into one of five classes, based on its directional variances. One expert predictor is optimized for stationary blocks, and each of the other four expert predictors are optimized to predict horizontal, vertical, 45 degrees , and 135 degrees diagonally oriented edge-blocks, respectively. An integrating unit is then used to select or combine the outputs of the experts in order to form the final output of the modular network. Therefore, no side information is transmitted to the receiver about the selected predictor or the integration of the predictors. Experimental results show that the proposed scheme gives an improvement of 1.7 dB over a single multilayer perceptron (MLP) predictor. Furthermore, if the information about the predictor selection is sent to the receiver, the improvement could be up to 3 dB over a single MLP predictor. The perceptual quality of the predicted images is also significantly improved.

Improving kidney and live donation rates in Asia: living donation.

Organ transplantation started with organs donated by living subjects. Increasing demands brought cadaveric organ donation. The brain-death law, mandatory for this procedure, is prevalent in all countries involved in organ transplantation except Pakistan. Spain is the leading country in cadaveric organ donation (32.5 pmp). Despite the sources of living and cadaveric organs, both heart-beating and non-heart-beating, the gap between the demand and supply has widened. An example is the United States, where the numbers of patients on the waiting list for kidney transplantation have risen from 30,000 in 1988 to more than 116,000 in 2001. This has caused a resurgence in living donors all over the world. These can be related, unrelated, spousal, marginal, or ABO-incompatible donors. Family apprehensions, medical care costs, and nonexistent social security can be barriers to this form of organ donation. Unrelated organ donation can open the doors to commercialism. To make this process more successful, transplantation should be made reachable by all sectors of the population. This is possible when transplantation is taken to the public sector institutions and financed jointly by the government and community. To increase living organ donation especially in Asian countries, which face barriers of low literacy rates, ignorance, and cultural and religious beliefs, more efforts are needed. Public awareness and education play an important role. Appreciation and supporting the donors is necessary and justified. It is a noble act and should be recognized by offering job security, health insurance, and free education for the donor's children.

A survey on the prevalence and management of hepatitis B after renal transplantation in Asian-Pacific countries.

The carrier rate for hepatitis B virus (HBV) varies from 1% to 2% to 10% in Asian-Pacific countries. A survey involving 12 transplant centers from 11 countries in this region showed that 1% to 25% of kidney transplant recipients were infected with HBV, and up to 60% of these subjects showed abnormal liver biochemistry. While nearly all centers tested anti-HBs in potential kidney transplant recipients, HBV vaccination of nonimmune subjects was routine in only 66.7%. One-third of the surveyed units rejected HBsAg-positive subjects as kidney donors, while the others demonstrated differing policies in choosing the respective recipients. Two units (16.7%) excluded HBsAg-positive patients from kidney transplantation, whereas the others only excluded those with severe liver disease. Heterogeneity also applies to the immunosuppressive regimens, the use of HBV DNA in serial monitoring, and the timing of antiviral therapy in HBsAg-positive kidney transplant recipients. The data showed that despite HBV infection being a significant problem in kidney transplantation, there is a lack of uniform management policy, attributable to the clinical complexity and deficiency of research data. Although improvement in clinical outcome is likely with the advent of nucleoside analogue therapy and better monitoring, the financial implications in the adoption of these recent advances remain realistic concerns.

Effects of income on drug choice in humans.

The effects of income (money available to spend during the experimental session) on human choice were examined in a concurrent-schedule arrangement. Subjects were 7 nicotine-dependent smokers, and reinforcers were puffs on the subject's usual brand of cigarette ("own") and puffs on a less preferred brand of cigarette with equal nicotine content ("other"). Across sessions, income varied and the price of the two reinforcers was held constant, with the other puffs one fifth the price of the own puffs. As income increased, consumption of own puffs increased while consumption of the less expensive other puffs decreased. These effects of income on choice were highly consistent across subjects. For some subjects, however, income had little effect on total puff consumption. Finally, an additional condition examined whether price and income manipulations would have functionally equivalent effects on choice by repeating an income condition in which the price of the other brand was increased. Although the increased price of the other puffs decreased their consumption in 4 subjects, 2 subjects showed increased consumption of the other puffs at the higher price. The results, when defined in economic terms, indicate that the own puffs were a normal good (consumption and income are directly related), the other puffs were an inferior good (consumption and income are inversely related), and the direct relationship between consumption of the other puffs and their price is defined as a Giffengood effect. The latter result also suggests that for these 2 subjects, price and income manipulations had equivalent effects on choice. These results extend findings from previous studies that have examined the effects of income on choice responding to human subjects and drug reinforcers, and provide a framework for further experimental tests of the effects of income on human choice behavior. Methodological and theoretical implications for the study of choice and for behavioral pharmacology are discussed.