Impact of severe acute respiratory syndrome-coronavirus-2 pandemic on postgraduate medical education in armed forces medical services institutions: A students' perspective

Introduction: The Severe acute respiratory syndrome coronavirus 2 pandemic situation brings us the opportunity to test the strength and limitations of our health delivery system. Residents being the backbone of quality-health-delivery of any institute have taken the brunt. Materials and Methods: A cross-sectional self-administered questionnaire-based survey was used to assess the effect on medical training and stress of postgraduate residents in clinical specialties of armed forces institutions.Results: 266 valid responses were analyzed. Eighty-seven percent of residents felt their surgical/procedure-related training was affected. Bedside/clinical training was found to be affected by 92% and theoretical learning by 78%. A significant difference was found between residents in medical and allied specialties and residents in surgery and allied specialties (81% vs. 96.3%) with regard to the negative effect of the COVID-19 pandemic on surgical/procedural skills training (P < 0.05). There was a significant difference in the likelihood of being posted for COVID duties based on gender (P = 0.01) and year of the course (P = 0.004). Posting on COVID duties did not significantly affect surgical, clinical, or theoretical training. Of the respondents, 37%, 49%, and 14% had a mild, moderate, and severe increase in stress, respectively. 18%, 52%, and 30% experienced mild, moderate, and severe increased stress among family members. Gender, age, category, year of residency, or subject of specialization did not have any significant effect on the level of personal or family stress. Conclusion: This survey attempts to bring forth the effect of the pandemic on medical training schedules and stress among residents. Such surveys would enhance understanding and bring solutions to the problem that the pandemic has brought.

Barriers to Accessing Essential Medicines in Nephrology and Related Non-Communicable Diseases: A Scoping Review

Introduction: Access to safe, effective, quality, and affordable essential medicines (EM) for all is one of the World Health Organization's Sustainable Development Goals for health. However, access to EM for the treatment of non-communicable diseases (NCDs) is lacking in many low-income (LICs) and lower-middle income countries (LMICs). Chronic kidney disease (CKD) is often a downstream consequence of other NCDs, such as diabetes (DM) and cardiovascular disease (CVD), further exacerbating the economic burden on healthcare systems and societies. In nephrology, access to EM is especially important to reduce the risk of CKD progression because kidney replacement therapy is unavailable or cost-prohibitive in many regions of the world. As members of the International Society of Nephrology (ISN) Emerging Leaders Program 2021 cohort, we conducted a scoping review to assess the breadth of evidence regarding EMs for management of CKD and related NCDs, with identification of barriers to EM access as one of our main aims. Method(s): We included English-language articles of any study design that addressed barriers to accessing essential medicines in populations with CKD (all stages, causes, and ages), CVD, hypertension, and/or DM. All ISN geographical regions and World Bank income categories were considered. We searched MEDLINE, EMBASE, Web of Science and Cochrane Central Register of Controlled Trials to May 2021. Titles and abstracts were screened, and full texts were retrieved for potentially relevant publications. Each full-text article was assessed for inclusion. For included articles, data extraction was performed with a standardized form using Covidence software. Each step was performed by one reviewer and checked by a 2nd reviewer. Applying an ecological model, barriers were categorized as occurring at the national/health policy level, regional level, organization level, provider level, or patient level. Result(s): Ninety-six publications addressed barriers to access to essential medicines, including LICs (16 articles), LMICs (43 articles), upper-middle income countries (25 articles), high-income countries (10 articles), plus 21 articles which did not specify countries. Most publications assessed barriers at the health policy-level, which included high EM prices in the setting of current patent laws;lack of effective systems for public procurement of EM, resulting in large out-of-pocket household expenditure for medicines in LIC/LMIC;inefficient distribution systems with multiple price mark-ups;and lack of regulatory systems, giving rise to counterfeit medications. Regional-level barriers included lack of governance of supply chain logistics, lack of regional coordination, and poor transportation infrastructure, especially in rural settings. Organization-level barriers included medication stock-outs at facilities, and health care worker shortages. Provider-level barriers included irrational prescribing, lack of CKD identification, and poor communication with patients. Patient-level barriers included poverty, informational barriers/health literacy, and negative perception of generic medicines (Figure). [Formula presented] Conclusion(s): Barriers to accessing EM exist at several levels, particularly the health system-level, and affect LICs and LMICs disproportionately. This scoping review serves as an initial step towards designing implementation studies to address barriers to improve EM access. Conflict of interest Potential conflict of interest: MMMY has a consultancy agreement with George Clinical and served on a CKD advisory board sponsored by AstraZenecaCopyright © 2023

Covid 19 Prediction Through Chest CT Scans using Deep Learning and Deploying Model on Flask Web

Given the infection's wide growth, one of the biggest challenges on the planet right now is identifying Corona Virus Disease 2019 (COVID-19). Recent findings show that, with over 225M confirmed instances, the number of people who have been diagnosed with COVID-19 is drastically increasing;Around the world, the sickness is affecting several countries. In this study, the global COVID-19 circulation incidence is briefly examined, and a deep convolutional neural network (CNN) artificial intelligence model is developed to identify COVID19 patients using real-world information. To find such patients, the model looks at chest CT scan images. The results show that such an approach is helpful in diagnosing COVID-19 since CT scans are easily accessible fast and inexpensively. This suggested approach is effective at detecting COVID-19 and achieves an F-measure range of 95-99%, according to empirical findings from 100 CT scan pictures of actual patients. The suggested model has a considerable impact in identifying sick individuals. © 2022 IEEE.

Two cases of adult-onset de novo immunoglobulin A vasculitis with nephritis: Post-Covishield (ChAdOx1 nCoV-19, Oxford-Astra Zeneca) vaccination

With the ongoing worldwide COVID-19 vaccination programs, new-onset glomerular disease and relapse of the preexisting glomerular disease have been reported after COVID-19 vaccines administration. These incidences are overall very rare and had just temporal association with vaccination. It is, therefore, the causal link with the COVID 19 vaccine is not firmly established. In this case-based review, we present two cases, who presented with purpuric rashes and joint pain between 2 and 3 weeks of 2nd dose of Covishield (ChAdOx1 nCoV-19;Oxford-Astra Zeneca) vaccination. Routine evaluation in both these cases revealed significant proteinuria and microscopic hematuria. The diagnosis of immunoglobulin A (IgA) vasculitis with nephritis was established with renal biopsy suggestive of IgA nephropathy and skin biopsy findings of leukocytoclastic vasculitis. Both these cases had severe renal involvement and responded to oral glucocorticoids after 8-16 weeks of treatment. Close observation and careful monitoring of these cases are required to determine the incidence of de novo or recurrence of glomerular disease postvaccination, the need for immunosuppressive therapy, response to aggressive treatment, and long-term clinical outcomes.

Longitudinally extensive transverse myelitis following ChAdOx1 nCoV-19 vaccine.

Transverse myelitis (TM) has been reported in association with various vaccinations. Herein we describe a case of longitudinally extensive transverse myelitis (LETM) associated with vaccination with ChAdOx1 nCoV-19 (COVISHIELD) vaccine. A 59-year-old woman with no prior co-morbidities presented with lower extremity numbness, weakness, acute urinary retention, and constipation. Numbness gradually extended up to the lower costal margin with band like sensation. She had received the vaccine 5 days prior to the onset of the symptoms. Extensive diagnostic evaluation effectively ruled out causes other than vaccination-associated transverse myelitis. Following treatment with intravenous methylprednisolone, the patient made a significant recovery. TM may be associated with vaccination against the novel ChAdOx1 nCoV-19 vaccine and we believe this to be the first report from India of LETM associated with this vaccine.

Enhancing Security of Medical Image Data in the Cloud Using Machine Learning Technique

To prevent medical data leakage to third parties, algorithm developers have enhanced and modified existing models and tightened the cloud security through complex processes. This research utilizes PlayFair and K-Means clustering algorithm as double-level encryption/ decryption technique with ArnoldCat maps towards securing the medical images in cloud. K-Means is used for segmenting images into pixels and auto-encoders to remove noise (de-noising);the Random Forest regressor, tree-method based ensemble model is used for classification. The study obtained CT scan-images as datasets from ‘Kaggle’ and classifies the images into ‘Non-Covid’ and ‘Covid’ categories. The software utilized is Jupyter-Notebook, in Python. PSNR with MSE evaluation metrics is done using Python. Through testing-and-training datasets, lower MSE score (‘0’) and higher PSNR score (60%) were obtained, stating that, the developed decryption/ encryption model is a good fit that enhances cloud security to preserve digital medical images. © 2022 MECS.

Controlled evaLuation of Angiotensin Receptor Blockers for COVID-19 respIraTorY disease (CLARITY): statistical analysis plan for a randomised controlled Bayesian adaptive sample size trial.

The CLARITY trial (Controlled evaLuation of Angiotensin Receptor Blockers for COVID-19 respIraTorY disease) is a two-arm, multi-centre, randomised controlled trial being run in India and Australia that investigates the effectiveness of angiotensin receptor blockers in addition to standard care compared to placebo (in Indian sites) with standard care in reducing the duration and severity of lung failure in patients with COVID-19. The trial was designed as a Bayesian adaptive sample size trial with regular planned analyses where pre-specified decision rules will be assessed to determine whether the trial should be stopped due to sufficient evidence of treatment effectiveness or futility. Here, we describe the statistical analysis plan for the trial and define the pre-specified decision rules, including those that could lead to the trial being halted. The primary outcome is clinical status on a 7-point ordinal scale adapted from the WHO Clinical Progression scale assessed at day 14. The primary analysis will follow the intention-to-treat principle. A Bayesian adaptive trial design was selected because there is considerable uncertainty about the extent of potential benefit of this treatment.Trial registrationClinicalTrials.gov NCT04394117 . Registered on 19 May 2020Clinical Trial Registry of India CTRI/2020/07/026831Version and revisionsVersion 1.0. No revisions.

POS-250 A RANDOMIZED TRIAL OF EFFECT OF CHOLECALCIFEROL SUPPLEMENTATION ON CARDIOVASCULAR DISEASE, INFLAMMATION, AND BONE METABOLISM MARKERS IN CKD: BASELINE CHARACTERISTICS OF FEASIBILITY PHASE

Introduction: Studies have linked lower vitamin D levels with cardiovascular disease (CVD) and mortality in general population and chronic kidney disease (CKD). The preliminary evidence of vitamin D supplementation is encouraging but there is a huge void with respect to good quality long term data supporting the use of this promising intervention for translation into better outcomes for CVD in CKD. This study is exploring the effect of cholecalciferol supplementation on cardiovascular disease, markers of inflammation and bone metabolism in CKD. We present the baseline characteristics of feasibility phase of the trial. Methods: The study is a multicentric, prospective, randomized, placebo controlled, double blind trial in two parallel groups and feasibility phase is being done at Postgraduate Institute of Medical Education and Research, Chandigarh, India. The trial is registered at Clinical Trials Registry of India (CTRI/2019/05/019211). After a run-in period of 2 weeks, the enrolled subjects are randomized in 1:1 to receive either 60,000 IU/2 weeks of cholecalciferol or matching placebo. The subjects will be then followed up every three month till 3 years. The primary outcome of the study is a composite of major adverse cardiac events (MACE). Secondary outcome measures include all-cause mortality, need of RRT, change in hsCRP, IL-6, iPTH, FGF-23, bone specific alkaline phosphatase, and CTX-1. Results: A total of 720 subjects have been screened till date. Out of 119 enrolled, 86 subjects have been randomized over 24 months period. 76% subjects have completed annual follow up at 12 months, 66% subjects - 15thmonths follow up, 40%- 18 months follow up, 26% subjects - 21 months follow up, 6% subjects – 24 months follow up. Baseline characteristics and serum biomarkers levels has been analysed in 80 subjects. Mean age of the subjects were 51.3 ± 12.2 years and 58.8 % were males. Serum haemoglobin levels were 11.6 ±1.7 g/dl. Mean eGFR was 26.3 (17.4, 35.1) ml/min/1.73m2. Outcome events were;MACE: 1 (due to CVD), death other than due to MACE: 1 (due to COVID 19), subjects with composite of all-cause death and non-fatal MACE: 2, subject with need of RRT:1 and subjects with composite of 50% decline in GFR or need of RRT: 3. 2 serious adverse events unrelated to study drug were reported during the course of study. Table: Baseline levels of various serum biomarkers [Formula presented] Conclusions: Despite COVID 19 related restrictions being in place for most of the last 18 months, the study has been able to screen and enrol participants. The follow ups have been ensured either through physical or remote (mobile/telephonic) means. Once in the multi-centric phase, the study will be able to test a relatively inexpensive intervention in the form of vitamin D supplementation for CVD in CKD. No conflict of interest

Automated People Monitoring System Using OpenCV and Raspberry Pi

Over the last decade, there has been a quantum leap in terms of the evolution of new methodologies to better our quest to understand artificial intelligence and machine learning. One such field, where there has been an unparalleled advancement, is computer vision. The paper aims to design and structure an automated monitoring system that automates the monitoring of the number of people in this COVID-19 scenario in a designated enclosure. We have deployed the system on Raspberry Pi module and integrated a HOG detector which transcends ordinary Haar cascades in terms of performance. This model can then subsequently be connected and integrated with other modules to further enhance its applicability and spectrum of usage. © 2022, The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd.

An online survey of the changing trends of the cardiac surgeries in the era of COVID-19

Objectives: To collect and assess cardiac surgeons' viewpoint about the changing cardiac surgery practices in India during COVID-19 pandemic. Methods: An online web-based study was conducted through an online questionnaire which was mailed to various cardiac surgeons in India (as retrieved from the cardiac surgeon directory). The responses were received and entered in an MS Excel spreadsheet and were analyzed. The ethical clearance for the study was not required as it was an online survey-based study without any patient data or treatment modification. Results: Out of 52 surgeons to whom the questionnaire was sent, 34 responded. Large number of surgeons (47.1%) pointed that reduction in cardiac surgical volume for long time during pandemics is associated with surgical expertise attrition. Importantly, in addition to 44.1% response rate for substantial reduction of patient management in cardiac surgery during pandemic, 38.2% of surgeons responded for its complete discontinuation. Another 44.1% of surgeons responded that the risk of exposure in a COVID-19-negative subject during perioperative period is increased and affects outcomes. Multiple responses were obtained regarding repetition of COVID-19 testing in postoperative period. Conclusion: This pandemic is not going to end in the immediate future. However, to put cardiac surgery in standby mode till pandemic last is not an option. Measures should be taken by hospital and regulatory bodies to resume services of cardiac surgery in addition to containing ad preventing infection by COVID-19. In the absence of evidence-based recommendation, strong consensus opinion of practicing cardiac surgeon will guide clinical decision-making.

COVID-19 pandemic highlights global inequities in chronic hemodialysis care: A dopps/isn survey

Background: Patients receiving chronic hemodialysis (HD) are highly vulnerable in all settings. It is unknown whether the COVID-19 pandemic has disproportionately affected the care of chronic HD patients in low (LIC) and low-middle income (LMIC) settings. This survey aimed to identify global challenges and inequities in HD care delivery during the COVID-19 pandemic. Methods: The Dialysis Outcomes and Practice Patterns Study (DOPPS) and the International Society of Nephrology (ISN) conducted a global online survey of HD units (HDU). Sample HDUs included DOPPS sites in China, a random sample stratified by region and HDU population, and an open invitation via ISN's membership list. The survey assessed availability of COVID-19 diagnostics and personal protective equipment, the impact of COVID-19 on HD delivery and patient outcomes from COVID-19. Responses were stratified by country income according to World Bank classification. Results: Responses were received from 412 HDUs across 78 countries (Table 1). Conclusions: Striking global inequities were identified in access to COVID-19 diagnostics, infection prevention, and access to routine HD care during the pandemic. Higher apparent mortality in patients on chronic HD in LICs and LMICs is likely multifactorial, reflecting poorer access to the diagnosis and care of COVID-19, as well as greater disruptions to HD delivery. Urgent action is required to address these inequities, which disproportionately affect low-income settings, exacerbate pre-existing vulnerabilities and lead to worse outcomes.

An isn-dopps survey of the global impact of the COVID-19 pandemic on in-centre haemodialysis services

Background: Haemodialysis units (HDUs) have had to rapidly adapt practices and policies to safely continue life-sustaining HD services during the COVID-19 pandemic. We aimed to describe the impact of COVID-19 in different parts of the world. Methods: The Dialysis Outcomes and Practice Patterns Study (DOPPS) and International Society of Nephrology (ISN) collaborated to web-survey individual HDUs. Responses were obtained in three ways: (1) a survey of DOPPS sites in China (May/ June 2020), (2) a random sample (20 units if > 40 units/ country;all units if < 40) stratified by region and HDU census (November 2020 -March 2021), and (3) an open invitation via ISN's membership list and social media (March 2021). Responses were compared between the ten ISN regions. Results: There were returns from 412 HDUs (46% public sector, 79% urban;70% adult, 2% paediatric, 28% adult & paediatric) from 78 countries (9% low-, 24% lowermiddle-, 28% upper-middle-, 39% high-income). Conclusions: The COVID-19 pandemic has had a significant impact on dialysis services and staffing worldwide. Differences in uptake of policies and practices across regions have likely been because of variable access to resources to enable implementation of diagnostic testing algorithms and adequate supply of PPE to implement infection prevention and control recommendations. Guidance should be consistent, adaptable to (nearly) all situations and locations, and evidence based. Going forward, the operationalisation of vaccine programs should be incorporated into guidelines. Disruptions to dialysis services should be minimised, and resource provision (including vaccines) prioritised by policymakers and governments in future waves of COVID-19 and pandemics if we are to protect HD patients, staff, and services.

An isn-dopps survey of the global impact of COVID-19 pandemic on home peritoneal dialysis services

Background: Home dialysis may be able to minimize SARS-CoV2 exposure risks. The pandemic may have introduced unique challenges related to supply disruption and care delivery changes. We sought to assess the global burden of COVID-19 on peritoneal dialysis units (PD) and understand PD unit practice changes during this time. Methods: The Peritoneal Dialysis/Dialysis Outcomes and Practice Patterns Study (PDOPPS/DOPPS) and International Society of Nephrology (ISN) administered a webbased survey (1) to dialysis units selected based on a random sample stratified by region (November 2020 -March 2021), and (2) to an open invitation via ISN's membership list and social media (March 2021). Responses were compared across 10 ISN regions. Results: Returned surveys included 167 PD facilities across 52 countries. Changes in several care domains including clinic communication and frequency, labwork frequency, method of communication, masking policies, changes in handling of PD effluent among infected individuals, PD supply disruption, access to methods of PD catheter insertion and frequency of new patient training are highlighted (table). Conclusions: Variability exists in routine PD care, and the availability and use of PPE, disruption in PD supplies among the different regions reflecting the availability of the resources and infrastructure differences. LMIC tended to be more severely impacted-this gap needs to be addressed in anticipation of future pandemics for treatment continuity. Although remote technology use among PD patients to communicate with their physicians has increased during the pandemic, optimal communication frequency, methods and schedule of routine bloodwork needs to be better elucidated.

POS-527 CONTINUUM OF CARE AMONG PARTICIPANTS OF DIALYSIS OUTCOMES REGISTRY IN INDIA DURING THE COVID-19 PANDEMIC LOCKDOWN

Introduction: Majority of ESKD patients in India avail in centre dialysis services. India imposed a nation-wide lockdown for over two months during the COVID-19 pandemic. Essential healthcare services including dialysis were disrupted. Patients on dialysis faced severe consequences as they as could not seek care at the health care facilities.1,2,3These disruptions have impacted the continuum of care and altered the care-seeking behaviour among dialysis patients.4,5 We monitored the care-seeking behaviour among dialysis patients enrolled in the India Dialysis Outcomes Registry during the lockdown. Methods: The India dialysis outcomes registry is a nationally representative study following up 1000 ESKD patients starting dialysis across 10 Indian states. The registry has established a mechanism for routine data collection on clinical, socio economic outcomes and patient reported quality of life. We contacted the participants telephonically to understand the continuum of care during the lockdown. Efforts were directed to describe reasons for missing dialysis session(s) and document any complications due to disruptions to the dialysis services. Results: We followed-up 526 participants at 9 dialysis centres after the onset of the Pandemic in India, 149 (28)% were not contactable after 3 attempts. 377 participants (61% males and 39% females) consented and participated in the telephonic survey. Of these, 270 (72 %) were continuing on hemodialysis, 83 (22%) died, 7 (2%) switched to Peritoneal Dialysis, while 3 % (12) had either received or were awaiting kidney transplant and 5(1%) had stopped dialysis. During the interviews, 31 (8 %) reported having missed prescribed dialysis sessions ranging from one missed session to 24 missed sessions. The reasons being, travel ban on account of the COVID-19 pandemic (68%), financial challenges (19%), transfer to another site (3%) and other reasons (29%) like hike in dialysis cost during pandemic, non-availability of dialysis sessions as facilities were designated as COVID-19 management units, absence of dialysis facilities in COVID-19 wards and non-availability of dialysis staff as they were quarantined (Figure 1). Out of those continuing dialysis, 15% reported being hospitalized during the pandemic. They were admitted due to poor vascular access (61%), infections (29%) and 8 patients reported testing positive for COVID-19. Other reasons for hospitalizations were cardiovascular complications and stroke.(Figure 2) Conclusions: The disruption to continuum of care for patients on dialysis due to travel restrictions during COVID-19 lockdown, not only resulted in difficulty in accessing the dialysis care but also contributed to worsening of their overall health. Our study also elicits patient’s experiences and their perspectives on the challenges faced by them during the lockdown. They identified lack of clear communications by health facilities, lack of adequate dialysis treatment facilities and non-availability of staff at dialysis units. The India Dialysis Registry helped understand the disruptions in continuity of services among a representative population across the country during the COVID19 pandemic, this iterates the significance of establishing disease registries to monitor outcomes longitudinally. Insights as gained from our registry will be critical to inform policy makers in time and thereby address gaps in health delivery systems in India. Conflict of Interest: OJ is recipient of a UIPA scholarship from University of New South Wales, Sydney.

POS-274 A RANDOMIZED TRIAL OF EFFECT OF CHOLECALCIFEROL SUPPLEMENTATION ON CVD, INFLAMMATION AND BONE METABOLISM MARKERS IN CKD: DESIGN AND METHODS

Introduction: Short term studies have shown that vitamin D supplementation may favorably influence vascular function, inflammation and bone metabolism in CKD. There are no long-term studies that have looked at hard clinical end points in this regard. This study will explore the effect of cholecalciferol supplementation on cardiovascular disease, markers of inflammation and bone metabolism in CKD. We present the design and results of initial pilot phase of the proposed clinical trial. Methods: The study is a multicenter, prospective, randomized, placebo-controlled, double blind trial in two parallel groups. After a run-in-phase of 2 weeks, the enrolled patients are randomized in 1:1 ratio to receive cholecalciferol or matching placebo. Cholecalciferol is given at the dosage of 60,000 IU/2 weeks. The patients will be followed up at 3, 6, 9, 12, 24 and 36 months after enrolment. All clinical events and hospitalizations during the course of the study will be recorded. Primary outcome is a composite of Major Adverse Cardiovascular Events (MACE) that includes new onset heart failure, coronary heart disease, peripheral vascular disease, cerebrovascular accident, any coronary or peripheral arterial revascularization procedure and death due to cardiovascular disease. Secondary outcomes include all-cause mortality, need for renal replacement therapy, change in hsCRP and IL-6, change in iPTH, FGF-23, bone specific alkaline phosphatase and CTX-1. The feasibility phase is currently being run at PGIMER, Chandigarh, India. Serum levels of 25(OH)D, calcium, and iPTH will be checked at every scheduled follow up visit. The concurrent clinical care will continue as per prevailing standards of care. We plan to enroll 1244 patients (622 in each group) across 11 centers. The trial is registered at Clinical Trials Registry of India (CTRI/2019/05/019211). Results: Till date, 340 patients have been screened for enrolment. 61 have been successfully randomized;their baseline samples have been collected and stored, and drugs have been dispensed to them. Till now, 30 patients have completed their 3 months follow up with 6 subjects having completed 6 months follow up as well. Figure 1 depicts the conduct of study so far. Table 1 shows the baseline characteristics of the study population. Though delayed due to ongoing COVID 19, the study has fulfilled the pre-specified feasibility criteria of recruitment of >50% eligible subjects (achieved 94.9%), recruitment rate of ≥7 subjects per month (achieved 8.7 subjects per month) and ≤25% overall subject withdrawal rate (subject withdrawal rate 10.63%). [Formula presented] [Formula presented] Conclusions: The study has achieved pre specified feasibility criteria. In the multi-centric phase, the study will set the stage for testing a relatively inexpensive intervention in the form of vitamin D supplementation for CVD in CKD. Conflict of Interest: The study is funded by Department of Biotechnology, Government of India under a grant to Dr Vivek Kumar (sanction order No BT/PR29764/PFN/20/1417/2018).