Kidney transplantation: The journey across a century.

The Journey of kidney transplantation began a century ago with animal experiments and xenotransplants. The initial attempts of human to human kidney transplant were made by Yuri Voronoy, Jean Hamburger and several others between 1930 and 40s, but most of these were unsuccessful. The first successful live related kidney transplant between identical twins was performed at the Brigham Hospital in Boston in December 1953, by Joseph Murray and John P. Merrill, which paved the way for future live transplants. With the gradual improvement in the understanding of immunity and tolerance, the use of immunosuppression was attempted using irradiation and steroids, which gradually evolved over the decades to include azathioprine and cyclosporine. Discoveries of human leukocyte antigen by Dausset, complement dependent cross match by Paul Terasaki, and other developments in transplant immunology improved outcomes of kidney transplant. This journey was marked by new discoveries and improvements in surgical techniques including laparoscopic and robotic transplant surgery, better and safer immunosuppression, advances in transplant immunology, advent of the concept of brain death and deceased donor transplant program, and complicated transplants like transplants in highly sensitised recipients and ABO incompatible transplants. India was not far behind the rest of the world, and after a few unsuccessful attempts, the first successful transplant was done in CMC Vellore in 1971, which was followed by advancements in kidney transplants keeping in pace with the rest of the world.

Brain abscess following kidney transplantation: A single centre observational study from North India.

Background: Amongst the infections in kidney transplant recipients, brain abscess represents an uncommon life-threatening complication. Mortality continues to be high despite improvements in diagnostics and therapeutics. Method: We conducted an observational study, describing the incidence, presentation, implicating pathogen, management and outcome of brain abscess following kidney transplantation at our centre. Result: Amongst the 1492 patients who underwent kidney transplantation at our centre between June 1991 and January 2023 (cumulative follow-up: 4936 patient-years), five females and four males, developed brain abscesses. The incidence proportion (risk) is 0.6% with an incidence rate of 6.03 cases per 1000 patient years. The median duration from transplant to development of brain abscess was 5 weeks (range: 4 weeks to 9 years). The commonest presentation was a headache. A definitive microbiological diagnosis was established in eight out of nine patients. The commonest implicated organism was a dematiaceous fungus, Cladophialophora bantiana (3 patients, 33.3%). Despite the reduction in immunosuppression, surgical evacuation and optimal medical therapy, five (55.55%) patients succumbed to their illness. Conclusions: Brain abscesses following kidney transplantation is an uncommon, life-threatening condition. It usually occurs in the early post-transplant period and the presentation is often subtle. Unlike immunocompetent individuals, a fungus is the most common causative organism in those with solid organ transplants. The management includes a reduction in immunosuppression, early antimicrobial therapy, and surgical decompression.

Mn-Modified ZnO Nanoflakes for Optimal Photoelectrochemical Performance Under Visible Light: Experimental Design and Theoretical Rationalization.

Doping of zinc oxide (ZnO) with manganese (Mn) tunes midbandgap states of ZnO to enhance its optical properties and makes it into an efficient photoactive material for photoelectrochemical water splitting, waste removal from water, and other applications. We demonstrate that ZnO modified with 1 at. % Mn exhibits the best performance, as rationalized by experimental, structural, and optical characterization and theoretical analysis. ZnO doped with the optimal Mn content possesses improved light absorption in the visible region and minimizes charge carrier recombination. The doping is substitutional and creates midgap states near the valence band. Mn atoms break localized charge traps at oxygen vacancy sites and eliminate photoluminescence peaks associated with oxygen vacancies. The optimal performance of Mn-modified ZnO is demonstrated with the photodegradation of Congo red and photoelectrochemical water splitting.

Enhancement of Photocatalytic and Photoelectrochemical Performance of ZnO by Mg Doping: Experimental and Density Functional Theory Insights.

Doped ZnO nanostructures have shown great potential for solar energy applications. Considering the compatible ionic radius, Mg atoms can be doped into ZnO at different concentrations. The current work reports a combined experimental and density functional theory study on the influence of the Mg dopant concentration on ZnO performance simultaneously for photocatalytic dye removal and photoelectrochemical water splitting. Among all the samples, Mg(3)-ZnO (3 at. % Mg) exhibits superior sunlight-driven photocatalytic performance. The optimal Mg-ZnO shows an 8-fold increase in the photocatalytic activity compared to the pristine ZnO. Likewise, the most active photocatalyst shows high photoelectrochemical performance with a photocurrent response of 1.54 mA at the lowest onset potential, 11 times higher than the pristine ZnO. Tuning of the Mg content results in the generation of extra charge carriers and a reduced recombination rate, which are the crucial factors responsible for enhanced photocatalytic and photoelectrochemical performance.

Effect of treatment regimens in severe COVID pneumonia at an Indian tertiary care hospital: An observational, real-world study.

Background: Corticosteroids have attracted attention as a treatment option for severe Coronavirus disease (COVID-19). However, published data on steroid therapy is debatable, and real-world data is lacking. This study evaluated the effect of treatment regimens, especially Pulse steroid therapy (Injection Methyl Prednisolone 250 mg iv once a day for three days) in severe-COVID-19 pneumonia at an Indian tertiary care hospital. Methods: This observational cross-sectional study included severe COVID-19 pneumonia patients aged >18 years, requiring assisted ventilation. As part of the hospital protocol, patients received either pulse steroid therapy, remdesivir or tocilizumab in addition to the recommended steroid doses i.e., injection of dexamethasone 6 mg iv once a day. The association of factors and treatment regimens to patient outcomes was evaluated. Results: Data of eighty-three patients were assessed, majority being above 60 years (n = 30, 36.14%) and males (n = 45/83, 54.21%). The commonest comorbidities were hypertension (n = 26), diabetes (n = 23) and obesity (n = 19), fifty-five patients (66.26%) reported at least one comorbidity. Sixty-one patients (73.49%) had received pulse steroid regimen, forty-eight patients (57.83%) were administered remdesivir-based regimen while twelve patients (14.46%) had received tocilizumab treatment. 54.1% patients managed with pulse steroid regimens were discharged after treatment, statistically similar to remdesivir-managed subgroup (62.5%, p > 0.05). On sub-group analysis, pulse steroids showed better outcomes in young males with no comorbidities. No comorbidity had significant relationship with patient outcomes (p > 0.05). Conclusion: Pulse steroid therapy is an effective therapy in management of patients with severe COVID-19 pneumonia in a real-world setting, with better outcomes in young males without comorbidities. Pulse steroids can be considered a viable option for severe-COVID-19 pneumonia management.

Optimal Gain Sensing of Quantum-Limited Phase-Insensitive Amplifiers.

Phase-insensitive optical amplifiers uniformly amplify each quadrature of an input field and are of both fundamental and technological importance. We find the quantum limit on the precision of estimating the gain of a quantum-limited phase-insensitive amplifier using a multimode probe that may also be entangled with an ancilla system. In stark contrast to the sensing of loss parameters, the average photon number N and number of input modes M of the probe are found to be equivalent and interchangeable resources for optimal gain sensing. All pure-state probes whose reduced state on the input modes to the amplifier is diagonal in the multimode number basis are proven to be quantum optimal under the same gain-independent measurement. We compare the best precision achievable using classical probes to the performance of an explicit photon-counting-based estimator on quantum probes and show that an advantage exists even for single-photon probes and inefficient photodetection. A closed-form expression for the energy-constrained Bures distance between two product amplifier channels is also derived.

Analysis of postoperative complications following elective arthroscopic surgeries of the knee- a retrospective cohort study.

Background: Since their introduction, arthroscopic procedures have been increasingly utilized for the treatment of knee pathologies, especially Anterior Cruciate Ligament (ACL) reconstruction. Reduction of post-operative morbidity, shortened hospital stay and recovery period have all been identified as the benefits of arthroscopy. However, despite tremendous increase in the number of these procedures done, the postoperative complications associated have been infrequently analyzed. Hence, we performed this study to analyze the perioperative complications of arthroscopic ACL reconstruction. Materials & methods: We performed a retrospective case control study from our hospital database from the cases performed in July 2015 to December 2016. We included 20 cases who developed postoperative complications within 30 days of the procedure and 60 controls operated during the same period who did not have any complications. Results: The complications noted in the cases were surgical site infection (SSI), deep vein thrombosis (DVT), effusion and superficial infection. The risk factors associated with each complication were compared with the cases and analyzed. Conclusions: It was found that the lack of specialist physiotherapy, surgical prophylaxis and prolonged postoperative antibiotics were the major risk factors in the development of complications among our patients who underwent arthroscopic ACL reconstruction.

Pneumoperitoneum needle vs. introducer needle: Comparison of complications and short-term outcomes in percutaneously inserted peritoneal dialysis catheters in naïve abdomens.

Percutaneous peritoneal dialysis catheter (PDC) insertion for continuous ambulatory peritoneal dialysis (CAPD) entails a higher risk of complications such as bowel injury, vascular injury, and catheter migration compared to the surgical insertions. We conducted a comparative analysis of two techniques of peritoneal entry for PDC insertion by Seldinger technique. We performed a retrospective review of 426 percutaneously inserted PDCs in nonobese naïve abdomens for CAPD at two tertiary care teaching hospitals in India over 6 years. Comparison of various mechanical complications, and short-term catheter survival was done between use of introducer needle (Group "I") and spring-loaded pneumoperitoneum (Veress) needle (Group "V"). Group "I" to "V" patient ratio was 277:149. Group "I" had heavier patients (p = 0.03) whereas "V" group had a dominance of diabetes (p = 0.009) and prior hemodialysis patients (p = 0.03). At 3 months, the odds of mechanical complications (OR = 0.27, p = 0.004), PDC migration (OR = 0.18, p = 0.02), and omental wrapping (OR = 0.13, p = 0.04) were less in "V" group. No bowel injury occurred with Veress needle use. At 6 months, "V" group had higher odds of event-free sustained PDC tip position (OR = 0.39, p = 0.003), and catheter survival (p = 0.03), and the cumulative events were lesser too (p = 0.002). Refractory peritonitis and deaths with functioning catheter were comparable between both the groups. In this first-of-its-kind study, spring-loaded Veress pneumoperitoneum needle use was safer, entrusted sustained PDC tip position in pelvis, and had a better catheter survival compared to use of introducer needle for peritoneal entry in percutaneously inserted PDCs. These findings should be confirmed by a randomized controlled study.

A single-center experience in use of tocilizumab in COVID-19 pneumonia in India.

BACKGROUND: IL-6 receptor antagonist tocilizumab (TCZ) has been used in several reported studies in the treatment of COVID-19 pneumonia and pieces of evidence are still emerging. METHODS: All patients with COVID-19 pneumonia showing features of hyperinflammatory syndrome receiving TCZ at a tertiary care center in India were included in the study and a retrospective descriptive analysis was done. RESULTS: Between May 2020 to August 2020, 21 patients received TCZ out of which 13 survived and 8 died. All non-survivors had longer duration (median 12 days, minimum 9, maximum 15 days compared to median 6 days, minimum 3 and maximum 14 days in survivors) of symptoms and severe disease requiring mechanical ventilation at the time of TCZ administration. Among survivors, 8 patients had severe disease, 3 had moderate disease, and 2 patients had mild disease. Six out of 8 (75%) among non-survivors and 8 out of 13 (62%) among survivors had preexisting medical comorbidities. The non-survivors had higher baseline neutrophil-to-leukocyte ratio (10.5 vs 8.8), serum ferritin (960 ng/ml vs 611 ng/ml), lactate dehydrogenase (795 IU/L vs 954 IU/L), and D-dimer (5900 µg/ml vs 1485 mg/ml) levels. No drug-related serious adverse effect was noted among the patients. CONCLUSION: In a scenario of emerging evidence for the role of TCZ in the management of severe COVID-19, our study provides useful data on its use in the Indian scenario. Deliberate patient selection and timing initiation of TCZ at a crucial stage of the disease may be beneficial in COVID-19 pneumonia with good safety returns.

Peritoneal Dialysis Catheter Insertion by Nephrologist Using Minilaparotomy: Do Survival and Complications Vary in Obese?

INTRODUCTION: Peritoneal dialysis catheter (PDC) placement for chronic kidney disease (CKD) amongst overweight and obese patients is difficult owing to deeper operating field. Literature being discordant on survival and complications in this patient subset, we attempted to analyse this research question in Indian population. MATERIALS AND METHODS: We retrospectively analysed PDC inserted by nephrologist using surgical minilaparotomy for survivals and complications amongst 'overweight and obese' cohort ('O') at two tertiary care government hospitals in India, and compared results with normo-weight cohort ('N'), with 12-36 months follow-up. RESULTS: 245 PDCs were inserted by surgical minilaparotomy and 'N' to 'O' ratio was 169:76. 'O' group were more rural residing (P = 0.003) and post-abdominal surgery (P = 0.008) patients. The 1, 2, and 3-year death censored catheter survival rate was 98.6%, 95.8%, and 88.2% respectively in 'O' group, and 97.6%, 94.5% and 91.8% in 'N' group respectively (P = 0.52). Patient survival (P = 0.63), mechanical complications (P = 0.09) and infective complications (P = 0.93) were comparable despite technically challenging surgery in 'O' group. Refractory peritonitis related PDC removal was comparable (P = 0.54). Prior haemodialysis or catheter related blood stream infections or diabetes were non-contributory to results. CONCLUSIONS: Catheter survival and patient survival amongst obese and overweight CAPD patients was non-inferior to normal weight patients. Mechanical, and infective complications were comparable despite technically challenging abdominal terrain in 'O' group. The overall CAPD performance was good amongst obese and overweight.

A Study on the Safety of Percutaneous Tracheostomy in Patients with Severe Acute Respiratory Syndrome Novel Corona Virus 2 (SARS-nCoV2) Infection: A Single-Center Observational Cohort Study in a CoVID Intensive Care Unit.

BACKGROUND: We studied the safety of percutaneous dilatational tracheostomy (PCDT) in severe acute respiratory syndrome novel coronavirus 2 (SARS-nCoV2). PATIENTS AND METHODS: From 01 March 20 to 30 November 2020, 1635 required hospital admission of which 145 (9%) required intensive (ICU) care. The primary outcomes are mortality and secondary outcomes were duration of invasive mechanical ventilation (IMV), length of stay (LOS) in ICU and hospital, and days required for decannulation. RESULTS: Out of the 145 (9%), 107 (73.7%) were males (mean 61.4 years, median body mass index (BMI) of 28.2 kg/m2), and 38 (26.2%) were females (mean 58.10 years, median BMI of 31.2 kg/m2). In the cohort of 80 (55.17%) requiring IMV, 19 (23.7%) died within 72 hours and were not included in the study, 37 (group "NT") and 24 (group "T") had a median duration of ventilation of 9 d (IQR, 6-11) and 12 d (IQR, 11-17.25) respectively. Patients in group "T" underwent PCDT based on clinical criteria (fraction of inspired oxygen (FiO2) of ≤ 50% with positive end-expiratory pressure (PEEP) of ≤ 10 cms of H2O with stable hemodynamics), and 16 (66.7%) had survived. The reverse transcription-polymerase chain reaction (RT-PCR) does not need to be negative, and none of the health care workers (HCW's) were infected. The Cox-hazard ratio [HR] is 0.19, 95% confidence interval [CI] (0.09, 0.41) with a P-value of <0.001, 83 (57.2%) were discharged with a mortality of 42.8%. CONCLUSIONS: PCDT is safe and effective in patients anticipated in need of prolonged mechanical ventilation.

Diabetes Mellitus and Hypertension Increase Risk of Death in Novel Corona Virus Patients Irrespective of Age: a Prospective Observational Study of Co-morbidities and COVID-19 from India.

Elderly people and people with co-morbidities have emerged as the most vulnerable group at risk of developing complications and succumbing to novel coronavirus (COVID-19) infection. We recorded the baseline demographic profile, baseline clinical and laboratory parameters, and prevalence of various co-morbidities and their effect on the prognosis of COVID-19 cases. We conducted a prospective observational study and analyzed baseline clinical and laboratory parameters and co-morbidities and their effect on severity and mortality in 710 COVID-19 cases. Seven hundred ten patients with laboratory-confirmed COVID-19 were recruited from the 28th of March to the 31st of August 2020. The mean age was 48.4 ± 16.4years. A total of 530 (74.6%) patients were male. Overall, the mean length of hospital stay was 12.7 days. In total, 645 patients(90.8%) were mild to moderate cases and did not require initial ICU care. Sixty-five (9.2%) cases required initial intensive care unit care. Fifty (7%) admitted patients succumbed to the illness. Diabetes mellitus and hypertension increased the risk of death in COVID-19 patients irrespective of age. Increasing age and co-morbidities adversely affect the prognosis of patients of COVID-19. Diabetes mellitus and hypertension increase the risk of death in COVID-19 patients and negate the incremental effect of age on death in these patients.

Reaching Out to the Millions: A 5 Key Messages Rapid IEC Campaign During the COVID-19 Pandemic.

The ongoing COVID-19 pandemic has necessitated providing populations with simple and relevant, actionable informational messages for them to be informed on individual and community level measures to combat the pandemic. Distilling guidance from various sources into simple actionable message themes in a short time frame should be the hallmark of any rapid health promotion campaign. We developed and disseminated actionable Information, Education and Communication (IEC) messages on prevention and control during the ongoing COVID-19 pandemic by selecting five key message themes of prevention. A modified Delphi technique was used for the development process which was peer reviewed after consensus was generated. An online training model using specifically developed YouTube videos and Zoom Meetings was utilized to train Master Trainers and the further hierarchy reaching out to 6989 Community Resource Persons at the peripheral echelons. Conservatively the population reached out has been estimated to be more than 6 million (across 1.2 million households), over a two week period in April 2020. The implementing agency has created 300 videos in around 22 languages based on the 5 Key Messages, which are available online for universal access. A rapid IEC campaign that can be developed, designed and rolled out in a short span is required for emergency situations such as the ongoing pandemic. NGOs play an important role in reaching out relevant messages to the community, filling in the gaps by virtue of their relative systemic agility.

Reinfection or Reactivation of Coronavirus-19 in Patients with Hematologic Malignancies: Case Report Series.

Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been relentless. We are into the 10th month of the pandemic, and we are still getting surprised every day. Although neutralizing antibodies are generated in response to coronavirus disease-19 (COVID-19), these antibodies do not appear to confer lifelong immunity, as lately there have been reports from various parts of the world of reinfection with the virus, starting from Hong Kong, Belgium, and the USA. The Indian Council of Medical Research (ICMR) has been on-record claiming three cases of reinfection in India. Herein, we report three patients of hematologic malignancy who most probably had reinfection with SARS-CoV-2, after complete documented recovery from first infection. All three patients were immunocompromised owing to their primary hematologic malignancy coupled with ongoing therapy, and the second infection was documented to be severe in all the three cases from the first episode.

Clinical Triaging in Cough Clinic Alleviates COVID-19 Overload in Emergency Department in India.

The importance of this study is the efficacy of "symptoms only" approach at a screening clinic for coronavirus disease 2019 (COVID-19) diagnosis in low- and middle-income countries (LMIC) setting. The objective of this study was to assess how efficiently primary care physicians at the screening clinic were able to predict whether a patient had COVID-19 or not, based on their symptom-based assessment alone. The current study is a cross-sectional retrospective observational study. This study was conducted at a single-center, tertiary care setting with a dedicated COVID-19 facility in a metropolitan city in eastern India. Participants are all suspected COVID-19 patients who presented themselves to this center during the outbreak from 1 August 2020 to 30 August 2020. Patients were referred to the Cough Clinic from the various outpatient departments of the hospital or from smaller satellite centers located in different parts of the city and other dependent geographical areas. The main outcome(s) and measure(s) is to study whether outcome of confirmatory test results can be predicted accurately by history taking alone. From 01 August 2020 to 30 Aug 2020, 511 patients with at least one symptom suggestive of COVID-19 reported to screening clinic. Out of these, 65.4% were males and 34.6% were females. Median age was 45 years with range being 01 to 92 years. Fever was seen in 70.4% while cough was present in 22% of cases. Overall positivity for SARS-CoV-2 during this period in this group was 54.21%. At 50% pre-test probability, the sensitivity of trained doctors working at the clinic, in predicting positive cases based on symptoms alone, was approximately 74.7%, and specificity for the same was 58.12%. The positive predictive value of the doctors' assessment was 67.87%, and the negative predictive value was 66.02%. Rapid triaging for confirmatory diagnosis of COVID-19 is feasible at screening clinic based on history taking alone by training of primary care physicians. This is particularly relevant in LMIC with scarce healthcare resources to overcome COVID-19 pandemic.

Use of immunoadsorption columns in ABO-incompatible renal transplantation: A prospective study at a tertiary care center in India.

BACKGROUND: We present our experience of ABO-incompatible renal transplant using immunoadsorption (IA) columns. We have compared efficacy of two commercially available columns. METHODS: This single-center prospective study was conducted at Army Hospital Research and Referral, Delhi. All consecutive ABO-incompatible renal transplants from January 2014 to February 2018 were analyzed. Of 30 patients who underwent transplantations, 28 underwent antibody depletion with immunoadsorption columns. Of them, 14 cases were in the "Glycosorb group," while 14 in the "Adsopak group." RESULTS: The donors in the Adsopak group were older than those in the Glycosorb group (p < 0.05). Both groups had spousal donors in majority. The cutoff for the antibody titer was 1:8. The median titer in the Adsopak group was 128 (range, 1:4 to 1:2048), while that in the Glycosorb group was 24 (range, 1:8 to 1:128). All patients in the Glycosorb group had baseline titers ≤1:128, while 13 patients in the Adsopak group had baseline titers ≤1:512. Nil titer was achievable with Glycosorb® (50%,7/14) but not with Adsopak® (P < 0.01). Around 4 sessions were required for the Glycosorb group, while around 8 sessions were required for the Adsopak group before transplantation (p < 0.001). The Glycosorb group was advantageous in terms of graft failure because no rejection was noticed in these patients in their follow-up period. Three patients in the Adsopak group developed rejection (two had mixed rejection, and one had antibody-mediated rejection). Four patients died of sepsis (three in the Glycosorb and one in the Adsopak group). Lower baseline serum creatinine level was achieved in the Glycosorb group. CONCLUSIONS: Results of ABO-incompatible renal transplantation were satisfactory, and the use of immunoadsorption columns could effectively deplete antibody titers. Glycosorb columns were more efficient than Adsopak columns. Graft survival was better with Glycosorb. Posttransplant infections were a major cause of mortality.

Cadaveric renal transplantation: Our experience at a tertiary care centre in India.

BACKGROUND: Renal transplantation in developing countries like India is largely live donor transplantation. Cadaveric transplantation comprises <2% of all transplants in India. METHODS: Ninety-two cadaveric renal transplantations were included. Various donor and recipient characteristics were analysed along with graft and patient survival, using Kaplan-Meier method. RESULTS: The mean age of the recipients was 35.5 ± 10.9 years while that of cadaver was 43.9 ± 17.0 years. Proportion of females among recipients was 47.8% while that of donors was 34.8%. The most common underlying pathology was chronic glomerulonephritis (44.6%). Antithymocyte globulin was used as induction in 84.8% of cases. Tacrolimus-based triple-drug regimen was most commonly used as maintenance (80.4%). The mean follow-up time was 39.02 ± 28.24 months. The most common cause of death was sepsis (47%). More than 50% deaths (9/17) occurred within first 3 years, while 61.5% of graft loss occurred 5 years after transplantation. The mean graft survival time was 81.6 months (95% confidence interval [CI]: 72.8-90.4). Cumulative proportion of graft survival was 91.6% at 3 years and 77.1% at 5 years. Although females have better mean graft survival time (91.6 vs 73.5 months), it was not a significant difference as shown by log-rank test (p value = 0.062). Pretransplant haemodialysis has no significant effect on graft loss, but patients on peritoneal dialysis have significantly higher odds of graft loss (odds: 4.86, p value < 0.05 [0.018]). The mean patient survival time was 99.5 months (95% CI: 84.0-114.9). Cumulative proportion of patient survival was 83.3% at 3 years and 70.8% at 5 years. CONCLUSION: Graft and patient survival rate of cadaveric transplant at our centre was satisfactory. There is need to sensitise and augment the rate of cadaveric transplantation to increase the donor pool.

Acute kidney injury due to acute cortical necrosis following vivax malaria.

Malaria is a parasitic infection of global importance but has a high prevalence in the developing countries. Renal failure is a common complication of severe Plasmodium falciparum malaria and has been reported in up to 40% of all cases. Acute kidney injury (AKI), however, is not commonly associated with Plasmodium vivax infection. In those patients who develop AKI following P. vivax infection, the cause is commonly attributed to mixed undiagnosed falciparum infection or coexistent sepsis, dehydration, or hypotension. Infrequently, an association of P. vivax infection with thrombotic microangiopathy (TMA) has been reported. The purpose of this report is to describe renal failure due to TMA following malaria caused by P. vivax. A 24-year-old female presented with a history of fever and jaundice of two weeks duration followed by progressive oliguria and swelling of the face and feet five days after the onset of fever. The evaluation revealed normal blood pressure, anemia, thrombocytopenia, azotemia, unconjugated hyperbilirubinemia with mildly elevated transaminases, and elevated lactate dehydrogenase. Peripheral smear was positive for P. vivax, and schistocytes were seen. She was given intravenous artesunate followed by oral primaquine for 14 days. Urine examination showed proteinuria and microscopic hematuria. She remained oliguric and dialysis dependent, and her kidney biopsy revealed patchy cortical necrosis involving 40% of sampled cortex with widespread fibrinoid necrosis of the vessel wall, red blood cell fragmentation, and luminal thrombotic occlusion. Hemodialysis was discontinued after three weeks when there was the improvement of renal function over time, and her serum creatinine decreased to 2.2 mg/dL by six weeks. Patients with P. vivax malaria developing renal failure may have TMA. Renal biopsy, if performed early in the course of the disease, may identify TMA and institution of plasma exchange in such patients could help in early recovery.

Quantum-Limited Loss Sensing: Multiparameter Estimation and Bures Distance between Loss Channels.

The problem of estimating multiple loss parameters of an optical system using the most general ancilla-assisted parallel strategy is solved under energy constraints. An upper bound on the quantum Fisher information matrix is derived assuming that the environment modes involved in the loss interaction can be accessed. Any pure-state probe that is number diagonal in the modes interacting with the loss elements is shown to exactly achieve this upper bound even if the environment modes are inaccessible, as is usually the case in practice. We explain this surprising phenomenon, and show that measuring the Schmidt bases of the probe is a parameter-independent optimal measurement. Our results imply that multiple copies of two-mode squeezed vacuum probes with an arbitrarily small nonzero degree of squeezing, or probes prepared using single-photon states and linear optics, can achieve quantum-optimal performance in conjunction with on-off detection. We also calculate explicitly the energy-constrained Bures distance between any two product loss channels. Our results are relevant to standoff image sensing, biological imaging, absorption spectroscopy, and photodetector calibration.

Role of Direct Antiviral Agents in Treatment of Chronic Hepatitis C Infection in Renal Transplant Recipients.

BACKGROUND: Since the introduction of direct antiviral agents (DAAs), morbidity of HCV has considerably decreased but still no guidelines have been formulated in renal transplant recipients (RTRs). We studied efficacy and tolerability of direct antiviral agents in RTRs. METHODS: This prospective observational study was conducted at Army Hospital Research & Referral, Delhi, from June 2016 to May 2017. Forty-five HCV infected RTRs with stable graft function were included. RESULTS: Median time between renal transplantation and the start of anti-HCV therapy was 36 months (1-120 months). The majority (66.7%) were infected with genotype 3. Baseline median HCV RNA level was 542648 IU/ml (1189-55028534 IU/ml). Sofosbuvir-Ribavirin combination (24 weeks) was given to 30 patients including 3 cirrhotics, Ledipasvir-Sofosbuvir combination to 8 patients, and Daclatasvir-Sofosbuvir combination to 7 patients, including 2 cirrhotics. Rapid virological response was observed in 29 patients treated with Sofosbuvir/Ribavirin, all 8 patients on Sofosbuvir/Ledipasvir, and all 7 patients on Sofosbuvir/Daclatasvir. End treatment response and sustained virological response (12 weeks) were achieved in all patients irrespective of genotype or treatment regimen. Decrease in mean HCV RNA level and transaminase level was statistically significant (p < 0.01). Ribavirin was significantly associated with anaemia (p = 0.032). CONCLUSIONS: DAA regimens are well tolerated and highly efficacious. Response to DAA is good irrespective of genotype, drug combination, initial HCV RNA level, age or sex of patient, or graft age. However, Sofosbuvir/Ledipasvir and Sofosbuvir/Daclatasvir combination is preferable.