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With the increased incidence and survival of lung transplant (LTx) recipients, the risk for chronic sequelae such as chronic kidney disease (CKD) is on the rise. Data on the long-term renal outcome are scarce. We performed a retrospective chart review of 171 adults with LTx from January 1, 2014, to January 1, 2019. Primary outcomes were prevalence of CKD/end-stage renal disease, acute kidney injury (AKI) as a risk factor for future CKD, and all-cause mortality in recipients with CKD compared with the non-CKD group. Secondary outcomes were frequency of utilization of modalities for CKD (urinalysis, imaging, biopsy, nephrology consultations). Baseline median creatinine and estimated glomerular filtration rate (eGFR) were 0.8 mg/dL and 90 mL/min/1.73 m2, respectively. Of the participants, 60% (96 of 161), 67% (102 of 153), 79% (37 of 47), 86% (10 of 12) had CKD at the end of 6, 12, 36, and 60 months, respectively, and 16% were on dialysis at the end of the study period; 3% received a subsequent renal transplant, and 27% mortality was noted over a 5-year follow-up period. The odds of CKD development in patients with an AKI during index hospitalization vs no AKI was 6.22 (2.87 to 13.06, P

In this article, GIS, remote sensing (RS) and fuzzy AHP are used to develop a methodology to delineate the groundwater potential zones. GIS-RS technique is used to prepare the different thematic ma...

The measurement of site amplification of microtremors is an important tool for evaluating seismic hazard at local and regional level. The H/V spectral ratio (HVSR) method is applied to estimate the amplification of ground motion at resonance frequency. The fundamental resonance frequency is estimated at 8 different sites in study region and shows the maximum vulnerability of the site to the earthquakes. This frequency ranges between a minimum of 2.8 Hz to a maximum of 9.3 Hz. The thickness of the sediments below the surface of recording sites is calculated using the empirical relationship that comes out to be in a particular range of 9.5 m–33.1 m above the bed rock. The sedimentary thickness and the resonance frequency clearly matched with geological setting of the study area. The observation shows a slow reduction in the thickness of the sediments and increase in the resonance frequency from South-western part to North-eastern part of the study region. The results show that most of the sites are highly vulnerable to seismic risks with high amplification of seismic waves in the area. Thus, current study provides a deep insight in to the seismic hazard of the Sikkim region with a clear emphasis on the site amplification and the sedimentary cover for the region.

PURPOSE: To identify the contribution of mutations in the Desert Hedgehog (DHH) gene to the disorders of sexual differentiation (DSD) and male infertility. METHODS: The study included a total 430 subjects, including 47 gonadal dysgenesis cases, 6 patients with undescended testis and infertility characterized by azoospermia, 125 infertile male patients characterized by oligoasthenozoospermia, 24 patients with oligoasthenoteratozoospermia, and 200 ethnically matched normozoospermic fertile men who had fathered a child in the last two years. Sequencing of the complete coding region of the DHH gene was undertaken to find its contribution to the DSD and male infertility. RESULTS: We observed four novel mutations in the DHH gene in the cases with different reproductive anomalies. A synonymous substitution, c. 543C>T (p.His181His) was observed in 6.6% oligoasthenozoospermic infertile males and 1.5% normozoospermic fertile control samples (RR = 4.4077, 95%CI 1.19–16.29). Another synonymous substitution, c.990G>A (p.Ala330Ala) was observed in an infertile patient with unilateral undescended testis (case #12). Insertion of G at c.1156insG (p.Arg385fs) was observed in a case with bilateral undescended testis and azoospermia (case #23). In gonadal dysgenesis category, two mutations, insertion of G at c.1156insG (p.Arg385fs) and c.997A>G (p.Thr333Ala) substitution were observed in one case (case #34). These mutations were completely absent in control samples. CONCLUSION: Mutations in the DHH gene impact reproduction with mild mutations affecting fertility, and severe or multiple mutations resulting in gonadal dysgenesis.

PurposeOne of the foremost research disciplines in medical image processing is to identify tumors, which is a challenging task practicing traditional methods. To overcome this, various research studies have been done effectively.Design/methodology/approachMedical image processing is evolving swiftly with modern technologies being developed every day. The advanced technologies improve medical fields in diagnosing diseases at the more advanced stages and serve to provide proper treatment.FindingsEither the mass growth or abnormal growth concerning the cells in the brain is called a brain tumor.Originality/valueThe brain tumor can be categorized into two significant varieties, non-cancerous and cancerous. The carcinogenic tumors or cancerous is termed as malignant and non-carcinogenic tumors are termed benign tumors. If the cells in the tumor are healthy then it is a benign tumor, whereas, the abnormal growth or the uncontrollable growth of the cell is indicated as malignant. To find the tumor the magnetic resonance imaging (MRI) is carried out which is a tiresome and monotonous task done by a radiologist. In-order to diagnosis the brain tumor at the initial stage effectively with improved accuracy, the computer-aided robotic research technology is incorporated. There are numerous segmentation procedures, which help in identifying tumor cells from MRI images. It is necessary to select a proper segmentation mechanism to detect brain tumors effectively that can be aided with robotic systems. This research paper focuses on self-organizing map (SOM) by applying the adaptive network-based fuzzy inference system (ANFIS). The execution measures are determined to employ the confusion matrix, accuracy, sensitivity, and furthermore, specificity. The results achieved conclusively explicate that the proposed model presents more reliable outcomes when compared to existing techniques.

kidney transplantation from Hepatitis C virus (HCV) viremic donors to uninfected recipients is associated with excellent short-term outcomes. However, HCV viremia might be associated with an increased risk for post-transplant viral complications.We designed a retrospective study of HCV-negative kidney-only transplant recipients between 2018 and 2020. Recipients were grouped into group 1; HCV-negative donors, and group 2; HCV-viremic donors. Patients were matched 1:1 using propensity score. The primary objectives were to compare the incidence of cytomegalovirus (CMV) viremia ≥ 200 ml/IU, and BK viremia ≥1000 copies/ml between the groups. Secondary outcomes included group comparison of CMV disease, BK viremia ≥10 000 copies/ml, and 1-year patient and allograft survival.The study included 634 patients in group 1, and 71 patients in group 2. Sixty-five pairs of patients were matched. Incidence of CMV viremia (33.3% vs. 40.0%, p = .4675), and BK viremia (15.9% vs. 27.7%, p = .1353) did not differ significantly between groups in the matched cohort. Incidence of CMV disease (81.0% vs. 76.9%, p = 1.000), and BK viremia ≥10 000 copies/ml (9.5% vs. 16.9%, p = .2987) were comparable between groups. There was no difference in the 1-year patient or allograft survival between groups.kidney transplant from HCV-viremic donors is not associated with increased risk for BK or CMV viremia.

Acute kidney injury (AKI) is a common complication after lung transplantation (LT) and is associated with higher cost and mortality. We sought to evaluate the incidence of postoperative AKI, defined as AKI within 14 days of transplant, and identify associated perioperative factors.We conducted a single-center, retrospective review of 153 lung transplant recipients. Postoperative AKI was determined using the RIFLE (Risk, Injury, Failure, Loss, End Stage) criteria. Perioperative covariates and their association with postoperative AKI were analyzed using Cox proportional hazards. Kaplan-Meier survival curves were constructed to evaluate patient survival at 1 year and data finalization. A sub-analysis was performed evaluating factors associated with early AKI (within 48 h of transplant) and late AKI.Postoperative AKI occurred in 36.6% of patients with 51.8% of cases occurring within 48 h of LT. Recipient race, transplant type, cardiopulmonary support, and red blood cell administration were associated with postoperative AKI. Survival was significantly lower in patients with postoperative AKI following LT.Postoperative AKI within 2 weeks of lung transplant is associated with lower short- and long-term survival. Perioperative factors associated with postoperative AKI may be potential points of intervention to minimize AKI development in the future.

The advent of direct-acting antiviral (DAA) therapies has allowed kidney transplantation from hepatitis C (HCV)-viremic donors into negative recipients. We evaluated the safety and feasibility of such practice when utilizing a patient's health plan to cover the cost for DAAs. Materials and methods This was a prospective, non-randomized, pilot clinical study. 30 HCV-negative participants received kidney transplant from HCV-viremic deceased donors. HCV polymerase chain reaction (PCR) was checked on day 3 post transplant, and a request for pan-genotypic DAA therapy was sent once viremia was confirmed. Primary outcomes were the percentage of patients achieving sustained virologic response defined as undetectable HCV PCR 12 weeks after therapy completion, and the percentage of patients receiving DAAs via patient's health plan. Results HCV viremia occurred in all 30 recipients. Sustained viral response was achieved in 93% of the patients. Two patients failed first-line DAAs, 1 patient due to non-compliance with the prescribed regimen while the other due to NS5A mutation. DAA therapy was successfully obtained via patient's health plan in 28/30 patients. There was no significant liver-related complication, patient death, or graft loss. Conclusion Kidney transplantation from HCV-viremic donors appears to be safe. However, challenges with obtaining DAA coverage in the United States persist.

Hydroxychloroquine (HCQ) has become the rheumatologists's "Swiss army knife" when it comes to managing the rheumatologic manifestations of SLE and other auto-immune disorders. By contrast, nephrologists are much less comfortable in managing the multifaceted effect of HCQ. As a result, nephrologists are inclined to abdicate their responsibility for HCQ management, if this therapy was initiated by a rheumatologist. This report describes such a situation, which had devastating consequences for the patient. On this basis we suggest that this report is a story worth telling, and should encourage the nephrologist to be more involved in their patients' HCQ management.

An approach for identifying and selecting the route alignment using GIS and fuzzy AHP is developed in the present study. Spatial multi-criteria decision analysis is applied to identify optimal route alignment with the consideration of criteria such as environmental, social, economic and technical spatial datasets. These criteria play a significant role in the identification and selection of optimal route alignment. Fuzzy set theory is used to handle vagueness-type uncertainty in the multi-criteria decision analysis. Fuzzy AHP is introduced to compare the fuzzy criteria for ranking purpose, and fuzzy criteria weights are used to develop relative surface cost maps. The least-cost path (LCP) method is applied to find alternate four route alignments from source to destination by considering several criteria in GIS. The criteria values of each four alignment and weight of each criterion on the basis of maximum priority weight are calculated. The designed four routes are evaluated using priority weight method and fuzzy-AHP method. The selection of optimum route is considered by maximum weight of the alignment. The technical route alignment (alignment 4) is considered as optimum route with weight value 80.38%. The proposed methodology is implemented for a study area, outer region of Allahabad city, India.

Published data regarding the approach to management of diabetes mellitus in solid organ transplant (SOT) recipients are limited. We performed a retrospective chart review of SOT recipients with diabetes, above 18 years of age, who were usisng dulaglutide. There was a sustained, statistically significant reduction in the primary endpoints of weight, body mass index (BMI) and insulin requirement in 63 SOT recipients at 6, 12 and 24 months, respectively. A total of 59, 50 and 13 recipients were followed during 6, 12 and 24 months, with a mean paired difference for weight reduction of 2.07 (P value

A 47-year-old man with a history of deceased donor kidney transplant in May 2019 was admitted with odynophagia, pancytopaenia and neutropaenic fever. He had new tongue lesions ongoing for 2 weeks. Examination showed a 3×3 cm elevated, adherent plaque (figure 1). He has a history of resistant cytomegalovirus (CMV) viraemia with failed therapy to low-dose valganciclovir, ganciclovir and letermovir. Foscarnet led to undetectable CMV viral load, but the treatment was complicated with acute renal injury, and he was transitioned to a high-dose valganciclovir. We held his valganciclovir on admission as his CMV PCR was

Background The COVID-19 pandemic has negatively impacted organ donation and transplantation across the globe. Methods This study analyzed transplant outcomes during the pre-pandemic [PPE, 1/2019-2/2020] and pandemic era [PE, 3/2020-8/2020] based on changes in induction immunosuppression. During PPE, high immunological risk patients received 4-6 mg/kg, moderate risk 2-4 mg/kg, and low risk 1-2 mg/kg of ATG. During PE, ATG doses were reduced to 3-4 mg/kg for high risk, 1-2 mg/kg for moderate, and low changed to basiliximab. Primary outcomes are as follows: biopsy-proven rejection [BPAR], de-novo donor-specific antibody [DSA], delayed graft function [DGF], infection rates, graft loss, and all-cause of mortality. Results During PPE, 224 kidney transplants [KTx] and 14 kidney/pancreas transplants [KP] were included, while 180 KTx and 5 KP were included for PE. Basiliximab use increased by 30% in the PE. The odds of DGF were statistically significant between PE vs PPE, OR 1.7 [1.05, 2.8, p-value = .042]. The odds of developing DSAs and BPAR during the PE vs. PPE were 0.34 [0.16, 0.71, p-value = .004] and OR 0.34 (0.1 to 1.1, p-value, .104)], respectively. Cytomegalovirus [19% in PE, 37% in PPE] and BK virus [5.4% PE vs. 16% PPE] incidence reduced during PE vs. PPE. COVID-19, graft loss, and mortality were comparable between groups. Conclusion KTx and KP transplants were performed safely during the COVID-19 pandemic with a reduction of induction immunosuppression.

The population of patients with kidney transplants in the United States is growing. The delivery of transplant care is complex, involves a multidisciplinary transplant team, and care coordination between transplant and community providers. The transplant nephrologist is central to the delivery of this care and assumes a multitude of clinical and nonclinical roles and responsibilities. With a growing population of patients requiring transplant care that spans a continuum from pretransplant referral to long-term posttransplant management, an understanding of the current state of the transplant nephrology workforce in the United States and the future that it faces is important in ensuring that current and future needs of both patients and physicians are met. In this article, we (1) review the scope of practice of the transplant nephrologist, (2) discuss the state of training in the field of transplant nephrology, (3) review the role of the referring primary nephrologist in the care of patients undergoing kidney transplant, and (4) discuss challenges and opportunities facing the transplant nephrology workforce.

Renal transplant patients on immunosuppression are at risk for malignancy. One form of malignancy that commonly affects this population is Kaposi-sarcoma. Kaposi-sarcoma is a human herpesvirus-8 (HHV-8)-driven process classically associated with skin lesions in immunocompromised patients. The pulmonary system may be involved in disseminated disease. In this case, a renal transplant patient was re-admitted with acute hypoxic respiratory failure and hemoptysis of an unclear etiology. Following a broad workup, HHV-8 PCR and a lymph node biopsy confirmed pulmonary Kaposi-sarcoma. Workup for multicentric Castleman disease was negative. The patient was treated with liposomal doxorubicin, ganciclovir, and prednisone. Her immunosuppression was changed to sirolimus and she is scheduled to complete six cycles of liposomal doxorubicin.

The attenuation of seismic wave is one of the basic physical parameters which is closely related to the seismicity and regional tectonics activity of a particular area. This is also important for seismic hazard measurement. Seismic wave attenuation for local earthquakes is determined from the analysis of direct body waves and coda waves. The dimensionless parameter, Q , is studied in the present work, which is defined as a measure of the rate of decay of the coda waves or body waves within a specific frequency band. Digital seismogram data of 75 earthquakes that occurred in Garhwal Himalaya region during 2004 – 2006 and recorded at 20 different stations have been analyzed to study the seismic body and coda wave attenuation. Seismic body wave attenuation characteristics are examined by estimating the frequency dependent relationship of quality factors for P -waves, Q α and for S -waves, Q β in the frequency range 1.5 – 28 Hz, using 95 seismic observations with hypo central distance less than 100 km. The extended coda normalization method was applied. The average value of Q α is found to be varied from 45.10 at 1.5 Hz to 1400.0 at 28 Hz, while it varies from 109.02 at 1.5 Hz to 3987.0 at 28 Hz for Q s . The estimated frequency dependent relation for quality factors are Q α = ( 29.077 ± 8.5 ) f ( 1.16 ± 0.01 ) and Q β = ( 67.84 ± 13.5 ) f ( 1.18 ± 0.02 ) for P and S -waves, respectively. The rate of increase of Q ( f ) for P and S waves in this region is comparable with the other regions of the Himalayas. The ratio Q β Q α is greater than unity in the entire analyzed frequency range. It indicates that scattering is an important factor contributing to the attenuation of body wave in the region. The low Q α , β values or high, attenuation at lower frequencies and high Q α , β values or low attenuation at higher frequency may indicate that the heterogeneity decreases with increasing depth in the study region.

Attenuation of seismic wave energy was estimated in and around the source region of the Sikkim earthquake of 18 September, 2011 using aftershocks. The main shock had a moment magnitude 6.9 and after this main shock, approximately 283 aftershocks with a magnitude distribution ranging from 1.02 to 5.0 were recorded by 8 temporary broad band seismometers. In the present study, the relative contributions of scattering attenuation and intrinsic absorption are estimated by multiple lapse time window analysis under the hypothesis of isotropic scattering and a uniform distribution of scatterers in the crustal part of the study area. The coda wave attenuation is also estimated using single backscattering method. All of the attenuation parameters are estimated as a function of frequency in the range 1–16 Hz. The results show that scattering attenuation is greater than intrinsic absorption for all of the frequencies. The relative contribution of scattering attenuation decreases with increasing frequency. Around the 1–4 Hz frequency band, scattering attenuation primarily contributes to seismic wave attenuation in the Sikkim region. The estimated values of seismic albedo ranges from 0.65 to 0.79; as seismic albedo is higher than 0.5 for all frequencies, it is concluded that the medium in the Sikkim Himalayas is highly heterogeneous and tectonically active. Our knowledge of the attenuation mechanism of the Sikkim region is enhanced by the application of the multiple lapse time window analysis method, and results can be useful for the hazard assessment.

Multimodal data modeling is fast growing area of research. It may used to combine the information from the different sources. The research interest in multimodal data modeling is increasingly attracting the attention in the field of transportation planning. In this study, multi-modal data is used to assess and design a socially efficient public transport bus route plan for the Allahabad city of Uttar Pradesh state, India. Data envelopment analysis (DEA) method is used for the efficiency assessment of existing 24 public transport bus routes by taking access point to locations of social facilities like as hospitals, shopping malls, colleges, coaching centers, schools, banks and the population, near to the particular route. Geographical Information System (GIS) technology is used for multimodal data modeling to design new more socially efficient routes for the existing roads of the city. DEAP Solver software is used for the evaluation of efficiency and rank for social priority routes and route number 15 and 24 are relative efficient route among the existing 24 routes. Finally, the social efficiency of existing public bus transport routes and newly designed routes are compared. We suggested ways to improve the performance of bus routes based on the social perspectives using multimodal data.

Purpose Acute kidney injury (AKI) has been increasingly recognized as a common post-operative complication of lung transplantation (LT). AKI incidence and severity in LT recipients has been associated with higher cost and decreased post-operative survival. To date, no study has evaluated early post-operative AKI and post-operative outcomes. We sought to evaluate the incidence of AKI in our LT program and to identify associated factors for possible intervention. Methods This study is a single center retrospective review conducted from January 2015 to March 2019 under institutional review board approval at our institution. Patients with multi-organ transplants, re-transplants, and patients who expired within 30 days of transplant were excluded. 171 patients were identified and 153 qualified for review. Our protocol adapted RIFLE criteria to identify post-operative AKI. Statistical analysis was completed analyzing incidence of AKI from post-operative days 1 to 14, with subgroup analyses of days 1 to 7 and 8 to 14. AKI status was compared with pre-specified individual covariates using Fisher's exact tests and logistic regression models with AKI status as the outcome and each covariate as the predictor. All calculations were performed using SAS 9.4 (SAS Institute, Cary, NC). Results Post-operative AKI incidence was 36.6%, and ESRD incidence was 9.8% between the years of 2015 and 2019. Survival at one year (p=0.024) and 5 years (p=0.038) following LT was significantly lower in patients with early post-operative AKI. African American recipients (p=0.014), bilateral transplant recipients (p=0.005), and those transplanted on cardiopulmonary bypass (p=0.018) were all more likely to have post-op AKI. Use of vasopressors, longer operative times, and the need for blood products within the first 24 hours of LT were also associated with AKI. The majority of renal injury occurred within the first 7 post-operative days. Conclusion Early post-operative AKI is associated with decreased 1 year and long term survival. Additionally, we identified the first 7 post-operative days to be the most likely time for patients to develop renal injury. We identified variables associated with renal hypoperfusion to be major risk factors for post-op AKI. We also identified susceptible patient populations and operative interventions associated with AKI.

Acute oxalate nephropathy has been associated with chronic diarrheal illness and only one case has been reported due to acute diarrhea secondary to Clostridium difficile colitis. To the best of our knowledge, this is the second case report of acute oxalate nephropathy due to C. difficile colitis. A 75-year-old man with a medical history of hypertension, type 2 diabetes mellitus, chronic kidney disease stage IV, recent C. difficile colitis was admitted for acute kidney injury with a creatinine (Cr) of 8.54 mg/dL (baseline Cr, 2.3–2.6 mg/dL). His urinalysis did not show any eosinophils, casts or crystals. Antinuclear antibody, antineutrophil cytoplasmic antibody, complement levels (C3 and C4) and hepatitis screen were negative; a renal ultrasound visualized no hydronephrosis. A kidney biopsy showed widespread tubular oxalate crystal deposition suggestive of hyperoxaluria as the cause of acute kidney injury. In conclusion, an acute diarrheal illness like C. difficile colitis can cause acute oxalate nephropathy.

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are gaining popularity in the management of diabetes in solid organ transplant (SOT) recipients. There are no studies available comparing the two GLP-1RAs dulaglutide and liraglutide in SOT. We performed a retrospective chart review to assess the safety and effectiveness of these agents in adult SOT with diabetes at 6, 12 and 24 months. There were 63 and 25 recipients on dulaglutide and liraglutide, respectively. There was a sustained reduction in primary endpoints of weight, BMI and insulin requirement with dulaglutide when compared to liraglutide. Decrease in weight was 2%, 4% and 5.2% with dulaglutide and 0.09%, 0.87% and 0.89% with liraglutide at 6, 12 and 24 months respectively. BMI reduction followed the same trend in the two groups. The percentage reduction for insulin was 26% with dulaglutide and 3.6% with liraglutide. There was a 10% reduction in creatinine and a 15% increase in estimated glomerular filtration rate (eGFR) at the end of 24 months with dulaglutide. However, there was an increase in creatinine by 7% and an 8% decrease in eGFR at the end of 24 months with liraglutide.

Following primary percutaneous coronary intervention (PPCI) for ST segment elevation myocardial infarction, microvascular perfusion is often impaired secondary to thrombotic embolization. Intracoronary (IC) fibrinolytic administration may reduce thrombotic burden and distal embolization. The ICE-T-TIMI-49 study evaluated the feasibility and safety of low-dose IC tenecteplase (TNK) during PPCI. The study randomized 40 PPCI patients to a volume matched bolus of IC TNK (4 mg) (n = 20) or IC saline placebo (n = 20) before and following PPCI. The primary end point was percent diameter stenosis of the culprit lesion following first bolus. The primary end point did not differ between IC placebo (median 100%, interquartile range [IQR] 83.0,100.0) and IC TNK (median 100% stenosis, IQR 91.0,100.0; p = 0.522). However, the proportion of patients with reduction in thrombus following first bolus tended to be greater with IC TNK (placebo: 12.5% vs IC TNK: 40.0%, p = 0.133). Following PPCI, the corrected Thrombolysis In Myocardial Infarction (TIMI) frame count (cTFC) was lower (faster) with placebo (16.0 frames [IQR 12.0,24.0] vs 24.0 frames [22.0,32.0], p = 0.045) due to a trend towards greater frequency of hyperemia (cTFC14), a marker of distal embolization (50.0% vs 8.3%, p = 0.056). There was no difference in TIMI major bleeds and no intracranial hemorrhage. In conclusion, treatment with low-dose IC TNK appears safe and well tolerated during PPCI. Although IC TNK administration did not improve percent stenosis, a trend towards reduced thrombus burden was demonstrated with less hyperemia (a marker of distal embolization). Our findings provide support for a large randomized study.

As the production of waste in India is set to increase from 62 to 162 million ton by 2030, the need for an integrated approach toward solid waste management becomes inevitable. Under these circumstances, the role private sector startups play in providing a feasible alternative for waste management and in mainstreaming the informal sector involved holds its relevance. The objective of this research paper is to study the emerging role of private sector startups in proper management and handling of solid waste in India. This paper also attempts to understand the role of startups in empowering the informal recyclers and providing them opportunities to participate and work together with the formal sector. The research design of this study will be exploratory in nature. This study relies mostly on secondary available data gathered from several sources such as reports, journals, books, and articles.

Background Post-transplant diabetes mellitus is a well-recognized complication of SOT. There is a limited published data regarding the approach to management. We aim to test the efficacy and safety of a GLP-1 analog, dulaglutide, an incretin-based therapy in this population. Methods We performed a retrospective, chart review of adult SOT recipients (> 18 years) with diabetes and on dulaglutide. We identified 63 recipients and collected data at 6, 12 and 24 months post GLP1 therapy. The primary endpoint was: change in weight, BMI, and insulin requirement. Safety endpoint included hypoglycemia, GI side-effects, and cancers. Secondary endpoints were: HbA1c, renal and liver function. Results There was a sustained, statistically significant reduction in weight, BMI, and insulin requirement with Dulaglutide at each study period. The mean of paired difference for weight reduction was 2.07 (p-value < 0.003), 4.007 (p-value < 0.001), and 5.23 kgs (p-value

Presentation: A 62-year-old woman with a Living Donor Kidney transplant in 2008 complicated with chronic kidney disease III, lupus nephritis, hypothyroidism (but no history of diabetes) presented with painful, bilateral, medial calf ischaemic ulcerations (figure 1), which on punch biopsy revealed calciphylaxis (figure 2). Her weight was 66.3 kg, height 1.6 m and body mass index of 25.9 kg/m2. She was on hydroxychloroquine, mycophenolate and prednisone for lupus/transplant and levothyroxine 125 mcg daily for hypothyroidism. Her baseline intact parathyroid harmone (iPTH), calcium, …

This paper develops a model to delineate groundwater potential zones by integrating tools of remote sensing, geographical information system (GIS) and Fuzzy Analytical Hierarchy Process (FAHP) to achieve multi-attribute decision making choice among various thematic layers which affect the groundwater resources such as geology, geomorphology, lineament density, slope, soil, rainfall, drainage density, land use/land cover, normalized difference vegetation index and elevation in the region of Prayagraj, Uttar Pradesh, India. Using Saaty's scale, suitable weights are allotted to the physical properties and their significant features according to their relative importance in groundwater occurrence. The allotted weights of the thematic layers and their significant features were then normalized by using FAHP. Finally, the estimated ten thematic maps from satellite images and conventional data are combined in a GIS platform to yield a groundwater potential zones map. Thus, seven groundwater potential zones are identified and demarcated in the study area as: excellent, very strong to excellent, strong to very strong, moderate to strong, moderate, equal to moderate and equal. The groundwater potential zones map is finally justified using the well annual discharge data and the result is found tolerable. This study clearly provides groundwater potential zones and offers future planning, managing and forecasting of groundwater resources in the study area. Information from remote sensing analysis also reduces the expenditure, time and risk to human life during the groundwater related research work.

Multi-objective transportation problem (MOTP) is a special case of vector minimization linear optimization problem with equality constraints and the objectives are conflicting in nature. Due to the conflicting nature of objectives, no method is available to find single optimal solution for MOTP. All the methods can find only the compromise solution. This paper presents an efficient method for solving MOTP to find fuzzy efficient and compromise solution using the qualities of three well known approaches i.e. (i) fuzzy programming, (ii) goal programming, (iii) interactive programming. In this approach, fuzzy goals are decided by the decision maker (DM) for each objectives and membership functions are constructed for each objective. Then the method is developed using fuzzy set theory and the best quality of the developed method is that the decision maker is focussed only in the part of evaluation of the solution at each step using the acceptable terms and conditions. The present method is the extension of Waeil and Lee (Omega 34:158–166, 2006). To measure the efficiency of the method, some distance metric functions are used and it is verified by two numerical examples. The results are compared with previous reported work for the same numerical problems.

Digital seismogram data of 82 earthquakes from the Northwestern Himalayan (India) region recorded at different stations during 2004–2006 were analyzed to study the seismic coda wave attenuation characteristics in this region. We used 132 seismic observations from local earthquakes with a hypocentral distance Q C using the single isotropic scattering model. These earthquakes were recorded at 20 temporary seismic stations installed in the Northwestern Himalayas (India) by the Wadia institute of Himalayan Geology, Dehradun. The Q C values were estimated at 10 central frequencies: 1.5, 3, 5, 7, 9, 12, 16, 20, 24, and 28 Hz using starting lapse-times of 10, 20, 30, 40, 50, and 60 s and coda window-lengths of 10, 20, 30, 40, and 50 s. The Q C fits the frequency dependent power-law, Q C = Q 0 f n . For a 10 s lapse time with a 10-s coda window length Q C = 47.42 f 1.012 and for a 50 s lapse time with a 50 s coda window length, Q C = 204.1 f 0.934 . Q 0 ( Q C at 1 Hz) varied from ∼47 for a 10 s lapse time and a 10 s window length, to ∼204 for a 50 s lapse time and a 50 s window length. An average frequency dependent power law fit for the study region may be given as Q C = 116.716 f 0.9943 . The exponent of the frequency dependence law n ranged from 1.08 to 0.9, which correlates well with values obtained in other seismically and tectonically active and heterogeneous regions of the world. In our study region, Q C increases both with respect to lapse time and frequency, i.e., the attenuation decreases as the quality factor is inversely proportional to attenuation. The low Q C values or high attenuation at lower frequencies and high Q C values or low attenuation at higher frequencies suggest that the heterogeneity decreases with increasing depth in our study region.

Objective Due to a progressive decline in beta-cell function, a considerable number of patients with type 2 diabetes mellitus (T2D) ultimately require multiple daily injections of large doses of insulin for glycemic control. Majority of studies have reported only short-term benefits of continuous subcutaneous insulin infusion (CSII) using an insulin pump in T2D. Our five-year follow-up data of CSII in T2D is one of the few studies showing persistent benefit in glucose control in this population. Research design and methods We did a chart review of patients treated with an insulin pump for five years. Inclusion criteria were: type 2 diabetes, 18-75 years of age, glycosylated hemoglobin (HbA1c) more than 6.5% (48 mmol/mol) on multiple doses of insulin (MDI > four injections per day) or more than 100 units of insulin/day, wide glycemic excursions, and intractable hypoglycemia. We identified a total of 13 patients. The primary endpoint was change in HbA1c from baseline to five years. We also reviewed the difference in weight, basal insulin requirements, hypoglycemia, and patient satisfaction questionnaire at one year. Exclusion criteria were: type 1 diabetes (T1D) and pregnancy. Results The HbA1c at five years was found to be 7.72% (61 mmol/mol) compared to a baseline of 8.89% (74 mmol/mol), p-value 0.0076. We did not find any increased risk of severe hypoglycemia, weight gain, and insulin requirement. Conclusions The beneficial effect of insulin pump persisted for five years of follow-up, suggesting it as a valuable treatment option for difficult to treat T2D.

Checkpoint inhibitors like programmed cell death-1 (PD1) are changing the way we envisage the prognostication of metastatic carcinomas. Binding of PD1 to PD1-ligand unleashes the power of naturally occurring antitumor T cells by suppressing T-cell migration, proliferation, and cytotoxic activities.1

Tectonics of a region plays important role on the attenuation characteristics of the region. Attenuation characteristics have been estimated to understand the effect of the heterogeneity of the region in a tectonically active Garhwal region of Himalaya. Seismic body wave attenuation characteristics in the region is studied using 234 short-period, seismic observations from local events. The P-wave attenuation (QP− 1) and S-wave attenuation (QS− 1) were estimated by applying the state-of-the-art, extended coda normalization method for the frequency range from 1.5 to 24 Hz. Estimates of QP− 1 and QS− 1 decrease from (15.86 ± 0.90) × 10− 3 and (5.35 ± 0.51) × 10− 3 at 1.5 Hz to (0.54 ± 0.11) × 10− 3 and (0.34 ± 0.06) × 10− 3 at 24 Hz, respectively. The values of QP− 1 and QS− 1 show strong frequency dependence and fit the power-law relation QP− 1(f) = (27.43 ± 3.15) × 10− 3f (− 1.16 ± 0.06) and QS− 1(f) = (8.05 ± 0.74) × 10− 3f (− 0.93 ± 0.05), respectively. Obtained results are in the range of those reported for QP− 1 and QS− 1 of the other seismically active regions. The ratio of QP− 1/QS− 1 is larger than unity in the entire analyzed frequency range and may suggest high degree of heterogeneity in the region.

Chronic mesenteric ischaemia is a severe disease that is often missed due to its non-specific presentation. Immunosuppressed patients are at risk for infectious gastrointestinal disease, which may further obscure the diagnosis of chronic mesenteric ischaemia. In this case, a patient’s symptoms and diagnostic workup were consistent with candida esophagitis. Worsening leukocytosis despite treatment, however, prompted re-evaluation ultimately revealing a superior mesenteric artery thrombus causing mesenteric ischaemia. The patient required urgent surgical intervention for the management of his disease.

Acute oxalate nephropathy has been associated with chronic diarrheal illness and only one case has been reported due to acute diarrhea secondary to Clostridium difficile colitis. To the best of our knowledge, this is the second case report of acute oxalate nephropathy due to C.difficile colitis. A 75-year-old man with a medical history of hypertension, type 2 diabetes mellitus, chronic kidney disease stage IV, recent C.difficile colitis was admitted for acute kidney injury with a creatinine (Cr) of 8.54 mg/dL (baseline Cr, 2.3–2.6 mg/dL). His urinalysis did not show any eosinophils, casts or crystals. Antinuclear antibody, antineutrophil cytoplasmic antibody, complement levels (C3 and C4) and hepatitis screen were negative; a renal ultrasound visualized no hydronephrosis. A kidney biopsy showed widespread tubular oxalate crystal deposition suggestive of hyperoxaluria as the cause of acute kidney injury. In conclusion, an acute diarrheal illness like C.difficile colitis can cause acute oxalate nephropathy.

Pharmaceutical agents currently used in clinical practice for early management of ST elevation myocardial infraction (STEMI) act primarily on the two pathways of clot formation: platelet aggregation and the coagulation cascade. Although percutaneous coronary intervention is the standard therapy for revascularization, new fibrinolytic drugs are being developed to provide increased safety and efficacy through a longer plasma half-life, more fibrin specificity, and resistance to plasminogen activator inhibitor-1. Antiplatelet therapies useful for early and extended management of STEMI include acetylsalicylic acid, glycoprotein IIb/IIIa inhibitors (eptifibatide, tirofiban, and abciximab), the thienopyridines (clopidogrel and prasugrel), and contemporary agents (ticagrelor, cangrelor, elinogrel, and vorapaxar). Novel therapies for long-term inhibition of thrombin formation following STEMI include factor Xa inhibitors, such as rivaroxaban and apixaban. Emerging areas of STEMI treatment include pharmacotherapy that specifically targets reperfusion injury and cardiomyoplasty, which involves the use of hematopoietic stem cell therapy or growth factors to induce proliferation and differentiation of cardiac myocytes.

Spinal muscular atrophy, a hereditary degenerative disorder of lower motor neurons associated with progressive muscle weakness and atrophy, is the most common genetic cause of infant mortality. It is caused by decreased levels of the "survival of motor neuron" (SMN) protein. Its inheritance pattern is autosomal recessive, resulting from mutations involving the SMN1 gene on chromosome 5q13. However, unlike many other autosomal recessive diseases, the SMN gene involves a unique structure (an inverted duplication) that presents potential therapeutic targets. Although no effective treatment for spinal muscular atrophy exists, the field of translational research in spinal muscular atrophy is active, and clinical trials are ongoing. Advances in the multidisciplinary supportive care of children with spinal muscular atrophy also offer hope for improved life expectancy and quality of life.

Seismic coda wave attenuation (\( Q_{\text{c}}^{ - 1} \)) characteristics in the Garhwal region, northwestern Himalaya is studied using 113 short-period, vertical component seismic observations from local events with hypocentral distance less than 250 km and magnitude range between 1.0 to 4.0. They are located mainly in the vicinity of the Main Boundary Thrust (MBT) and the Main Central Thrust (MCT), which are well-defined tectonic discontinuities in the Himalayas. Coda wave attenuation (\( Q_{\text{c}}^{ - 1} \)) is estimated using the single isotropic scattering method at central frequencies 1.5, 3, 5, 7, 9, 12, 16, 20, 24 and 28 Hz using several starting lapse times and coda window lengths for the analysis. Results show that the (\( Q_{\text{c}}^{ - 1} \)) values are frequency dependent in the considered frequency range, and they fit the frequency power law (\( Q_{\text{c}}^{ - 1} \left( f \right) = Q_{0}^{ - 1} f^{ - n} \)). The Q0 (Qc at 1 Hz) estimates vary from about 50 for a 10 s lapse time and 10 s window length, to about 350 for a 60 s lapse time and 60 s window length combination. The exponent of the frequency dependence law, n ranges from 1.2 to 0.7; however, it is greater than 0.8, in general, which correlates well with the values obtained in other seismically and tectonically active and highly heterogeneous regions. The attenuation in the Garhwal region is found to be lower than the Qc−1 values obtained for other seismically active regions of the world; however, it is comparable to other regions of India. The spatial variation of coda attenuation indicates that the level of heterogeneity decreases with increasing depth. The variation of coda attenuation has been estimated for different lapse time and window length combinations to observe the effect with depth and it indicates that the upper lithosphere is more active seismically as compared to the lower lithosphere and the heterogeneity decreases with increasing depth.

Autism is a disorder of neural development which affects about one in every 150 kids on average. Autism deals with major complexities regarding social communication and retention power. Now days, due to the increased use of the computer, the technology is being used to assist the treatment and to interact with an autistic child. To make the learning environment more attractive, the animated pictures are used in the applications. In this paper a gaming model is proposed which will first teach basic traffic rules to Autistic children with the help of some animated videos and then help them decide what action must be taken in certain situations thus increasing their intelligibility. The use of tangible objects is introduced so as to keep the sessions more interesting for autistic children.

If we adopt the definition that an earthquake is shaking of the earth due to natural causes, then we may argue that earthquakes have been occurring since the very beginning of the earth about 4.5 billion years ago.

Purpose of review Spinal muscular atrophy (SMA) is a pediatric neuromuscular condition characterized by progressive proximal muscle weakness. It is one of the most common genetic causes of infant mortality across different races and is caused by mutation of the survival of motor neuron 1 (SMN1) gene on chromosome 5q13. Recent findings To date, there have been many therapeutics developments for SMA targeting various potential pathways such as increasing SMN gene expression, enhancing SMN2 exon 7 inclusion, neuroprotection, cell replacement, and gene therapy. Summary Although SMA remains an incurable disease to date, recent advances in the field of basic and translational research have enhanced our understanding of the pathogenesis of the disease and opened new possibilities for therapeutic intervention. This article reviews and highlights past and current translational research on SMA therapeutics.

Introduction: The purpose of continuous quality improvement programs is to improve health care by identifying problems, implementing and monitoring corrective action, and studying its effectiveness. Aim: The present study aims to find out the present length of stay (LOS) of inpatients at a superspeciality hospital. Objectives: 1. To study the existing system of discharge process of patients, 2. to find out the reasons for the delays, 3. To recommend suitable suggestions to reduce length of stay. Mehodology and Results: By considering the LOS of 128 random patients, 32 from each ward A, B, C, and D. The average LOS (ALOS) was found to be 5.69. Factors have been identified by studying the delays through time and motion study in the discharge process. Recommendations: Recommendations have been made for appropriate changes to be considered to reduce ALOS and bring it to 5.0 so that proper resource utilization occurs, and at the same time, there is an improvement in bed turnover rate and thereby in bed occupancy rates.