Publications by authors named "Oommen John"

51 Publications

Telehealth and the COVID-19 Pandemic: International Perspectives and a Health Systems Framework for Telehealth Implementation to Support Critical Response.

Yearb Med Inform 2021 Apr 21. Epub 2021 Apr 21.

Sri Sathya Sai Central Trust, Puttaparthi, India.

Objectives: Telehealth implementation is a complex systems-based endeavour. This paper compares telehealth responses to (COrona VIrus Disease 2019) COVID-19 across ten countries to identify lessons learned about the complexity of telehealth during critical response such as in response to a global pandemic. Our overall objective is to develop a health systems-based framework for telehealth implementation to support critical response.

Methods: We sought responses from the members of the International Medical Informatics Association (IMIA) Telehealth Working Group (WG) on their practices and perception of telehealth practices during the times of COVID-19 pandemic in their respective countries. We then analysed their responses to identify six emerging themes that we mapped to the World Health Organization (WHO) model of health systems.

Results: Our analysis identified six emergent themes. (1) Government, legal or regulatory aspects of telehealth; (2) Increase in telehealth capacity and delivery; (3) Regulated and unregulated telehealth; (4) Changes in the uptake and perception of telemedicine; (5) Public engagement in telehealth responses to COVID-19; and (6) Implications for training and education. We discuss these themes and then use them to develop a systems framework for telehealth support in critical response.

Conclusion: COVID-19 has introduced new challenges for telehealth support in times of critical response. Our themes and systems framework extend the WHO systems model and highlight that telemedicine usage in response to the COVID-19 pandemic is complex and multidimensional. Our systems-based framework provides guidance for telehealth implementation as part of health systems response to a global pandemic such as COVID-19.
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http://dx.doi.org/10.1055/s-0041-1726484DOI Listing
April 2021

Continuum of care for non-communicable diseases during COVID-19 pandemic in rural India: A mixed methods study.

J Family Med Prim Care 2020 Dec 31;9(12):6012-6017. Epub 2020 Dec 31.

George Institute for Global Health, UNSW, New Delhi, India.

Background: COVID-19 pandemic has resulted in disruption to routine health services delivery as strict lockdowns were implemented in India and health workforce redeployed for COVID-19 focused responses. We assess the perceptions about COVID-19, the impact of the lockdown on access to health services and continuum of care for Non-communicable diseases (NCDs) among a cohort of adults in rural India.

Methodology: Since 2018, we have been following up a cohort of persons with non-communicable diseases in a high NCD burden region in Srikakulam District of Andhra Pradesh under the STOP CKDu study. We conducted this mixed methods study, administered through a structured telephonic questionnaire and interview to determine the awareness, perceptions and their compliance to ongoing treatment schedules.

Results: Overall, 68% of the participants exhibited adequate knowledge of symptoms of COVID-19, while 43% were not aware of the mode of transmission of the virus. In all, 822 (36.1%) participants reported at least one NCD condition. Among them, 115 (14%) missed their follow-up visit, 110 (13.4%) reported facing challenges in medication procurement and 11.6% either developed new complaints or experienced worsening of pre-existing symptoms. A total of 233 (28.5%) used a telemedicine facility and took telephonic advice from (private) physicians. As the access to medicines was restricted due to the lockdown, majority of the respondents were depending on rural medical practitioners (RMPs) for the procurement of medication.

Conclusion: Our finding implies the need for the future guidelines on adaptation of telehealth approaches within health systems to maintain the continuum of care, digital health tools to facilitate the patient's appointments including virtual follow-up visits for those with NCDs coupled with regular engagement by frontline healthcare workers at the local levels, evidence informed public health messaging taking into consideration the social and behavioural aspect and uninterrupted essential primary healthcare services.
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http://dx.doi.org/10.4103/jfmpc.jfmpc_1805_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7928131PMC
December 2020

Higher vs lower doses of dexamethasone in patients with COVID-19 and severe hypoxia (COVID STEROID 2) trial: Protocol and statistical analysis plan.

Acta Anaesthesiol Scand 2021 02 14. Epub 2021 Feb 14.

Department of Anaesthesia and Critical Care Medicine, Odense University Hospital, Odense C, Denmark.

Background: The coronavirus disease 2019 (COVID-19) pandemic has resulted in millions of deaths and overburdened healthcare systems worldwide. Systemic low-dose corticosteroids have proven clinical benefit in patients with severe COVID-19. Higher doses of corticosteroids are used in other inflammatory lung diseases and may offer additional clinical benefits in COVID-19. At present, the balance between benefits and harms of higher vs. lower doses of corticosteroids for patients with COVID-19 is unclear.

Methods: The COVID STEROID 2 trial is an investigator-initiated, international, parallel-grouped, blinded, centrally randomised and stratified clinical trial assessing higher (12 mg) vs. lower (6 mg) doses of dexamethasone for adults with COVID-19 and severe hypoxia. We plan to enrol 1,000 patients in Denmark, Sweden, Switzerland and India. The primary outcome is days alive without life support (invasive mechanical ventilation, circulatory support or renal replacement therapy) at day 28. Secondary outcomes include serious adverse reactions at day 28; all-cause mortality at day 28, 90 and 180; days alive without life support at day 90; days alive and out of hospital at day 90; and health-related quality of life at day 180. The primary outcome will be analysed using the Kryger Jensen and Lange test adjusted for stratification variables and reported as adjusted mean differences and median differences. The full statistical analysis plan is outlined in this protocol.

Discussion: The COVID STEROID 2 trial will provide evidence on the optimal dosing of systemic corticosteroids for COVID-19 patients with severe hypoxia with important implications for patients, their relatives and society.
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http://dx.doi.org/10.1111/aas.13795DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8014264PMC
February 2021

Higher vs Lower Doses of Dexamethasone in Patients with COVID-19 and Severe Hypoxia (COVID STEROID 2) trial: Protocol for a secondary Bayesian analysis.

Acta Anaesthesiol Scand 2021 05 25;65(5):702-710. Epub 2021 Feb 25.

Department of Anaesthesia and Critical Care Medicine, Odense University Hospital, Odense C, Denmark.

Background: Coronavirus disease 2019 (COVID-19) can lead to severe hypoxic respiratory failure and death. Corticosteroids decrease mortality in severely or critically ill patients with COVID-19. However, the optimal dose remains unresolved. The ongoing randomised COVID STEROID 2 trial investigates the effects of higher vs lower doses of dexamethasone (12 vs 6 mg intravenously daily for up to 10 days) in 1,000 adult patients with COVID-19 and severe hypoxia.

Methods: This protocol outlines the rationale and statistical methods for a secondary, pre-planned Bayesian analysis of the primary outcome (days alive without life support at day 28) and all secondary outcomes registered up to day 90. We will use hurdle-negative binomial models to estimate the mean number of days alive without life support in each group and present results as mean differences and incidence rate ratios with 95% credibility intervals (CrIs). Additional count outcomes will be analysed similarly and binary outcomes will be analysed using logistic regression models with results presented as probabilities, relative risks and risk differences with 95% CrIs. We will present probabilities of any benefit/harm, clinically important benefit/harm and probabilities of effects smaller than pre-defined clinically minimally important differences for all outcomes analysed. Analyses will be adjusted for stratification variables and conducted using weakly informative priors supplemented by sensitivity analyses using sceptic priors.

Discussion: This secondary, pre-planned Bayesian analysis will supplement the primary, conventional analysis and may help clinicians, researchers and policymakers interpret the results of the COVID STEROID 2 trial while avoiding arbitrarily dichotomised interpretations of the results.

Trial Registration: ClinicalTrials.gov: NCT04509973; EudraCT: 2020-003363-25.
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http://dx.doi.org/10.1111/aas.13793DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8014670PMC
May 2021

The 2020 "WHO Technical Specifications for Automated Non-Invasive Blood Pressure Measuring Devices With Cuff".

Hypertension 2021 Mar 1;77(3):806-812. Epub 2021 Feb 1.

Biomedical Engineer, Independent Senior Consultant, Veracrus, México (L.P.L.M.).

High systolic blood pressure (BP) is the single leading modifiable risk factor for death worldwide. Accurate BP measurement is the cornerstone for screening, diagnosis, and management of hypertension. Inaccurate BP measurement is a leading patient safety challenge. A recent World Health Organization report has outlined the technical specifications for automated noninvasive clinical BP measurement with cuff. The report is applicable to ambulatory, home, and office devices used for clinical purposes. The report recommends that for routine clinical purposes, (1) automated devices be used, (2) an upper arm cuff be used, and (3) that only automated devices that have passed accepted international accuracy standards (eg, the International Organization for Standardization 81060-2; 2018 protocol) be used. Accurate measurement also depends on standardized patient preparation and measurement technique and a quiet, comfortable setting. The World Health Organization report provides steps for governments, manufacturers, health care providers, and their organizations that need to be taken to implement the report recommendations and to ensure accurate BP measurement for clinical purposes. Although, health and scientific organizations have had similar recommendations for many years, the World Health Organization as the leading governmental health organization globally provides a potentially synergistic nongovernment government opportunity to enhance the accuracy of clinical BP assessment.
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http://dx.doi.org/10.1161/HYPERTENSIONAHA.120.16625DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7884242PMC
March 2021

A Systematic Study of the Prevalence and Risk Factors of CKD in Uddanam, India.

Kidney Int Rep 2020 Dec 16;5(12):2246-2255. Epub 2020 Oct 16.

George Institute for Global Health, University of New South Wales, New Delhi, India.

Introduction: Despite reports of a high prevalence of chronic kidney disease (CKD) from the coastal Uddanam region of Andhra Pradesh, India, there are no accurate data on the distribution of kidney function abnormalities and CKD risk factors in this region.

Methods: A total of 2419 participants were recruited through multistage cluster random sampling from 67 villages. Serum creatinine and urine protein creatinine ratio were measured using validated methodologies. All abnormal estimated glomerular filtration rate (eGFR) and urine protein creatinine ratio values were reconfirmed after 3 months. A range of sociodemographic factors were evaluated for their association with CKD using Poisson regression.

Results: Of 2402 eligible subjects (mean ± SD age, 45.67 ± 13.29 years; 51% female), 506 (21.07%) had CKD (mean ± SD age, 51.79 ± 13.12 years; 41.3% female). A total of 246 (10.24%) had eGFR <60 ml/min/1.73 m, whereas 371 (15.45%) had an elevated urine protein creatinine ratio (>0.15 g/g). The poststratified estimates, adjusted for age and sex distribution of the region for CKD prevalence, are 18.7% (range, 16.4%-21.0%) overall and 21.3% (range, 18.2%-24.4% ) and 16.2% (range, 13.7%-18.8%) in men and women, respectively. Older age, male sex, tobacco use, hypertension, and family history of CKD were independently associated with CKD. Compared with those with higher eGFR, those with eGFR <60 ml/min/1.73m were older, were more likely to be uneducated, manual laborers/farmers, or tobacco users, and were more likely to have hypertension, a family history of CKD, a diagnosis of heart disease, and a lower body mass index. Among those with low eGFR, there was no difference between those with urine protein creatinine ratio <0.15 or >0.15, except a lower frequency of males in the former.

Conclusion: We confirmed the high prevalence of CKD in the adult population of Uddanam. The cause was not apparent in a majority. Subjects with a low eGFR with or without elevated proteinuria were phenotypically distinct from those with proteinuria and preserved eGFR. Our data suggest the need to apply a population-based approach to screening and prevention and studies to understand the causes of CKD in this region.
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http://dx.doi.org/10.1016/j.ekir.2020.10.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7710882PMC
December 2020

Hydroxychloroquine plus personal protective equipment versus standard personal protective equipment alone for the prevention of COVID-19 infections among frontline healthcare workers: the HydrOxychloroquine Prophylaxis Evaluation(HOPE) trial: A structured summary of a study protocol for a randomized controlled trial.

Trials 2020 Aug 31;21(1):754. Epub 2020 Aug 31.

The George Institute for Global Health, Sydney, New South Wales, Australia.

Objectives: To evaluate the effect of the combination of hydroxychloroquine (HCQ) and standard personal protective equipment (PPE) compared to the use of standard personal protective equipment alone on the proportion of laboratory confirmed COVID-19 infections among frontline healthcare workers(HCWs) in India TRIAL DESIGN: HOPE is an investigator initiated multi-centre open-label parallel group randomized controlled trial.

Participants: All HCWs currently working in an environment with direct exposure to patients with confirmed COVID-19 infection are eligible to participate in the trial. The trial aims to be conducted across 20-30 centres (public and private hospitals) in India. HCWs who decline consent, who have a confirmed COVID-19 infection, those who are already on chloroquine/HCQ for any indication, or if pregnant or breast-feeding, or have known QT prolongation or are on medications that when taken with HCQ can prolong the QTc will be excluded.

Intervention And Comparator: The interventions to be compared in this trial are standard practice (use of recommended PPE) and HCQ plus standard practice. In the standard practice arm, HCWs will use recommended PPE as per institutional guidelines and based on their roles. They will be discouraged from taking HCQ to prevent contamination and contacted every week for the duration of the study to ascertain if they have taken any HCQ. Any such use will be reported as a protocol violation. In the intervention arm, HCWs will be administered 800mg of HCQ as a loading dose on the day of randomization (as two 400mg doses 12hrs apart) and subsequently continued on 400mg once a week for 12 weeks. This will be in addition to the use of recommended PPE as per institutional guidelines and based on their roles. HCWs will collect the drug once every week from designated research and pharmacy staff at site. A weekly phone reminder will be provided to participants in this arm to ensure compliance. An ECG will be performed between 4-6 weeks in this arm and if the QTc is prolonged (greater than 450milliseconds), the drug will be stopped. Follow-up will however continue. Participants in both arms will receive a weekly phone call for evaluation of the primary outcome, to monitor protocol compliance and development of any adverse events (in the HCQ group).

Main Outcomes: Participants will be followed on a weekly basis. The primary outcome is the proportion of HCWs developing laboratory confirmed COVID-19 infection within 6 months of randomization. We will also evaluate a number of secondary outcomes, including hospitalization related to suspected/confirmed COVID-19 infection, intensive care unit or high-dependency unit admission due to suspected/confirmed COVID-19 infection, all-cause mortality, need for organ support ( non-invasive or invasive ventilation, vasopressors and renal replacement therapy), ICU and hospital length of stay, readmission, days off work and treatment-related adverse events.

Randomisation: Randomisation will be conducted through a password-protected, secure website using a central, computer-based randomisation program. Randomisation will be stratified by participating institutions and by the role of HCW - nursing, medical and other. Participants will be randomised 1:1 to either standard practice only or HCQ plus standard practice. Allocation concealment is maintained by central web-based randomisation BLINDING (MASKING): This is an unblinded study: study assigned treatment will be known to the research team and participant. Bias will be mitigated through an objective end point (laboratory confirmed COVID-19 infection).

Numbers To Be Randomised (sample Size): A total of 6,950 HCWs will be enrolled (3475 to the intervention) and (3475 to the standard practice group) to detect a 25% relative reduction, or 2.5% absolute reduction, in the infection rate from an estimated baseline infection rate of 10%, with 80% statistical power using a two-sided test at 5% level of significance. Available data from China and Italy indicate that the rate of infection among frontline healthcare workers varies between 4% to 12%. We therefore assumed a baseline infection rate of 10% among HCWs. This sample size allows for a potential loss to follow-up rate of 10% and a potential non-compliance rate of 10% in both the treatment and control arms.

Trial Status: HOPE protocol version 3.0 dated June 3 2020. Recruitment started on 29 June 2020 and currently 56 participants have been enrolled. Planned completion of enrolment is January 31 2021.

Trial Registration: Clinical Trials Registry of India: CTRI/2020/05/025067 (prospectively registered) Date of registration: 6 May 2020 FULL PROTOCOL: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest of expedited dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol. The study protocol has been reported in accordance with the Standard Protocol Items: Recommendations for Clinical Interventional Trials (SPIRIT) guidelines (Additional file 2).
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http://dx.doi.org/10.1186/s13063-020-04679-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7456761PMC
August 2020

Achieving Fair Load Balancing by Invoking a Learning Automata-Based Two-Time-Scale Separation Paradigm.

IEEE Trans Neural Netw Learn Syst 2020 Aug 5;PP. Epub 2020 Aug 5.

In this article, we consider the problem of load balancing (LB), but, unlike the approaches that have been proposed earlier, we attempt to resolve the problem in a fair manner (or rather, it would probably be more appropriate to describe it as an ε-fair manner because, although the LB can, probably, never be totally fair, we achieve this by being ``as close to fair as possible''). The solution that we propose invokes a novel stochastic learning automaton (LA) scheme, so as to attain a distribution of the load to a number of nodes, where the performance level at the different nodes is approximately equal and each user experiences approximately the same Quality of the Service (QoS) irrespective of which node that he/she is connected to. Since the load is dynamically varying, static resource allocation schemes are doomed to underperform. This is further relevant in cloud environments, where we need dynamic approaches because the available resources are unpredictable (or rather, uncertain) by virtue of the shared nature of the resource pool. Furthermore, we prove here that there is a coupling involving LA's probabilities and the dynamics of the rewards themselves, which renders the environments to be nonstationary. This leads to the emergence of the so-called property of ``stochastic diminishing rewards.'' Our newly proposed novel LA algorithm ε-optimally solves the problem, and this is done by resorting to a two-time-scale-based stochastic learning paradigm. As far as we know, the results presented here are of a pioneering sort, and we are unaware of any comparable results.
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http://dx.doi.org/10.1109/TNNLS.2020.3010888DOI Listing
August 2020

An overview of mobile applications (apps) to support the coronavirus disease 2019 response in India.

Indian J Med Res 2020 May;151(5):468-473

The George Institute for Global Health, New Delhi, India.

Background & Objectives: The potential benefits of mobile health (mHealth) initiatives to manage the coronavirus disease 2019 (COVID-19) pandemic have been explored. The Government of India, State governments, and healthcare organizations have developed various mobile apps for the containment of COVID-19. This study was aimed to systematically review COVID-19 related mobile apps and highlight gaps to inform the development of future mHealth initiatives.

Methods: Google Play and the Apple app stores were searched using the terms 'COVID-19', 'coronavirus', 'pandemic', and 'epidemic' in the first week of April 2020. A list of COVID-19-specific functions was compiled based on the review of the selected apps, the literature on epidemic surveillance, and national and international media reports. The World Health Organization guideline on Digital Health Interventions was used to classify the app functions under the categories of the general public, health workers, health system managers, and data services.

Results: The search yielded 346 potential COVID-19 apps, of which 50 met the inclusion criteria. Dissemination of untargeted COVID-19-related information on preventative strategies and monitoring the movements of quarantined individuals was the function of 27 (54%) and 19 (32%) apps, respectively. Eight (16%) apps had a contact tracing and hotspot identification function.

Interpretation & Conclusions: Our study highlights the current emphasis on the development of self-testing, quarantine monitoring, and contact tracing apps. India's response to COVID-19 can be strengthened by developing comprehensive mHealth solutions for frontline healthcare workers, rapid response teams and public health authorities. Among this unprecedented global health emergency, the Governments must ensure the necessary but least intrusive measures for disease surveillance.
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http://dx.doi.org/10.4103/ijmr.IJMR_1200_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7530460PMC
May 2020

Video consultations for triage of patients with covid-19.

Authors:
Oommen John

BMJ 2020 04 23;369:m1583. Epub 2020 Apr 23.

George Institute for Global Health India, New Delhi 110025, India.

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http://dx.doi.org/10.1136/bmj.m1583DOI Listing
April 2020

Ethics in Telehealth: Comparison between Guidelines and Practice-based Experience -the Case for Learning Health Systems.

Yearb Med Inform 2020 Aug 17;29(1):44-50. Epub 2020 Apr 17.

School of Health Sciences, University of Canterbury, New Zealand.

Objectives: To understand ethical issues within the tele-health domain, specifically how well established macro level telehealth guidelines map with micro level practitioner perspectives.

Methods: We developed four overarching issues to use as a starting point for developing an ethical framework for telehealth. We then reviewed telemedicine ethics guidelines elaborated by the American Medical Association (AMA), the World Medical Association (WMA), and the telehealth component of the Health Professions council of South Africa (HPCSA). We then compared these guidelines with practitioner perspectives to identify the similarities and differences between them. Finally, we generated suggestions to bridge the gap between ethics guidelines and the micro level use of telehealth.

Results: Clear differences emerged between the ethics guidelines and the practitioner perspectives. The main reason for the differences were the different contexts where telehealth was used, for example, variability in international practice and variations in the complexity of patient-provider interactions. Overall, published guidelines largely focus on macro level issues related to technology and maintaining data security in patient-provider interactions while practitioner concern is focused on applying the guidelines to specific micro level contexts.

Conclusions: Ethics guidelines on telehealth have a macro level focus in contrast to the micro level needs of practitioners. Work is needed to close this gap. We recommend that both telehealth practitioners and ethics guideline developers better understand healthcare systems and adopt a learning health system approach that draws upon different contexts of clinical practice, innovative models of care delivery, emergent data and evidence-based outcomes. This would help develop a clearer set of priorities and guidelines for the ethical conduct of telehealth.
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http://dx.doi.org/10.1055/s-0040-1701976DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7442533PMC
August 2020

Fine Mapping of Glucose 6 Phosphate Dehydrogenase (G6PD) Deficiency in a Rural Malaria Area of South West Odisha Using the Clinical, Hematological and Molecular Approach.

Mediterr J Hematol Infect Dis 2020 1;12(1):e2020015. Epub 2020 Mar 1.

Division of Genetic Disorder, ICMR-National Institute of Research in Tribal Health, Jabalpur, Madhya Pradesh.

Introduction: The aim of the study was to enumerate the clinical, hematological, and molecular spectrum of G6PD deficiency in malaria endemic regions of south west Odisha.

Methods: Diagnosis of G6PD deficiency was made by using the Di-chloroindophenol Dye test in two south west districts (Kalahandi and Rayagada) of Odisha State. Demographic and clinical history was taken from each individual using a pre-structured questionnaire. Molecular characterization of G6PD deficiency was done using PCR-RFLP and Sanger sequencing.

Results: A total of 1981 individuals were screened; among them, 59 (2.97%) individuals were G6PD deficient. The analysis revealed that G6PD deficiency was more among males (4.0%) as compared to females (2.3%). Prevalence of G6PD deficiency was significantly higher among tribal populations (4.8%) as compared to non-tribal populations (2.4%) (p=0.012, OR=2.014, 95%CI=1.206-3.365). Twenty four individuals with G6PD deficiency had mild to moderate anemia, whereas 26 G6PD deficient individuals had a history of malaria infection. Among them, 3 (11.5%) required blood transfusion during treatment. Molecular analysis revealed G6PD Orissa as the most common (88%) mutation in the studied cohort. G6PD Kaiping (n=3), G6PD Coimbra (n=2) and G6PD Union (n=1) were also noted in this cohort.

Conclusion: The cumulative prevalence of G6PD deficiency in the present study is below the estimated national prevalence. G6PD deficiency was higher among tribes as compared to non-tribes. Clinical significance for G6PD deficiency was noted only in malaria infected individuals. Rare G6PD Kaiping and G6PD Union variants were also present.
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http://dx.doi.org/10.4084/MJHID.2020.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7059741PMC
March 2020

Access to CKD Care in Rural Communities of India: a qualitative study exploring the barriers and potential facilitators.

BMC Nephrol 2020 01 29;21(1):26. Epub 2020 Jan 29.

The George Institute for Global Health, University of New South Wales, New Delhi, India.

Background: Despite the high and rising burden of chronic kidney disease (CKD) in South Asia, factors that influence access to CKD care at the community level have not been studied previously, especially in the rural areas. We conducted a mixed methods study and interviewed key stakeholders to explore the views and experiences of key stakeholders, and identify barriers and potential facilitators that influence access to CKD care at the primary care level in rural India.

Methods: A total of 21 stakeholders participated in the study. We conducted 15 in-depth interviews on a purposive sample of stakeholders (CKD patients, healthcare providers and health planners) and one focus group discussion with 6 community health workers. The interviews were audio-recorded and transcribed verbatim. We employed the Lévesque's framework for access to care to base interview guides and structure the initial codes. By inductive and deductive approaches, thematic analysis was undertaken using QSR NVivo version 11.

Results: The major patient-level barriers to CKD care as reported by the most patients and healthcare providers was poor knowledge and awareness of CKD. Health system-level barriers included shortages of skilled healthcare professionals and medicines, fragmented referrals pathways to the specialists at the hospitals with inadequate follow up care. Many patients and healthcare providers, when asked about areas for improving access to CKD care, reported educational initiatives to increase awareness of CKD among healthcare providers and patients, provision of CKD related supplies, and a systems-level approach to care coordination including task shifting by engaging community health workers in CKD care, as potential facilitators.

Conclusions: We identified several barriers to access CKD care at the primary care level in rural India that need urgent attention. Targeted CKD screening programs and CKD specific educational initiatives may improve awareness of CKD. Additionally, primary care infrastructure needs to be strengthened for CKD care, ensuring trained staff, availability of essential diagnostics and medications, and creating efficient referral pathways for quality CKD care.
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http://dx.doi.org/10.1186/s12882-020-1702-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6988353PMC
January 2020

Three Dimensional Rhinoplasty and Nasal Airway Improvement in Cleft-Nose Deformity.

Indian J Otolaryngol Head Neck Surg 2019 Dec 19;71(4):512-516. Epub 2019 Jun 19.

Department of Plastic and Reconstructive Surgery, Baby Memorial Hospital, Kozhikode, Kerala India.

Septorhinoplasty is particularly challenging among revision surgeries for cleft sequelae. The challenge of cleft septorhinoplasty is mainly due to the complex anatomy of nose, deformity of each of its components and the difficulty and lack of clarity in surgical management. From 2014 to 2017, 26 patients with cleft lip nose deformity were operated by the same cleft team. The study was conducted to assess the improvement in nasal airway and appearance following secondary rhinoplasty with extracorporeal septoplasty. Post operatively each patient was evaluated using the standard modified rhinoplasty outcome evaluation questionnaire, a validated instrument that aids in stratifying patients according to their subjective response. All patients reported great relief of nasal obstruction and improved breathing. More than 80% of our patients were satisfied with improved aesthetics and reported better self-confidence. Secondary cleft rhinoplasty with extracorporeal septoplasty surgery significantly improves the cosmesis and nasal airway opening, subsequently giving them improved self-confidence.
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http://dx.doi.org/10.1007/s12070-019-01690-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6838296PMC
December 2019

Study to Test and Operationalize Preventive Approaches for CKD of Undetermined Etiology in Andhra Pradesh, India.

Kidney Int Rep 2019 Oct 21;4(10):1412-1419. Epub 2019 Jun 21.

George Institute for Global Health, University of New South Wales, New Delhi, India.

Introduction: High prevalence of chronic kidney disease (CKD) not associated with known risk factors has been reported from coastal districts of Andhra Pradesh. The Study to Test and Operationalize Preventive Approaches for Chronic Kidney Disease of Undetermined Etiology in Andhra Pradesh (STOP CKDu AP) aims to ascertain the burden (prevalence and incidence) of CKD, the risk factor profile, and the community perceptions about the disease in the Uddanam area of Andhra Pradesh.

Methods: Study participants will be sampled from the Uddanam area using multistage cluster random sampling. Information will be collected on the demographic profile, occupational history, and presence of conventional as well as nonconventional risk factors. Glomerular filtration rate (GFR) will be estimated using the Chronic Kidney Disease Epidemiology Collaboration equation, and proteinuria will be measured. All abnormal values will be confirmed by repeat testing after 3 months. Cases of CKD not associated with identified etiologies will be identified. Biospecimens will be stored to explore future hypotheses. The entire cohort will be followed up every 6 months to determine the incidence of CKD and to identify risk factors for decline in kidney function. Qualitative studies will be performed to understand the community perceptions and expectations with respect to the interventions.

Implications: CKD is an important public health challenge in low- and middle-income countries. This study will establish the prevalence and determine the incidence of CKD not associated with known risk factors in a reported high-burden region, and will provide insights to help design targeted health systems responses. The findings will contribute to the policy development to tackle CKD in the region and will permit international comparisons with other regions with similar high prevalence.
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http://dx.doi.org/10.1016/j.ekir.2019.06.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6829197PMC
October 2019

Role of Artificial Intelligence within the Telehealth Domain.

Yearb Med Inform 2019 Aug 25;28(1):35-40. Epub 2019 Apr 25.

IBM Research, Brazil.

Objectives: This paper provides a discussion about the potential scope of applicability of Artificial Intelligence methods within the telehealth domain. These methods are focussed on clinical needs and provide some insight to current directions, based on reports of recent advances.

Methods: Examples of telehealth innovations involving Artificial Intelligence to support or supplement remote health care delivery were identified from recent literature by the authors, on the basis of expert knowledge. Observations from the examples were synthesized to yield an overview of contemporary directions for the perceived role of Artificial Intelligence in telehealth.

Results: Two major focus areas for related contemporary directions were established. These were first, quality improvement for existing clinical practice and service delivery, and second, the development and support of new models of care. Case studies from each focus area have been chosen for illustration purposes.

Conclusion: Examples of the role of Artificial Intelligence in delivery of health care remotely include use of tele-assessment, tele-diagnosis, tele-interactions, and tele-monitoring. Further developments of underlying algorithms and validation of methods will be required for wider adoption. Certain key social and ethical considerations also need consideration more generally in the health system, as Artificial-Intelligence-enabled-telehealth becomes more commonplace.
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http://dx.doi.org/10.1055/s-0039-1677897DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6697552PMC
August 2019

The Hierarchical Continuous Pursuit Learning Automation: A Novel Scheme for Environments With Large Numbers of Actions.

IEEE Trans Neural Netw Learn Syst 2020 Feb 11;31(2):512-526. Epub 2019 Apr 11.

Although the field of learning automata (LA) has made significant progress in the past four decades, the LA-based methods to tackle problems involving environments with a large number of actions is, in reality, relatively unresolved. The extension of the traditional LA to problems within this domain cannot be easily established when the number of actions is very large. This is because the dimensionality of the action probability vector is correspondingly large, and so, most components of the vector will soon have values that are smaller than the machine accuracy permits, implying that they will never be chosen. This paper presents a solution that extends the continuous pursuit paradigm to such large-actioned problem domains. The beauty of the solution is that it is hierarchical, where all the actions offered by the environment reside as leaves of the hierarchy. Furthermore, at every level, we merely require a two-action LA that automatically resolves the problem of dealing with arbitrarily small action probabilities. In addition, since all the LA invoke the pursuit paradigm, the best action at every level trickles up toward the root. Thus, by invoking the property of the "max" operator, in which the maximum of numerous maxima is the overall maximum, the hierarchy of LA converges to the optimal action. This paper describes the scheme and formally proves its ϵ -optimal convergence. The results presented here can, rather trivially, be extended for the families of discretized and Bayesian pursuit LA too. This paper also reports extensive experimental results (including for environments having 128 and 256 actions) that demonstrate the power of the scheme and its computational advantages. As far as we know, there are no comparable pursuit-based results in the field of LA. In some cases, the hierarchical continuous pursuit automaton requires less than 18% of the number of iterations than the benchmark L scheme, which is, by all metrics, phenomenal.
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http://dx.doi.org/10.1109/TNNLS.2019.2905162DOI Listing
February 2020

A Conclusive Analysis of the Finite-Time Behavior of the Discretized Pursuit Learning Automaton.

IEEE Trans Neural Netw Learn Syst 2020 Jan 19;31(1):284-294. Epub 2019 Mar 19.

This paper deals with the finite-time analysis (FTA) of learning automata (LA), which is a topic for which very little work has been reported in the literature. This is as opposed to the asymptotic steady-state analysis for which there are, probably, scores of papers. As clarified later, unarguably, the FTA of Markov chains, in general, and of LA, in particular, is far more complex than the asymptotic steady-state analysis. Such an FTA provides rigid bounds for the time required for the LA to attain to a given convergence accuracy. We concentrate on the FTA of the Discretized Pursuit Automaton (DPA), which is probably one of the fastest and most accurate reported LA. Although such an analysis was carried out many years ago, we record that the previous work is flawed. More specifically, in all brevity, the flaw lies in the wrongly "derived" monotonic behavior of the LA after a certain number of iterations. Rather, we claim that the property should be invoked is the submartingale property. This renders the proof to be much more involved and deep. In this paper, we rectify the flaw and reestablish the FTA based on such a submartingale phenomenon. More importantly, from the derived analysis, we are able to discover and clarify, for the first time, the underlying dilemma between the DPA's exploitation and exploration properties. We also nontrivially confirm the existence of the optimal learning rate, which yields a better comprehension of the DPA itself.
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http://dx.doi.org/10.1109/TNNLS.2019.2900639DOI Listing
January 2020

Neonatal Teratoma: Craniofacial Treatment.

J Craniofac Surg 2019 Jan;30(1):e17-e19

Department of Plastic Surgery, Baby Memorial Hospital.

Teratomas are rare congenital neoplasms. Head and neck locations of the tumor are uncommon with combined intracranial and extracranial extensions being even more rare. The authors present a case of teratoma involving the temporal, buccal, maxillary, orbital and extending to the intracranial regions, which was successfully managed by surgical resection.
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http://dx.doi.org/10.1097/SCS.0000000000004906DOI Listing
January 2019

Current Status and Future Directions of mHealth Interventions for Health System Strengthening in India: Systematic Review.

JMIR Mhealth Uhealth 2018 Oct 26;6(10):e11440. Epub 2018 Oct 26.

George Institute for Global Health, India, New Delhi, India.

Background: With the exponential increase in mobile phone users in India, a large number of public health initiatives are leveraging information technology and mobile devices for health care delivery. Given the considerable financial and human resources being invested in these initiatives, it is important to ascertain their role in strengthening health care systems.

Objective: We undertook this review to identify the published mobile health (mHealth) or telemedicine initiatives in India in terms of their current role in health systems strengthening. The review classifies these initiatives based on the disease areas, geographical distribution, and target users and assesses the quality of the available literature.

Methods: A search of the literature was done to identify mHealth or telemedicine articles published between January 1997 and June 2017 from India. The electronic bibliographic databases and registries searched included MEDLINE, EMBASE, Joanna Briggs Institute Database, and Clinical Trial Registry of India. The World Health Organization health system building block framework was used to categorize the published initiatives as per their role in the health system. Quality assessment of the selected articles was done using the Cochrane risk of bias assessment and National Institutes of Health, US tools.

Results: The combined search strategies yielded 2150 citations out of which 318 articles were included (primary research articles=125; reviews and system architectural, case studies, and opinion articles=193). A sharp increase was seen after 2012, driven primarily by noncommunicable disease-focused articles. Majority of the primary studies had their sites in the south Indian states, with no published articles from Jammu and Kashmir and north-eastern parts of India. Service delivery was the primary focus of 57.6% (72/125) of the selected articles. A majority of these articles had their focus on 1 (36.0%, 45/125) or 2 (45.6%, 57/125) domains of health system, most frequently service delivery and health workforce. Initiatives commonly used client education as a tool for improving the health system. More than 91.2% (114/125) of the studies, which lacked a sample size justification, had used convenience sampling. Methodological rigor of the selected trials (n=11) was assessed to be poor as majority of the studies had a high risk for bias in at least 2 categories.

Conclusions: In conclusion, mHealth initiatives are being increasingly tested to improve health care delivery in India. Our review highlights the poor quality of the current evidence base and an urgent need for focused research aimed at generating high-quality evidence on the efficacy, user acceptability, and cost-effectiveness of mHealth interventions aimed toward health systems strengthening. A pragmatic approach would be to include an implementation research component into the existing and proposed digital health initiatives to support the generation of evidence for health systems strengthening on strategically important outcomes.
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http://dx.doi.org/10.2196/11440DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6229512PMC
October 2018

Utilization, costs, and outcomes for patients receiving publicly funded hemodialysis in India.

Kidney Int 2018 09;94(3):440-445

The George Institute for Global Health, New Delhi, India; The George Institute for Global Health, University of Oxford, Oxford, United Kingdom. Electronic address:

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http://dx.doi.org/10.1016/j.kint.2018.03.028DOI Listing
September 2018

Universal health coverage and chronic kidney disease in India.

Bull World Health Organ 2018 07;96(7):442

The George Institute for Global Health, Sydney, Australia.

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http://dx.doi.org/10.2471/BLT.18.208207DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6022621PMC
July 2018

Methodological challenges to collecting clinical and economic outcome data: Lessons from the pilot dialysis outcomes India study.

Nephrology (Carlton) 2019 Apr;24(4):445-449

The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia.

Aim: Contemporary data on clinical and economic outcomes and quality of care amongst dialysis patients in India are not available. This pilot prospective study aimed to evaluate the feasibility of data collection and follow up within routine dialysis practice to inform setting up a dialysis registry.

Methods: An electronic instrument was developed to collect information on clinical and socio-demographic characteristics, outcome and out-of-pocket expenditure on incident patients commencing haemodialysis (HD) at two centres. Dialysis unit staff were trained in collecting and entering information on an electronic case record form. Patients were followed up at 1, 3, 6, 9 and 12 months to ascertain outcomes and treatment related costs.

Results: A total of 119 patients (37 females, age 47.5 ± 17.2 years) were enrolled. After 1 year, 38 (32%) patients were continuing on HD; 35 (29%) had died, 30 (25%) underwent a kidney transplant, and 16 (13%) had stopped dialysis. We noted a high prevalence of catastrophic health expenditure. Data collection was facilitated by appointing a designated staff member who received an incentive. Collection of financial information, clinical course for patients transferring out of the primary unit and the cause of death, when it occurred out of hospital was challenging.

Conclusion: Prospective data collection of incident dialysis patients was feasible but is resource-intensive. High out-of-pocket costs force some patients to stop dialysis and can generate a sense of despair. Poor patient experiences and suspicion over the use of such data adversely affects collection of important clinical and health economic data.
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http://dx.doi.org/10.1111/nep.13257DOI Listing
April 2019

The Potential Impact of Public Health Interventions in Preventing Kidney Disease.

Semin Nephrol 2017 05;37(3):234-244

The George Institute for Global Health India, New Delhi, India; Department of Nephrology, University of Oxford, Oxford, United Kingdom. Electronic address:

The years of life lost and years lived with disability resulting from chronic kidney disease (CKD) increased globally by 90% and 49.5%, respectively, between 1990 and 2013. In addition to the traditional factors, infections, low birthweight, environmental factors, and low socioeconomic status contribute to the CKD burden in low- and middle-income countries. System-level challenges such as poor appreciation of the burden, insufficient human resources, high health care costs, poor referral pathways, unreliable health information systems, and inadequate medicine supply pose barriers to CKD control. In this article, we present evidence that the CKD burden in low- and middle-income countries is related to system-wide issues, which could be reduced effectively using innovative, affordable, and scalable interventions. A multipronged approach is required including improving socioeconomic determinants of health, enabling the environment for healthy decision making, and sustainable interventions. Innovative approaches include promoting healthy behaviors, counseling, and education in primary care, task-sharing between physicians and nonphysicians, using technology to train nonphysicians to screen, diagnose, refer, follow-up, and educate patients, and ensuring quality. Stronger political will and system-level change are needed to prevent and manage CKD if the sustainable development goals of reducing premature mortality from noncommunicable diseases by 2030 are to be attained.
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http://dx.doi.org/10.1016/j.semnephrol.2017.02.004DOI Listing
May 2017

On Solving the Problem of Identifying Unreliable Sensors Without a Knowledge of the Ground Truth: The Case of Stochastic Environments.

IEEE Trans Cybern 2017 Jul 28;47(7):1604-1617. Epub 2016 Apr 28.

The purpose of this paper is to propose a solution to an extremely pertinent problem, namely, that of identifying unreliable sensors (in a domain of reliable and unreliable ones) without any knowledge of the ground truth. This fascinating paradox can be formulated in simple terms as trying to identify stochastic liars without any additional information about the truth. Though apparently impossible, we will show that it is feasible to solve the problem, a claim that is counter-intuitive in and of itself. One aspect of our contribution is to show how redundancy can be introduced, and how it can be effectively utilized in resolving this paradox. Legacy work and the reported literature (for example, in the so-called weighted majority algorithm) have merely addressed assessing the reliability of a sensor by comparing its reading to the ground truth either in an online or an offline manner. Unfortunately, the fundamental assumption of revealing the ground truth cannot be always guaranteed (or even expected) in many real life scenarios. While some extensions of the Condorcet jury theorem [9] can lead to a probabilistic guarantee on the quality of the fused process, they do not provide a solution to the unreliable sensor identification problem. The essence of our approach involves studying the agreement of each sensor with the rest of the sensors, and not comparing the reading of the individual sensors with the ground truth-as advocated in the literature. Under some mild conditions on the reliability of the sensors, we can prove that we can, indeed, filter out the unreliable ones. Our approach leverages the power of the theory of learning automata (LA) so as to gradually learn the identity of the reliable and unreliable sensors. To achieve this, we resort to a team of LA, where a distinct automaton is associated with each sensor. The solution provided here has been subjected to rigorous experimental tests, and the results presented are, in our opinion, both novel and conclusive.
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http://dx.doi.org/10.1109/TCYB.2016.2552979DOI Listing
July 2017

Indian chronic kidney disease study: Design and methods.

Nephrology (Carlton) 2017 Apr;22(4):273-278

Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India.

Aim: The rate and factors that influence progression of chronic kidney disease (CKD) in developing countries like India are unknown. A pan-country prospective, observational cohort study is needed to address these knowledge gaps.

Methods: The Indian Chronic Kidney Disease (ICKD) study will be a cohort study of approximately 5000 patients with mild to moderate CKD presenting to centres that represent different geographical regions in India. Time to 50% decline in baseline estimated glomerular filtration rate, need of renal replacement therapy or any new cardiovascular disease (CVD) event or death from CVD are the primary end points.

Value Of Study: This study will provide the opportunity to determine risk factors for CKD progression and development of CVD in Indian subjects and perform international comparisons to determine ethnic and geographical differences. A bio-repository will provide a chance to discover biomarkers and explore genetic risk factors.
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http://dx.doi.org/10.1111/nep.12789DOI Listing
April 2017

A randomized, controlled trial of an aerosolized vaccine against measles.

N Engl J Med 2015 Apr;372(16):1519-29

From the Institute of Social and Preventive Medicine, University of Bern, Bern (N.L., P.S.), and the World Health Organization (WHO), Geneva (A.X.R.-B., A.M.H.R.) - both in Switzerland; the Department of Pediatrics, King Edward Memorial Hospital Research Centre (A.B.), the National Institute of Virology (N.S., R.S.J.), the Serum Institute of India (R.D., P.S.K.), and Shirdi Sai Baba Hospital (S.H.), Pune, the Department of Biostatistics, Christian Medical College, Vellore (L.J., K.R., A.R.), and the WHO Regional Office for South-East Asia, New Delhi (O.J.) - all in India; the Statistics Unit (N.J.A.) and Virus Reference Department (K.E.B., D.B.), Public Health England, London; Aerogen, Galway, Ireland (J.B.F.); and Sainte-Foy-lès-Lyon, France (M.G.).

Background: Aerosolized vaccine can be used as a needle-free method of immunization against measles, a disease that remains a major cause of illness and death. Data on the immunogenicity of aerosolized vaccine against measles in children are inconsistent.

Methods: We conducted an open-label noninferiority trial involving children 9.0 to 11.9 months of age in India who were eligible to receive a first dose of measles vaccine. Children were randomly assigned to receive a single dose of vaccine by means of either aerosol inhalation or a subcutaneous injection. The primary end points were seropositivity for antibodies against measles and adverse events 91 days after vaccination. The noninferiority margin was 5 percentage points.

Results: A total of 1001 children were assigned to receive aerosolized vaccine, and 1003 children were assigned to receive subcutaneous vaccine; 1956 of all the children (97.6%) were followed to day 91, but outcome data were missing for 331 children because of thawed specimens. In the per-protocol population, data on 1560 of 2004 children (77.8%) could be evaluated. At day 91, a total of 662 of 775 children (85.4%; 95% confidence interval [CI], 82.5 to 88.0) in the aerosol group, as compared with 743 of 785 children (94.6%; 95% CI, 92.7 to 96.1) in the subcutaneous group, were seropositive, a difference of -9.2 percentage points (95% CI, -12.2 to -6.3). Findings were similar in the full-analysis set (673 of 788 children in the aerosol group [85.4%] and 754 of 796 children in the subcutaneous group [94.7%] were seropositive at day 91, a difference of -9.3 percentage points [95% CI, -12.3 to -6.4]) and after multiple imputation of missing results. No serious adverse events were attributable to measles vaccination. Adverse-event profiles were similar in the two groups.

Conclusions: Aerosolized vaccine against measles was immunogenic, but, at the prespecified margin, the aerosolized vaccine was inferior to the subcutaneous vaccine with respect to the rate of seropositivity. (Funded by the Bill and Melinda Gates Foundation; Measles Aerosol Vaccine Project Clinical Trials Registry-India number, CTRI/2009/091/000673.).
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http://dx.doi.org/10.1056/NEJMoa1407417DOI Listing
April 2015

Dialysis outcomes in India: a pilot study.

Nephrology (Carlton) 2015 May;20(5):329-34

The George Institute for Global Health, New Delhi, India; The George Institute for Global Health, University of Oxford, Oxford, UK.

Aim: Long-term prospective studies of health outcomes for dialysis patients are common in many parts of the world but have been rare in India. As renal replacement therapy becomes more widespread and more affordable, the measurement of patient outcomes and comparison with national and international benchmarks will be a valuable tool in planning health services and demonstrating effective use of resources. To this end, we describe a pilot study of dialysis outcomes in India which could form the basis of a comprehensive national programme of data collection.

Methods: One hundred incident patients commencing chronic haemodialysis in two north Indian nephrology centres will be followed prospectively for 12 months. Clinical outcome data will be collected comparable with that used by established dialysis registries in other countries. The economic impact of dialysis upon patients is central to the use of this treatment, so data will be collected on the direct and indirect costs of the treatment and the economic impact of dialysis on the patient and their family.

Value Of Project: This prospective cohort study of dialysis outcomes in northern India is a pilot for the collection of similar comparative data in dialysis centres in different states across the country with a view to the development of a national dialysis registry. The information on the economic impact of dialysis on patients and their families will provide one of the first detailed insights into this critical aspect of dialysis services.
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http://dx.doi.org/10.1111/nep.12404DOI Listing
May 2015

Case based measles surveillance in Pune: evidence to guide current and future measles control and elimination efforts in India.

PLoS One 2014 7;9(10):e108786. Epub 2014 Oct 7.

Immunization Vaccines and Biologicals, World Health Organization, Geneva, Switzerland.

Background: According to WHO estimates, 35% of global measles deaths in 2011 occurred in India. In 2013, India committed to a goal of measles elimination by 2020. Laboratory supported case based measles surveillance is an essential component of measles elimination strategies. Results from a case-based measles surveillance system in Pune district (November 2009 through December 2011) are reported here with wider implications for measles elimination efforts in India.

Methods: Standard protocols were followed for case identification, investigation and classification. Suspected measles cases were confirmed through serology (IgM) or epidemiological linkage or clinical presentation. Data regarding age, sex, vaccination status were collected and annualized incidence rates for measles and rubella cases calculated.

Results: Of the 1011 suspected measles cases reported to the surveillance system, 76% were confirmed measles, 6% were confirmed rubella, and 17% were non-measles, non-rubella cases. Of the confirmed measles cases, 95% were less than 15 years of age. Annual measles incidence rate was more than 250 per million persons and nearly half were associated with outbreaks. Thirty-nine per cent of the confirmed measles cases were vaccinated with one dose of measles vaccine (MCV1).

Conclusion: Surveillance demonstrated high measles incidence and frequent outbreaks in Pune where MCV1 coverage in infants was above 90%. Results indicate that even high coverage with a single dose of measles vaccine was insufficient to provide population protection and prevent measles outbreaks. An effective measles and rubella surveillance system provides essential information to plan, implement and evaluate measles immunization strategies and monitor progress towards measles elimination.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0108786PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4188558PMC
June 2015

Modeling the “learning process” of the teacher in a tutorial-like system using learning automata.

IEEE Trans Cybern 2013 Dec;43(6):2020-31

Unlike the field of tutorial systems, where a real-life student interacts and learns from a software system, our research focuses on a new philosophy in which no entity needs to be a real-life individual. Such systems are termed as tutorial-like systems, and research in this field endeavors to model every component of the system using an appropriate learning model [in our case, a learning automaton (LA)].1 While models for the student, the domain, the teacher, etc., have been presented elsewhere, the aim of this paper is to present a new approach to model how the teacher, in this paradigm, of our tutorial-like system "learns and improves his "teaching skills" while being himself an integral component of the system. We propose to model the "learning process" of the teacher by using a higher level LA, referred to as the metateacher, whose task is to assist the teacher himself. Ultimately, the intention is that the latter can communicate the teaching material to the student(s) in a manner customized to the particular student's ability and progress. In short, the teacher will infer the progress of the student and initiate a strategy by which he can "custom-communicate" the material to each individual student. The results that we present in a simulated environment validate the model for the teacher and for the metateacher. The use of the latter can be seen to significantly improve the teaching abilities of the teacher.
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http://dx.doi.org/10.1109/TSMCB.2013.2238230DOI Listing
December 2013