Capacity for the management of kidney failure in the International Society of Nephrology South Asia region: report from the 2023 ISN Global Kidney Health Atlas (ISN-GKHA).

The South Asia region is facing a high burden of chronic kidney disease (CKD) with limited health resources and low expenditure on health care. In addition to the burden of CKD and kidney failure from traditional risk factors, CKD of unknown etiologies from India and Sri Lanka compounds the challenges of optimal management of CKD in the region. From the third edition of the International Society of Nephrology Global Kidney Health Atlas (ISN-GKHA), we present the status of CKD burden, infrastructure, funding, resources, and health care personnel using the World Health Organization's building blocks for health systems in the ISN South Asia region. The poor status of the public health care system and low health care expenditure resulted in high out-of-pocket expenditures for people with kidney disease, which further compounded the situation. There is insufficient country capacity across the region to provide kidney replacement therapies to cover the burden. The infrastructure was also not uniformly distributed among the countries in the region. There were no chronic hemodialysis centers in Afghanistan, and peritoneal dialysis services were only available in Bangladesh, India, Nepal, Pakistan, and Sri Lanka. Kidney transplantation was not available in Afghanistan, Bhutan, and Maldives. Conservative kidney management was reported as available in 63% (n = 5) of the countries, yet no country reported availability of the core CKM care components. There was a high hospitalization rate and early mortality because of inadequate kidney care. The lack of national registries and actual disease burden estimates reported in the region prevent policymakers' attention to CKD as an important cause of morbidity and mortality. Data from the 2023 ISN-GKHA, although with some limitations, may be used for advocacy and improving CKD care in the region.

Assessment of South Asian Pediatric Acute Kidney Injury: Epidemiology and Risk Factors (ASPIRE)-a prospective study on "severe dialysis dependent pediatric AKI".

BACKGROUND: Pediatric acute kidney injury (AKI) is a global health concern with an associated mortality risk disproportionately pronounced in resource-limited settings. There is a pertinent need to understand the epidemiology of pediatric AKI in vulnerable populations. Here, we proposed a prospective study to investigate the epidemiology and associated risk factors of "severe dialysis dependent AKI" in children among South Asian nations which would be the first and largest of its kind. METHODS: The ASPIRE study (part of PCRRT-ICONIC Foundation initiative) is a multi-center, prospective observational study conducted in South Asian countries. All children and adolescents ≤ 18 years of age who required dialysis for AKI in any of the collaborating medical centers were enrolled. Data collection was performed until one of the following endpoints was observed: (1) discharge, (2) death, and (3) discharge against medical advice. RESULTS: From 2019 to 2022, a total of 308 children with severe AKI were enrolled. The mean age was 6.17 years (63% males). Secondary AKI was more prevalent than primary AKI (67.2%), which predominantly occurred due to infections, dehydration, and nephrotoxins. Common causes of primary AKI were glomerulonephritis, hemolytic uremic syndrome, lupus nephritis, and obstructive uropathy. Shock, need for ventilation, and coagulopathy were commonly seen in children with severe AKI who needed dialysis. The foremost kidney replacement therapy used was peritoneal dialysis (60.7%). The mortality rate was 32.1%. CONCLUSIONS: Common causes of AKI in children in South Asia are preventable. Mortality is high among these children suffering from "severe dialysis dependent AKI." Targeted interventions to prevent and identify AKI early and initiate supportive care in less-resourced nations are needed.

Epidemiologic and economic considerations regarding persistently infected cattle during vaccinate-to-live strategies for control of foot-and-mouth disease in FMD-free regions.

Development of a foot-and-mouth disease (FMD) carrier state following FMD virus (FMDV) infection is a well-established phenomenon in cattle. However, the proportion of cattle likely to become carriers and the duration of the carrier state at a herd or population-level are incompletely understood. The objective of this study was to examine the epidemiologic and economic impacts of vaccination-to-live strategy in a disease-free region or country. We developed and simulated scenarios of FMD spread and control in the US livestock population, which included depopulation for a limited period, followed by a vaccinate-to-live strategy with strong biosecurity and movement restrictions. Six scenarios of FMD spread and control were simulated in the InterSpread Plus (ISP) modeling tool. Data on the number of infected and depopulated cattle (by operation types) from ISP model runs were used to estimate the monthly number of infected but not depopulated (potential carrier) cattle after the infection. Using available literature data on the FMD carrier state, we estimated the monthly proportion of carrier cattle (from infected but not depopulated cattle) over time following infection. Among the simulated scenarios, the median (25th, 75th percentile) number of infected cattle ranged from 43,217 (42,819, 55,274) head to 148,907 (75,819, 205,350) head, and the epidemic duration ranged from 20 (11, 30) to 76 (38, 136) days. In general, larger outbreaks occurred when depopulation was carried out through longer periods, and the onset of the vaccination was late (p > 0.05). The estimated proportion of surviving cattle, which were infected and not depopulated and had the potential to become persistently infected ranged from 14 to 35% of total infected cattle. Production losses in beef and dairy sectors were higher when outbreaks started in multiple states simultaneously, but production losses were small compared to trade losses and consumer avoidance losses. These results can be used to inform the consideration of a vaccinate-to-live strategy for FMD outbreaks and the development of appropriate post-outbreak management strategies. Furthermore, this output will enable a more detailed examination of the epidemiologic and economic implications of allowing convalescent cattle to survive and remain in production chains after FMD outbreaks in FMD-free regions.

Steroid induced psychosis in a child with nephrotic syndrome: A case report.

Background: and Importance: Steroids induced psychosis is one of major adverse effects of corticosteroids therapy especially in patients with disease causing low serum albumin level like nephrotic syndrome. The literature review about this adverse effects is lesser in children than adults population. The management is done by tapering dose of steroids in aid of immunosuppressive drug with an antipsychotics drug. Case presentation: Here we present a case of 14 years old female child known case of nephrotic syndrome secondary to Focal segmental glomerulosclerosis with steroids induced psychosis who is managed by tapering dose of prednisolone with Tacrolimus as immunosuppressive and Quetiapine as antipsychotic. Conclusion: The prevalence of steroids induced psychosis is higher in our locality which is still unreported due to lack of detailed history and proper diagnosis and it is manageable if early diagnosis and treatment is initiated. Thus, proper counselling to parents about the adverse effect of steroids therapy and timely follow up will prevent Nepalese children from this illness.

Parameterization of the durations of phases of foot-and-mouth disease in pigs.

The global interconnectedness of the pig-production industry and the diversity of foot-and-mouth disease (FMD) viruses (FMDVs) currently circulating, makes modeling disease spread and control in FMD-free areas challenging. However, advances in experimental design and transmission studies create opportunities to strengthen our understanding and ability to model FMD transmission. In the current study, we estimated the duration of defined phases of FMDV infection in pigs by using data from a large collection of controlled in vivo experiments. Because the detection of low-levels of viral RNA does not correspond to infectiousness, an experimentally defined minimum threshold of FMDV RNA shedding in oropharyngeal fluids was used to estimate the onset of infectiousness in experiments in which transmission was not evaluated. Animal-level data were used in Accelerated Failure Time models to assess the effect of experimental design factors in the duration of defined phases of FMDV infection: latent, incubation, pre-clinical infectious, clinical infectious, and total infectious periods. The estimated means of the phases were latent: 25 h (95%CI 21, 29), incubation: 70 h (95%CI 64, 76), pre-clinical infectious: 36 h (95%CI 32, 41), clinical infectious: 265 h (95%CI 258, 272) and total infectious: 282 h (95%CI 273, 290). Virus strains and exposure methods had no significant influence on the duration of latency, incubation, or clinical infectious phases. By contrast, the estimated means of the duration of the pre-clinical infectious and total infectious phases were significantly influenced by virus strains, and the duration of the pre-clinical infectious phase was significantly influenced by exposure methods. This study provides disease parameters based on an estimated threshold of the onset of infectiousness and a probability distribution representing the end of infectiousness. Disease parameters that incorporate experimentally-based quantitative proxies to define phases of FMDV infection may improve planning and preparedness for FMD.

Gestational age specific anthropometric postnatal percentile charts for neonates born at tertiary hospital in Eastern Nepal.

BACKGROUND AND OBJECTIVES: Birth weight, Head circumference (HC), and Length are important clinical indicators for evaluation of prenatal growth and identification of neonates requiring detail assessment and monitoring. Gestational age-specific percentile charts are essential tool for both obstetricians and pediatricians in their day to day practice. This study aimed to develop gestational age specific percentile chart of Birth weight, Length and HC for neonates. METHODS: In this Cross sectional observational study, HC, Birth weight and Length of live singleton neonates from 28 to 42 weeks of gestation fulfilling the inclusion criteria were measured over a period of one year. Mean, standard deviation, and percentiles values for different gestational age were calculated. Graphs were constructed using two way graph and Lowess smoothening method. RESULTS: Of total 2662 neonates, male: female ratio was 1.3:1 with maximum neonates in 40 weeks of gestation. The mean Birth weight, HC and Length was 2852.02 gm, 33.6 and 48.42 cm respectively. Overall males have more mean weight than females by 46.35gms. However, mean HC of male and female were similar 33.6 and 33.61 cm respectively and on average males were 0.27 cm longer compared to female. The mean Birth weight, HC and Length at 40 weeks was 3123.43gm (± 427.82), 34.249 cm (± 0.87) and 49.61 cm(± 1.85) respectively. The 10th, 50th and 90th percentile at 40 weeks for Birth weight being 2550gm, 3100gm and 3750gm respectively. The gestational age specific percentile chart and growth curve are appropriately placed in the manuscript. CONCLUSIONS: The percentile charts in this study may be used as reference for local population and similar data from various parts of the nation can provide a national reference curve for healthy neonates.

Development of a transboundary model of livestock disease in Europe.

Epidemiological models of notifiable livestock disease are typically framed at a national level and targeted for specific diseases. There are inherent difficulties in extending models beyond national borders as details of the livestock population, production systems and marketing systems of neighbouring countries are not always readily available. It can also be a challenge to capture heterogeneities in production systems, control policies, and response resourcing across multiple countries, in a single transboundary model. In this paper, we describe EuFMDiS, a continental-scale modelling framework for transboundary animal disease, specifically designed to support emergency animal disease planning in Europe. EuFMDiS simulates the spread of livestock disease within and between countries and allows control policies to be enacted and resourced on a per-country basis. It provides a sophisticated decision support tool that can be used to look at the risk of disease introduction, establishment and spread; control approaches in terms of effectiveness and costs; resource management; and post-outbreak management issues.

Association of geographic distribution and birth weight with sociodemographic factors of the maternal and newborn child of hilly and mountain regions of eastern Nepal: a cross-sectional study.

OBJECTIVES: To determine the association of geographic distribution, and birth weight with sociodemographic factors of the maternal and newborn child of hilly region (lower altitude) and mountain region (high altitude) of eastern Nepal as well as the prevalence of low birth weight (LBW) and large for gestational age (LGA) among term singleton deliveries in eastern Nepal. METHODOLOGY: A cross-sectional study was conducted in the district-level hospitals of Dhankuta, Tehrathum, Solukhumbu and Taplejung districts of eastern Nepal of Province 1. Mothers with preterm or post-term delivery, multiple pregnancies, stillbirth/intrauterine fetal death and incomplete records were excluded from the study with only 1386 term pregnancies (37-42 weeks) delivered at the respective facilities between 17 July 2019 and 16 July 2020 were included. The appropriate data were entered in Microsoft Excel 2019 V.16.0 and statistical analysis was performed by using the statistical package for social sciences, IBM SPSS V.29. RESULTS: The low maternal age, Dalit ethnic group, low gravidity, low parity, higher antenatal care (ANC) visits (≥4), incomplete deworming and dT vaccination status, breech deliveries and LBW newborns were significantly attributed to hilly region (lower altitude) (p value <0.05). Similarly, the hilly region, lower and/or no ANC visits and early term gestation had significant negative association with birth weight at the lower quantiles only. Meanwhile, the female newborn had significant and negative association with birth weight distribution at all seven quantiles. The prevalence of the LBW, average for gestational age and LGA newborn child among term singleton deliveries in Eastern Nepal is 6.6%, 85.8% and 7.6%, respectively. CONCLUSIONS: The local organisations should focus on adequate antenatal care visits in mountain region and coverage of dT vaccine and deworming medications in hilly region. Appropriate measures and programmes should be initiated to bring down LBW in hilly region.

Extinction Dynamics of the Foot-and-Mouth Disease Virus Carrier State Under Natural Conditions.

Foot-and-mouth disease (FMD) is one of the most economically important livestock diseases worldwide. Following the clinical phase of FMD, a large proportion of ruminants remain persistently infected for extended periods. Although extinction of this carrier state occurs continuously at the animal and population levels, studies vary widely in their estimates of the duration of persistent infection. There is a need for robust statistical models to capture the dynamics of persistent infection for the sake of guiding FMD control and trade policies. The goal of the current study was to develop and assess statistical models to describe the extinction of FMD virus (FMDV) persistent infection using data from primary longitudinal studies of naturally infected cattle and Asian buffalo in Vietnam and India. Specifically, accelerated failure time (AFT) models and generalized linear mixed models (GLMM) were developed to predict the probability of persistent infection in seropositive animals and identified carriers at the individual animal level at sequential time points after outbreaks. The primary studies were analyzed by country and combined using an individual-participant data meta-analysis approach. The models estimated similar trends in the duration of persistent infection for the study/species groups included in the analyses, however the significance of the trends differed between the models. The overall probabilities of persistent infection were similar as predicted by the AFT and GLMM models: 6 months: 99% (AFT) /80% (GLMM), 12 months: 51% (AFT) /32% (GLMM), 18 months: 6% (AFT) /5% (GLMM), 24 months: 0.8% (AFT) /0.6% (GLMM). These models utilizing diverse and robust data sets predict higher probabilities of persistence than previously published, suggesting greater endurance of carriers subsequent to an outbreak. This study demonstrates the utility of statistical models to investigate the dynamics of persistent infection and the importance of large datasets, which can be achieved by combining data from several smaller studies in meta-analyses. Results of this study enhance current knowledge of the FMDV carrier state and may inform policy decisions regarding FMDV persistent infection.

Parameterization of the Durations of Phases of Foot-And-Mouth Disease in Cattle.

The objective of the current study was to update parameterization of mathematical simulation models for foot-and-mouth disease (FMD) spread in cattle utilizing recent knowledge of FMD virus (FMDV) pathogenesis and infection dynamics to estimate the duration of distinct phases of FMD. Specifically, the durations of incubation, latent, and infectious periods were estimated for 3 serotypes (O, Asia1, and A) of FMDV, individually and collectively (pan-serotypic). Animal-level data were used in Accelerated Failure Time (AFT) models to estimate the duration of the defined phases of infection, while also investigating the influence of factors related to the experimental design (exposure methods) and virus serotype on disease progression. Substantial influences upon the estimated duration of distinct phases of FMD included the quantity of viral shedding used as a proxy for the onset of infectiousness, virus serotypes, and experimental exposure methods. The use of detection of any viral RNA in nasal secretions as a proxy of infectiousness lengthened the total infectious period compared to use of threshold-based detection. Additionally, the experimental system used to infect the animals also had significant effects on the duration of distinct phases of disease. Overall, the mean [95% Confidence Interval (CI)] durations of pan-serotype disease phases in cattle were estimated to be: incubation phase = 3.6 days (2.7-4.8), latent phase = 1.5 days (1.1-2.1), subclinical infectious phase = 2.2 days (1.5-3.5), clinical infectious phase = 8.5 days (6.2-11.6), and total infectious phase = 10.8 days (8.2-14.2). This study highlights the importance of identifying appropriate proxy measures to define the onset and duration of infectiousness in FMDV-infected cattle in the absence of actual transmission data. Additionally, it is demonstrated herein that factors associated with experimental design, such as virus exposure methods, may significantly affect disease progression in individual animals and should be considered when data is extrapolated from experimental studies. Given limitations in experimental data availability, pan-serotypic parameters which include all routes of exposure and a threshold-defined onset of infectiousness may be the most robust parameters for exploratory disease spread modeling approaches, when information on the specific virus of interest is not available.

Quantitative impacts of incubation phase transmission of foot-and-mouth disease virus.

The current investigation applied a Bayesian modeling approach to a unique experimental transmission study to estimate the occurrence of transmission of foot-and-mouth disease (FMD) during the incubation phase amongst group-housed pigs. The primary outcome was that transmission occurred approximately one day prior to development of visible signs of disease (posterior median 21 hours, 95% CI: 1.1-45.0). Updated disease state durations were incorporated into a simulation model to examine the importance of addressing preclinical transmission in the face of robust response measures. Simulation of FMD outbreaks in the US pig production sector demonstrated that including a preclinical infectious period of one day would result in a 40% increase in the median number of farms affected (166 additional farms and 664,912 pigs euthanized) compared to the scenario of no preclinical transmission, assuming suboptimal outbreak response. These findings emphasize the importance of considering transmission of FMD during the incubation phase in modeling and response planning.

Estimating the scale of adverse animal welfare consequences of movement restriction and mitigation strategies in a classical swine fever outbreak.

BACKGROUND: The study aim was to quantify the impact of movement restriction on the well-being of pigs and the associated mitigation responses during a classical swine fever (CSF) outbreak. We developed a stochastic risk assessment model and incorporated Indiana swine industry statistics to estimate the timing and number of swine premises that would encounter overcrowding or feed interruption resulting from movement restriction. Our model also quantified the amount of on-farm euthanasia and movement of pigs to slaughter plants required to alleviate those conditions. We simulated various single-site (i.e., an outbreak initiated from one location) and multiple-site (i.e., an outbreak initiated from more than one location) outbreak scenarios in Indiana to estimate outputs. RESULTS: The study estimated that 14% of the swine premises in Indiana would encounter overcrowding or feed interruption due to movement restriction implemented during a CSF outbreak. The number of premises that would experience animal welfare conditions was about 2.5 fold of the number of infected premises. On-farm euthanasia needed to be performed on 33% of those swine premises to alleviate adverse animal welfare conditions, and more than 90% of on-farm euthanasia had to be carried out within 2 weeks after the implementation of movement restriction. Conversely, movement of pigs to slaughter plants could alleviate 67% of adverse animal welfare conditions due to movement restriction, and only less than 1% of movement of pigs to slaughter plants had to be initiated in the first 2 weeks of movement restrictions. The risk of secondary outbreaks due to movement of pigs from movement restriction areas to slaughter plants was low and only seven pigs from each shipment needed to be tested for CSF infection to prevent a secondary outbreak. CONCLUSIONS: We found that the scale of adverse animal welfare consequences of movement restriction during a CSF outbreak in Indiana was substantial, and controlled movement of pigs to slaughter plants was an efficient and low-risk alternative mitigation response to on-farm euthanasia. The output estimates generated from this study provide empirical evidence for decision makers to properly incorporate required resources for mitigating adverse animal welfare conditions in CSF outbreak management strategic planning.

Pattern of renal diseases in children: A developing country experience.

Spectrum of renal disease varies in different ethnic population, geographical location, and by environmental factors. The purpose of this study was to find out the clinical spectrum and occurrence of different pediatric renal diseases at a teaching hospital in the Eastern part of Nepal. All cases of renal diseases from one month to 15 years of age, attending the pediatric renal outpatient department and/or were admitted to the wards during the period of February 2012 to January 2013, were included in the study. Detailed clinical and laboratory evaluations were performed on all patients. Diseases were categorized as per standard definitions and managed with hospital protocols. Renal diseases accounted to be 206 cases (6.9%) of total annual pediatric admissions, of which (58%) were male and (42%) female. Acute glomerulonephritis (AGN) was the most common disorder (37.7%) followed by nephrotic syndrome (26.1%), urinary tract infection (21.3%), acute kidney injury (AKI) (17.9%), obstructive uropathy (1.9%), chronic kidney disease (CKD) (1.2%), and others. In AGN group, the most common cause was post-infectious glomerulonephritis (PIGN) (32.9%) followed by lupus nephritis (4%) and Henoch-Schonlein purpura nephritis (0.8%). Urine culture was positive in (9.22%) and the most common organism was Escherichia coli (57.9%). The causes of AKI were urosepsis, septicemia, and AGN (18.9%) each, followed by dehydration (13.5%). Mortality was found in 5% of cases and the etiologies were AKI in (72.7%), PIGN (18.1%), and CKD (9%). Renal diseases are a significant problem among children and are one of the common causes of hospital admission. These patients need comprehensive services for early identification and management.

Modeling Classical Swine Fever Outbreak-Related Outcomes.

The study was carried out to estimate classical swine fever (CSF) outbreak-related outcomes, such as epidemic duration and number of infected, vaccinated, and depopulated premises, using defined most likely CSF outbreak scenarios. Risk metrics were established using empirical data to select the most likely CSF outbreak scenarios in Indiana. These scenarios were simulated using a stochastic between-premises disease spread model to estimate outbreak-related outcomes. A total of 19 single-site (i.e., with one index premises at the onset of an outbreak) and 15 multiple-site (i.e., with more than one index premises at the onset of an outbreak) outbreak scenarios of CSF were selected using the risk metrics. The number of index premises in the multiple-site outbreak scenarios ranged from 4 to 32. The multiple-site outbreak scenarios were further classified into clustered (N = 6) and non-clustered (N = 9) groups. The estimated median (5th, 95th percentiles) epidemic duration (days) was 224 (24, 343) in the single-site and was 190 (157, 251) and 210 (167, 302) in the clustered and non-clustered multiple-site outbreak scenarios, respectively. The median (5th, 95th percentiles) number of infected premises was 323 (0, 488) in the single-site outbreak scenarios and was 529 (395, 662) and 465 (295, 640) in the clustered and non-clustered multiple-site outbreak scenarios, respectively. Both the number and spatial distributions of the index premises affected the outcome estimates. The results also showed the importance of implementing vaccinations to accommodate depopulation in the CSF outbreak controls. The use of routinely collected surveillance data in the risk metrics and disease spread model allows end users to generate timely outbreak-related information based on the initial outbreak's characteristics. Swine producers can use this information to make an informed decision on the management of swine operations and continuity of business, so that potential losses could be minimized during a CSF outbreak. Government authorities might use the information to make emergency preparedness plans for CSF outbreak control.

Evaluation of Movement Restriction Zone Sizes in Controlling Classical Swine Fever Outbreaks.

The objective of this study was to compare the impacts of movement restriction zone sizes of 3, 5, 9, and 11 km with that of 7 km (the recommended zone size in the United States) in controlling a classical swine fever (CSF) outbreak. In addition to zone size, different compliance assumptions and outbreak types (single site and multiple site) were incorporated in the study. Three assumptions of compliance level were simulated: baseline, baseline ± 10%, and baseline ± 15%. The compliance level was held constant across all zone sizes in the baseline simulation. In the baseline ± 10% and baseline ± 15% simulations, the compliance level was increased for 3 and 5 km and decreased for 9 and 11 km from the baseline by the indicated percentages. The compliance level remained constant in all simulations for the 7-km zone size. Four single-site (i.e., with one index premises at the onset of outbreak) and four multiple-site (i.e., with more than one index premises at the onset of outbreak) CSF outbreak scenarios in Indiana were simulated incorporating various zone sizes and compliance assumptions using a stochastic between-premises disease spread model to estimate epidemic duration, percentage of infected, and preemptively culled swine premises. Furthermore, a risk assessment model that incorporated the results from the disease spread model was developed to estimate the number of swine premises under movement restrictions that would experience animal welfare outcomes of overcrowding or feed interruption during a CSF outbreak in Indiana. Compared with the 7-km zone size, the 3-km zone size resulted in a longer median epidemic duration, larger percentages of infected premises, and preemptively culled premises (P's < 0.001) across all compliance assumptions and outbreak types. With the assumption of a higher compliance level, the 5-km zone size significantly (P < 0.001) reduced the epidemic duration and percentage of swine premises that would experience animal welfare outcomes in both outbreak types, whereas assumption of a lower compliance level for 9- and 11-km zone sizes significantly (P < 0.001) increased the epidemic duration and percentage of swine premises with animal welfare outcomes compared with the 7-km zone size. The magnitude of impact due to a zone size varied across the outbreak types (single site and multiple site). Overall, the 7-km zone size was found to be most effective in controlling CSF outbreaks, whereas the 5-km zone size was comparable to the 7-km zone size in some circumstances.