Human organ and tissue transplantation was started in India in 1962. Initially, the organ transplant was unregulated, and organ trafficking was rampant. The act governing the transplantation was passed in 1994. This has been subsequently amended in 2011, and new rules came into force in 2014. Many of the students as well as practicing physicians are not aware of the act as it is generally not a part of the curriculum. This article highlights the important components of the act and focuses on what all physicians involved in transplant should know about the legal aspects of transplantation.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]

Background: South India (SI) is the area encompassing India's states of Andhra Pradesh, Karnataka, Kerala, Telangana, and Tamil Nadu as well as the union territories of Lakshadweep and Pondicherry. South Indians are heterogeneous population with different ways of life, language, and physical appearance. A majority of Indians from the southern region speak one of the languages: Tamil, Telugu, Kannada, Malayalam, or Tulu. A large number of south-Indians have now migrated to different parts of the world and often need human leukocyte antigen (HLA) matched donors for treatment of different disorders. Knowledge of allele and haplotype frequencies of the HLA system is important in the search for unrelated bone marrow donors. The South Indian population is very heterogeneous and the HLA system is highly informative of populations because of the high level of polymorphisms. We investigated distribution of HLA A, B and DRB1 loci in five linguistic groups from SI. Materials & methods: All the data were collected from the Marrow Donor Registry India (MDRI) which has pool of volunteer stem cell donors from these linguistic groups. DNA extracted from EDTA-blood sample of recruited donors, and HLA typing done using Luminex XMAP technology and sequence specific primer (SSP) technique at low–intermediate resolution. Graph pad InStat 3 and the software from National Marrow Donor Program (NMDP) were used for determining p values and haplotype frequency respectively. Results: MDRI donors belonging to these five linguistic groups namely Tamil, Telugu, Tulu, Kannada, and Malayalam speaking donors were analyzed. The most common haplotypes were A*01-B*57-DRB1*07, A*33-B*44-DRB1*07, A*02-B*40-DRB1*15, A*24-B*07-DRB1*15, A*24-B*40-DRB1*15. A few unique haplotypes were seen as most common haplotype in each linguistic group. Conclusion: Each linguistic group has unique haplotypes along with a few common haplotypes. In order to adequately represent the Indian population on the registry, each linguistic group should be targeted for donor recruitment. This would enable a better chance for any patient to find a matched unrelated donor.

[ABSTRACT]   Full text not available  [PDF] [CITATIONS]

Background: Occurrence of new onset diabetes after transplant (NODAT) has major impact on patient and graft survival, and cardiovascular mortality. Methods: In this retrospective study, among all renal transplant recipients who followed-up at our center during the period of January 1998 to April 2012, the development of NODAT was assessed by reviewing case records. Characteristics of patients with NODAT were compared with the patients who did not develop post-transplant diabetes. Results: Total 68 non-diabetic renal transplant recipients were included in analysis. Emergence of NODAT was observed in 13 (19.12%) recipients, with mean duration of onset at 52.73 ± 49.57 months post-transplant. Development of NODAT was significantly associated with; age of ≥45 years at transplant time (P 0.029, odds ratio 4.38), pre-transplant weight (P 0.031), presence of ADPKD (P 0.020, odds ratio 16.20), positive family history of diabetes (P 0.009, odds ratio 5.96), pre-transplant hypercholesterolemia (P 0.029, odds ratio 4.38), and pre-transplant hypertriglyceridemia (P 0.023, odds ratio 5.03). Risk of development of diabetes was not related to type of calcineurin inhibitor used. Conclusion: NODAT is common in our renal transplant patients. Risk of development of post-transplant diabetes was more closely related to traditional risk factors and was not influenced by immunosuppressive therapy.

[ABSTRACT]   Full text not available  [PDF] [CITATIONS]

Aim: To identify the major challenges faced by bone marrow donor registries in India. Materials and methods: HLA typing, using the Sequence specific oligonucliotide probe (SSOP) Luminex-xMap technology, was performed for all 18,000 donors. Haplotype analysis was performed using the Arlequin software. Results: In a cohort of 18,000 donors only 19% patients could find a donor at 10/10 low resolution level. The chances of finding a donor at high resolution 10/10 level is even less. The major challenges faced are lack of awareness, patient's economic status, unavailability of unrelated matched donors, lack of funding for function of registry and high donor dropout rates. Conclusion: As cost is a major challenge, we need to strive to increase donor pool and also take major steps to decrease the donor dropout rates by increasingly motivating potential donors and trying to help them overcome any myth or fear from donating stem cells.

[ABSTRACT]   Full text not available  [PDF] [CITATIONS]

Background: Viral infections cause significant morbidity and mortality in post-transplant period. A highly sensitive and specific detection tool if used may help in early diagnosis and better management in these patients. The study aimed to assess the utility of quantitative real-time polymerase chain reaction (qRT-PCR) as a diagnostic and monitoring tool for viral infections in post renal transplant patients. Methods: A quantitative real-time polymerase chain reaction (qRT-PCR) was performed to detect EBV and CMV infection in 50 patients on 1st, 2nd, 3rd, and after 6 months of renal transplantation. Results: CMV infection was found in 34%, EBV in 28% of recipients, and 17% showed dual infection. Viruses were detectable after the first month of transplantation followed by symptomatic infections within first three months of follow-up, with diarrhea being the commonest symptom. These patients were also at high risk for developing other infections. Anti-thymocyte globulin (ATG) induction was a definitive risk factor for CMV/EBV infection in post operative period. Conclusion: Renal transplant patients frequently develop one or more viral infections at a time. Regular monitoring with qRT-PCR and prompt antiviral therapy with reduction in immunosuppression may be an ideal approach for management of these patients.

[ABSTRACT]   Full text not available  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]

Renal transplantation is the treatment of choice in most patients with end-stage renal disease, especially with improvement in surgical techniques and immunosuppressive regimens; however, the long-term graft survival remains to be improved. Immunological graft injury leading to rejection plays a major role in long-term graft loss. With pretransplant immunological evaluation using various crossmatch tests, identification of donor-specific antibodies, a better understanding of renal allograft pathology and its standardization with the Banff classification having regular updates led to prevention, early and accurate diagnosis of rejection and its histological differentiation. Some newer biomarkers are in pipeline may enable early and accurate identification of graft pathology noninvasively.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]

Sirolimus, one of the leading drugs of the mammalian target of rapamycin inhibitor (mTORi) family, is a promising immunosuppressive drug being used after solid organ transplantation. The introduction of sirolimus in renal transplantation has increased the repertoire of immunosuppressive protocols substantially. It has a different mode of action and a different side effect profile (i.e. lower nephrotoxicity, less hypertension and less neoplastic potential) than the calcineurin inhibitors, the other commonly used post transplant immunosuppressive drugs. Here we present a case report of a 40-year-old patient who presented with oligospermia after consuming the sirolimus for three years.

[ABSTRACT]   Full text not available  [PDF] [CITATIONS]

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]

[FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]

Small-for-size syndrome remains the greatest limiting factor for the expansion of liver transplantation (apart from cadaveric organ donation) and has been the major cause of worse short-term prognoses after LDLT. The size of the graft, ( GRWR < 0.8 or graft to SLV ratio <30–40%, portal hyperperfusion, obstructed hepatic venous drainage, MELD score, and graft steatosis may be responsible for the pathogenesis of SFSS. Sinusoidal shear stress may be the principal common pathway in the pathogenesis. Living donor grafts with portal pressure more than 20 mmHg or portal flow exceeding 250 mL/min per 100 g have a higher risk of graft failure. The role of decrease arterial flow in response to portal hyperflow remains to be elucidated. Acute portal hypertension and increased shear stress caused by a partial hepatectomy triggers the regeneration of the remaining liver, though liver dysfunction is seen to be due to sudden portal hypertension, microcirculatory ischemia, reduced oxygen delivery, and hepatocellular dysfunction. The differences in sinusoidal pressure, or differences in the hepatotropic substances delivered to the graft or the liver remnant may be the difference between grafts that survive and grafts that don't. We need to find the threshold level of hyperperfusion that does more harm than good.

[ABSTRACT]   Full text not available  [PDF] [CITATIONS]

Background: Knowledge of allele and haplotype frequencies of the HLA system is not only important in the search for unrelated bone marrow donors but it also provides useful insights to the probable susceptibility and resistance to disease as well as drug tolerance and toxicity in the Bengali population. Methods: In this study, 322 Bengali speaking donors registered with MDRI were analyzed for the HLA ABDRB1 alleles using Luminex and SSP techniques. The haplotype analysis and HW test was performed using arlequin 3.5 software. Results: The most prevalent HLA A alleles are A*33(20%), A*24(19%), A*11(16%), A*02(14%), A*01(11%), which are known to be associated with increased risk of pulmonary tuberculosis, leprosy, cytomegalovirus and enterovirus 71 infections. The common B alleles B*15 (15%), B*35, B*40, B*44 (11%), B*52 (9%) and B*57 (6%) are associated with increased risk to cervical cancer and vasculitis. The most prevalent DRB1*15 (29%), DRB1*07 (21%), DRB1*04 (11%) and DRB1*12 (9%) are associated with Rheumatoid arthritis, bronchial asthma and inflammatory bowel disease. The most common haplotype A*33-B*44-DRB1*07 with the haplotype frequency of 6.4% was prevalent Bengali population from India. Many other common haplotypes seen in Bengali are present in other parts of the world like Asian population in USA, China, Brazil and neighboring Bangladesh and Pakistan. Conclusion: This study shows presence of common Bengali haplotypes across many countries. This will enable sharing of donors stem cells to the needy patients worldwide.

[ABSTRACT]   Full text not available  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]

Background: Organ donation (OD) is the process of surgically removing an organ or tissue from one person (donor) and placing it into another person (recipient). Of the overall deaths occurring annually in India, nearly one lakh deaths occur due to organ failure. Shortage of donor organs can be resolved by raising awareness and educating the youth about various aspects of OD since they comprise of the majority of the population. The purpose of our study is to determine the level of awareness, knowledge and attitude regarding OD among pupils related to both medical and non-medical fields. Objective: To assess the awareness, knowledge, and attitude regarding OD among final year students of medical, dental, engineering, and arts and science students in Thiruvallur and Chennai. Materials and Methods: A cross-sectional study was conducted among 486 undergraduate students belonging to medical, dental, engineering, and arts and science from various colleges in Thiruvallur and Chennai. A 30 item self administered English questionnaire was given which assessed levels of awareness from Q1-Q7, knowledge from Q8- Q20 and attitude from Q21-Q30 among the study population regarding organ donation. Results: A total of 486 students participated in the study, out of which 183 (37.7%) were males and 303 (62.3%) were females. Among the study population, 455 (94%) were aware and 31 (6.4%) were not aware of the term OD. A total of 261 (54%) students were aware and 225 (46%) were not aware of the “organ transplantation act”. A total of 240 (49.4%) students had the knowledge about the risks involved in OD. A total of 329 (68%) students felt the need for laws to govern the process of OD. Knowledge about the human donor card was observed among 169 (35%) students among the study population. Three hundred and eight (63.4%) wanted to be a part of any OD group and also motivate others for OD. Conclusion: A well-organized approach is required to raise awareness among the youth about various aspects of OD which is necessary to eliminate the setbacks that affect the rate of availability of donor organs. Motivational messages and facts are some of the means of intervention to bring about changes regarding perceptions and intentions about OD among the students.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]

Aim/Objective: ABO incompatible kidney transplantations are getting popular all over the world. It is essential that such transplantations are carried out in our country also. Material and methods: Thirteen patients who had undergone ABO incompatible transplantations in a single center since 2009 were studied. The transplantations have been across different blood group combinations. The preconditioning of the patient was done as per the Japanese protocol. Results: The patients were followed up between 4 weeks to 28 months. Two patients had immediate antibody-mediated rejection with loss of graft. The rest 11 patients have normal graft function without any complication. Conclusion: Successful ABO incompatible transplantation is feasible in our country without endangering the life of recipient with reasonable cost control. Further studies are required to modify the protocol to prevent immediate antibody-mediated rejections (ABMR).

[ABSTRACT]   Full text not available  [PDF] [CITATIONS]

Emphysematous pyelonephritis (EPN) is a rare gas forming, necrotizing infection of the renal parenchyma. It is potentially lethal, if not recognized and treated promptly. EPN-affecting renal allografts has been reported infrequently. We report a case of 34-year-old male renal allograft recipient presented with urosepsis and acute graft dysfunction, found to have EPN. He was treated conservatively with antibiotics and ureteral stenting along with reduction of immunosuppression, with complete recovery.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]

Acute pancreatitis is a rare but often lethal complication in post-transplant patients. We describe a case of acute pancreatitis in a male patient 11 years after renal transplantation with azathioprine for immunosuppression as possible causative agent. Laboratory and imaging diagnosis of acute pancreatitis followed by successful endoscopic interventional management using transgastric catheter drainage is presented.

[ABSTRACT]   Full text not available  [PDF] [CITATIONS]

Invasive fungal infections are associated with morbidity and mortality in immunocompromised patients. Infection of rhinocerebral region are mainly due to opportunistic fungal pathogens. Although zygomycosis and aspergillosis are two major causes of paranasal infections, reports of combined mucormycosis and aspergillosis infections of rhinocerebral region are limited. We report a case of combined rhinocerebral fungal infection in post renal transplant diabetic patient. Identification of two fungal pathogens helps in appropriate management of patient with clinical cure.

[ABSTRACT]   Full text not available  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]

With the onset of 21^st century, organ donation (OD) has taken a big stride, still waiting for organ transplants is higher than its availability. Donating a life after one's death to someone you even do not know is one of the noble humanity causes. In Indian scenario, with the inception of Transplantation of Human Organs Act, 1994, multiple active initiatives were undertaken time to time for promoting OD; similarly, green corridors have also come in a big way for transfer of organs for interinstitutional transplantation. The institute undertook its first green corridor for OD in 2015 when liver was sent to one of the hospitals, and till date, 25 green corridors have been established where 27 organs have been shared with other institutes nationwide besides intrainstitute transplantations. Although this noble cause has taken its initial steps, still, innovations, and opportunities for promoting OD should be explored in a continuum for foreseeable better future.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]

Aim: Co-occurrence of Epstein–Barr virus (EBV) with Cytomegalovirus (CMV) is associated with an increased risk of EBV-associated posttransplant lymphoproliferative disorder (PTLD). Quantitation of EBV by real-time polymerase chain reaction (PCR) can aid the clinicians in the initiation of preemptive measures to improve the survival of the graft. Methods: The study was conducted among postrenal transplant recipients (PRTRs) who were attending the nephrology department from 2011 to 2016. Real-time quantitative PCR for EBV was performed in whole blood. PRTRs were classified into asymptomatic with altered renal parameters (Group A) and symptomatic (Group B), which were further subcategorized into Group B1 (fever with anemia, leukopenia, thrombocytopenia, or altered liver enzymes (any two), Group B2 (Group B1 + end-organ disease or only end-organ disease), and Group B3 (graft dysfunction [GDF]). The posttransplant period was also defined. DNA was extracted (Qiagen, Hilden, Germany) from whole blood, and real-time PCR was performed using QuantiTect multiplex PCR kit. Unpaired t-tests and ANOVA were used to analyze the data. Results: A total of 89 PRTRs were enrolled, of which 39.3% (n = 35) had EBV DNAemia, 43.1% during very late, 41.1% in late and 28.6% in immediate post transplant periods. EBV DNAemia ranged from 324 to 32,436 copies/ml. EBV DNAemia was found in 84% (n = 75) of symptomatic (Group B) and 16% (n = 14) of asymptomatic (Group A). Among the PRTRs with GDF (Group B3), 44% (n = 11/25) had EBV DNAemia of 2893.9 ± 1869 copies/ml. EBV DNAemia was considerably higher in PRTRs without GDF (8700.2 ± 9675.6 copies/ml) than PRTRs with GDF and the difference was statistically significant (P = 0.004). EBV DNAemia with CMV DNAemia among PRTRs was found in 21.3% (n = 19). Conclusion: High EBV DNAemia may precede PTLD or GDF; therefore, regular screening of EBV DNAemia is warranted. CMV and EBV DNAemia may also co-exist in PRTRs. As CMV is an immunomodulating virus, it increases the risk of opportunistic infections, especially EBV.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]

Introduction: ABO-incompatible (ABOi) renal transplant is the only option for patients who have neither blood group-compatible donors nor a suitable swap available. Published Indian experience of ABOi transplants has been far and few. Materials and Methods: This study was conducted across two different centers. All the consecutive ABOi renal transplants performed from November 2011 onward and who had completed at least 6 months of follow-up were included. Data were accessed retrospectively from the medical records. Results: There were fifty ABOi recipients who had completed at least 6 months of follow-up. Most common recipient blood group was group O. Median baseline antiblood group antibody titer (immunoglobulin G) was 256. Patient and death-censored graft survival were 94% and 88%, respectively, and biopsy-proven acute rejection was 22%. Acute antibody-mediated rejection was seen in 8% of the patients. Mean serum creatinine was 1.12 mg/dl at 1-month posttransplant and infection rate was 22%. Conclusion: The outcomes of ABOi transplant were acceptable and it should be promoted to bridge the demand and supply gap for renal transplant and expand the living donor pool.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]

Introduction: Treatment options for recurrent C3 glomerulopathy (C3G) are not explored in large trials. Only Eculizumab has been successfully used to improve the renal function in patients with recurrent C3G. In the current report, we are sharing our experience with plasma exchange (PLEX) in the management of early recurrent C3G post-renal transplantation. Materials and Methods: A total of four patients underwent PLEX. Time to recur was less than two weeks in all the patients. Serology levels, autoantibody testing and limited genetic workup was done in all the four patients. The clinical details of patients were recorded. Results: All the patients underwent 5 PLEX (40 ml/kg/session) with fresh frozen plasma as the replacement. The median time for post-transplant recurrence was 3-days. Immediate reduction in serum creatinine was seen in three (75%) patients. After a median last follow-up of 8.5 (range: 4-18) months, two (50%) patients achieved remission and the other two (50%) had resistant disease resulting in graft loss. Three patients tested positive for autoantibodies (two cases had positive C3-nephritic factor and one had anti-complement factor-H autoantibodies. Complement factor H gene analysis revealed rs1061170; p.His402Tyr (missense variant), rs1061147; p.Ala307= (synonymous variant) and rs2274700; p.Ala473= (synonymous variant) in three cases. All the three patients who had immediate response to PLEX had positive autoantibodies against complement pathway regulators. Conclusion: In the present report, we performed extensive workup for complement pathway abnormality and found that patients with recurrent C3G following transplantation having autoantibodies benefited with PLEX.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]

Background: Liver transplantation is the most durable treatment option for ESLD. Due to acute shortage of cadaveric organs Living donor liver transplantation has gained momentum especially in Asian countries. Size of the liver graft or the remnant liver is often expressed as a percentage of the standard liver volume (SLV) of the patient. Various formulas for SLV have been derived but only Chandramohan formula is derived for Indian population. Our aim was to carry out a study to validate the Indian formula based on the actual liver volumes (ALV) that we got from the cadaveric donor livers. Material and methods: This prospective study included 33-brain dead cadaveric donor of either sex. Body surface area was calculated by Mosteller's formula. Graft weight was measured after the bench surgery. Standard liver volume was calculated by formula derived by Chandramohan et al and compared with actual liver weight. Result: Chandramohan formula underestimates actual liver weight in Indian population. With our data we derived a formula for standard liver volume for Indian population. Conclusion: No accurate formula of SLV for Indian population. We attempted to derive a formula for SLV for Indian population. However our data is very limited needs larger cohort for proper estimation.

[ABSTRACT]   Full text not available  [PDF] [CITATIONS]

Background: Hepatic arterial inflow to the liver graft following liver transplantation is critical to graft survival. When recipient hepatic artery is not available due to injury or recipient hepatic artery flow is inadequate extra anatomic hepatic arterial reconstruction during deceased donor liver transplantation is required to ensure adequate hepatic arterial blood flow to the graft. The outcome in such patients is analyzed and compared with patient with standard hepatic artery reconstruction. Methods: Retrospective analysis of 30 patients who underwent Deceased Donor Liver Transplantation (DDLT) from March 2007 to May 2010 was done to assess the outcome of extra anatomic arterial inflow reconstruction. DDLT with standard end to end Hepatic Artery anastomosis performed in 24 patients (n = 24) served as control. Extra anatomic hepatic arterial reconstruction (EAHAR) was performed in 6 patients. The preferred choice of EAHAR was to fashion an infrarenal aortic conduit using stored donor iliac artery graft routed through the base of the transverse mesocolon. Results: Extra anatomic hepatic arterial reconstruction is not associated with increased morbidity, mortality, blood loss, operating room time or thrombosis. Conclusion: Extra anatomic hepatic arterial reconstructions are associated with excellent long-term outcomes and provide acceptable alternatives for arterial reconstruction.

[ABSTRACT]   Full text not available  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]

Background: We aimed to determine the incidence of lymphoceles in patients undergoing renal transplantation and the effect of povidone–iodine on lymphoceles. Material and methods: The study included a total of 26 cases (12 females, 14 males; mean age, 40.0 ± 10.1 years) treated with dialysis due to end-stage renal failure and underwent renal transplantation in our hospital between December 2010 and February 2012. Transplantation was performed using a cadaveric donor in 17 of the 26 patients, and a living donor in 9 patients. Post-operative ultrasound examination was performed in all patients on the first and seventh days, and repeated when indicated. Small and asymptomatic collections were followed. Large and symptomatic lesions underwent percutaneous catheter drainage, and daily injections of 10% povidone–iodine (30 mL) were applied for 30 min. Results: Lymphoceles were detected in 6 (23%) of the 26 transplant patients, all of which were treated with povidone–iodine effectively (100% success rate). There was no complications or lymphocele recurrence during three months follow-up. Conclusions: In spite of recent advances in renal transplantation surgery, lymphocele is still a common post-operative complication. Percutaneous sclerotherapy of lymphoceles with povidone–iodine is an easy to perform and effective treatment method without any complications or recurrence.

[ABSTRACT]   Full text not available  [PDF] [CITATIONS]

Despite improvements in the immunosuppressive protocols, and infection preventive method infections remains a major impediment to long-term renal graft survival especially in developing countries. Opportunistic infections after renal transplant usually follow a time table pattern with highest risk during first 6 month when intensity of immunosuppression is maximum, although this was not uniformly found in patients from this continent. In renal allograft recipient, immunosuppressive drug therapy is the major cause of immunocompromised status and occurrence of infections, which arise most commonly as a result of invasion by endogenous opportunists. Cytomegalovirus (CMV) remains one of the most important viral pathogen and studies suggest increased rejection episode associated with CMV infection. Polyomavirus-associated nephropathy (PVAN) remains an important cause of allograft dysfunction and graft loss after kidney transplantation. Tuberculosis (TB) is an important cause of morbidity in renal transplant recipients in developing world and the incidence of posttransplant tuberculosis in India has been reported to be highest in the world at 5.7–10% in various studies. The opportunistic infections with Nocardia and fungal infection like Aspergillosis, Mucormycosis, Candidiasis and others like Pneumocystis carinii in immunosuppressed patients were present with severe complications that are reviewed in this article. As a result of use of strong immunosuppressive drugs like tacrolimus, mycophenolate mofetyl (MMF) and antirejection therapy with antithymocyte globulins (ATG), these infections are now seen frequently, so they should always be included in differential diagnostic consideration.

[ABSTRACT]   Full text not available  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]

Full text not available  [PDF] [CITATIONS]