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   Table of Contents - Current issue
March-April 2020
Volume 13 | Issue 2
Page Nos. 97-187

Online since Friday, February 28, 2020

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Empathy in the time of artificial intelligence: Fiction not fact may hold the key Highly accessed article p. 97
Amitav Banerjee
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Lesson in humanities from movies: Its subtle role in promoting empathy p. 100
Harshal Tukaram Pandve
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The Competency-Based Medical Education Curriculum: An Appraisal of the Remedial Measures for Internal Assessment p. 101
Ajeet Kumar Khilnani, Rekha Thaddanee, Gurudas Khilnani, Gyaneshwar Rao
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Structured framework for teaching professionalism to medical students p. 104
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
Professionalism among medical students has been identified as one of the core competencies expected of a medical graduate. Acknowledging the need to teach professionalism, the formulation of a formal curriculum is a must. The drafted curriculum should extend across all the professional year, including internship and should specify the topics to be covered in each professional year, hours of teaching, teaching-learning method and the preferable mode of assessment. However, considering the basic fact that professionalism is more of an attitudinal change, it is vital to accept that formal curriculum will provide a structural framework, but for the better outcomes, it has to be supported by informal teaching. In conclusion, professionalism is an integral component in the development of a medical practitioner and the need of the hour is to resort to a combined formal-informal mode of teaching so that medical students are benefitted in the long run.
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Diseases with skin and lung involvement: Pulmonologist's perspective p. 106
Vishnu Sharma Moleyar, Anupama Noojibail
A variety of conditions/diseases can involve skin and lungs together. Knowledge about these conditions and the skin and respiratory manifestations in these conditions will lead to early diagnosis and proper management. Some of the dermatological manifestations may be very classical where the diagnosis will be obvious at a glance. Many a times, dermatological manifestations may narrow the differential diagnoses. In some cases, dermatological manifestations may indicate the severity/stage of the disease and prognosis. In some diseases with dermatological manifestations, where no obvious respiratory symptoms or signs are evident, screening for the underlying lung disease may be indicated. Some dermatological manifestations may indicate the underlying lung or other systemic diseases where further evaluation may be warranted even in the absence of other symptoms or signs. Diseases with skin and lung involvement can be classified into congenital/developmental disorders with cutaneous and pulmonary manifestations; primary dermatological diseases with pulmonary manifestations; primary pulmonary diseases with cutaneous manifestations; skin changes due to drugs used to treat respiratory diseases; and miscellaneous conditions involving skin and lungs. In this article, we discuss the various conditions/diseases with skin and lung involvement which a pulmonologist must know.
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Do women justify the violence they face? Intimate partner violence among married women p. 113
Rajneesh Kumar Joshi, Manisha Arora, Reema Mukherjee
Introduction: Intimate partner violence (IPV) is a significant public health problem with harmful consequences for affected individuals. We report the prevalence of physical and sexual violence and justification of this violence by ever-married women. Methodology: We conducted this cross-sectional study on 500 women in an urban area of a metropolitan city of North India. We used a validated questionnaire to estimate the prevalence and forms of IPV and proportion of women who justify the violence they face. We used logistic regression to determine the association of violence with certain sociodemographic factors. We also studied the association of justification of violence with these sociodemographic factors. Results: Ninety-one (18.2%) women had “ever” experienced physical violence. Alcohol consumption by the husband, initial place of residence, and controlling behavior by the husband were significantly associated with physical violence. Fifty two (10.4%) had “ever” experienced sexual violence. Higher education status of the women, justification of violence by the women, controlling behaviour and alcohol consumption by the husbands was significantly associated with sexual violence. Women who had faced any one form of violence (physical or sexual) were at higher risk of facing the other form as well. One hundred and eight two women (36.2%) justified violence by husbands. Women who faced controlling behavior, experienced sexual violence, were poorly educated, or were married for more than 10 years were more likely to justify any form of IPV they faced. Conclusion: Alcohol consumption, controlling behavior, and justification of violence are important behavioral predictors for physical or sexual violence. We recommend behavioral change communication strategies targeted at male partners and also the families to curb the menace of IPV.
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Comparative retrospective evaluation of efficacy of rituximab therapy with dexamethasone cyclophosphamide pulse therapy in patients of pemphigus vulgaris at a tertiary care hospital p. 120
Preema Sinha, Bhavni Oberoi, Arun Kumar Yadav, Vikas Pathania, Durga Madhab Tripathy
Background: Popular treatment modalities for pemphigus vulgaris are dexamethasone cyclophosphamide pulse (DCP) therapy and rituximab. However, no previous studies are available which have compared the efficacy of the two modalities. Aim: This study aims to study the response of pemphigus vulgaris to DCP and rituximab therapy and to compare the efficacy and safety of the two modalities over a period of 1½ years. Materials and Methods: This was an observational retrospective study. The medical records of a total of 14 pemphigus vulgaris patients from July 2016 to July 2018 were retrieved for analysis who were treated with either DCP therapy or rituximab (7 in each group). Patients treated with any other modality except DCP/rituximab were excluded from the study. The pemphigus disease area index (PDAI) scores at baseline, 1 month, 6 months, 12 months, and 18 months were analyzed using statistical software (Stata Corp. 2013. Stata Statistical Software: Release 13. College Station, TX, Stata Corp. LP, Texas, USA). Outcome Measures: Time to achieve the end of consolidation phase, improvement in PDAI scores, adverse effects, and relapse. Results: Rituximab group achieved early remission; however, there was no statistically significant difference in the two groups in the time when they reached the end of consolidation phase. Repeated measure anova showed significant difference in PDAI scores within the two groups over time. One patient in DCP group relapsed following discontinuation of cyclophosphamide due to complications. Overall, the scoring of disease severity was markedly reduced in both the groups. Conclusion: Both DCP therapy and rituximab were found to be extremely and equally effective in inducing and maintaining remission.
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Clinico-pathological correlation in Indian women presenting with cutaneous features of hyperandrogenism: A cross-sectional study p. 125
Vikas Pathania, RS Grewal, Prerna Shankar, Rajiv Pakhetra, Praveen Kumar
Background: Androgen excess is one of the most common endocrine disorders of reproductive-aged women, which can present in the form of hirsutism, androgenic alopecia, acne, ovulatory dysfunction, and if extreme and prolonged, even virilization. It is important to diagnose the underlying abnormality in young women presenting with cutaneous signs of hyperandrogenism so that appropriate treatment can be offered and long-term consequences of androgen excess in young females such as ovulatory dysfunction and infertility can be avoided besides improving the cosmetic appearance. Aims: The aim of this study was to study the cutaneous manifestations of hyperandrogenism and the various underlying clinicopathological conditions. Settings and Design: The study design was a cross-sectional descriptive study. Materials and Methods: One hundred women patients of reproductive age were studied for clinical manifestations of hyperandrogenism (excess hair growth, seborrhea, acne, alopecia, and/or menstrual disturbances), hormone levels, radioimaging, and underlying endocrinological diagnosis. Statistical Analysis Used: The data were analyzed with CDC EPI Info software computer program (version 7.2) using the appropriate statistical techniques. Results: A majority of 55% of cases were in the third decade. A family history of hirsutism was present in 8% of cases. Menstrual dysfunction was present in 50%. Seborrhea was present in 93%, acne in 71%, hirsutism in 91%, alopecia in 62%, and altogether were present in 39%. Biochemical evidence of hyperandrogenism was present in 75% and correlated with the severity of the grade of hirsutism. Polycystic ovarian syndrome (PCOS) was the most common underlying condition in 72% followed by idiopathic hirsutism in 13%. Conclusions: The present study shows PCOS as the most common underlying cause of cutaneous manifestations of hyperandrogenism. The severity of hirsutism correlates with serum testosterone levels.
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A Study of the Association of Early Pregnancy Serum Levels of Pregnancy-Associated Plasma Protein-A with Adverse Pregnancy Outcome p. 131
Namgay Choden, Santosh Kumar Singh, Sushil Chawla
Background: Decreased levels of pregnancy-associated plasma protein-A (PAPP-A) in maternal serum can be a marker not only for some chromosomal disorders and anomalies in the fetus but also specific for adverse pregnancy outcomes too, such as preeclampsia, spontaneous preterm birth, gestational diabetes, and fetal growth restriction (FGR) and to the extent of stillbirth. Hence, measurement of early pregnancy PAPP-A levels may help identify the areas of intervention for reducing the adverse outcome in later gestations. Materials and Methods: This was a prospective observational study. A total of 250 antenatal cases fulfilling the inclusion criteria were taken in the study. Early pregnancy serum levels of PAPP-A were measured for antenatal cases visiting outpatient department of tertiary level teaching hospital between 10 and 14 weeks period of gestation, and these cases were followed up for development of adverse pregnancy outcome. Results: Two hundred and thirty-five patients had normal outcomes, among which 24 patients had PAPP-A values ≤0.4 multiples of the median (MoM) and 211 patients had PAPP-A level >0.4 MoM. Twenty-nine patients out of 250 in our study group had PAPP-A level <0.4 MoM, 1 patient developed preeclampsia (P = 0.211) but underwent normal vaginal delivery at term, and 1 had FGR (P = 0.513). Three patients had preterm delivery and the PAPP-A values in preterm group were lower as compared to term group, and this result was statistically significant (P = 0.005). Conclusion: The study concludes that the patients with low early pregnancy PAPP-A levels may be deemed to develop preterm labor subsequently and effective measures may be taken to prevent the same. However, it would be prudent to replicate the study in a wider and more representative sample over multiple centers to see if the results hold true.
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Correlation of perceived stress with waist-hip ratio, lipid profile, and fasting sugar in newly diagnosed patients with polycystic ovarian syndrome in an Urban population of West Bengal p. 136
Nikhil Chandra Mondal, Arunima Chaudhuri, Abhijit Biswas
Background: Higher prevalence of stress in polycystic ovarian syndrome (PCOS) patients may have a critical role in their altered body composition. Aims: The aim is to study the correlation of perceived stress with waist-hip ratio (WHR), lipid profile, and fasting sugar in newly diagnosed patients with polycystic ovarian syndrome in an urban population of West Bengal. Materials and Methods: This cross-sectional pilot project was conducted in the Department of Physiology, Burdwan Medical College, in a time span of 1 year after taking institutional ethical clearance and informed consent of the participants. One hundred newly diagnosed PCOS patients and 100 age-, dietary habit-, and body mass index (BMI)-matched controls were included in the study. The Perceived Stress Scale (PSS) scores of the participants were assessed. Fasting blood samples were drawn from participants for analysis of fasting blood sugar (FBS) and lipid profile. Height, weight, BMI, WHR, resting pulse rate (measured after 15 min of rest with participants in supine posture), and blood pressure (measured by mercury manometer) were measured. The computer software “Statistical Package for the Social Sciences (SPSS) version 16” was used to analyze the data, and unpaired t-test was used to compare different parameters of the two groups. Correlation of PSS with other parameters was assessed. Results: There was a significant difference in PSS, WHR, pulse, blood pressure, FBS, and lipid profile between the two groups. There was a significant positive correlation between PSS and WHR, FBS, and lipid profile, and high-density lipoprotein cholesterol was negatively correlated with PSS. However, no difference in BMI was observed. Conclusion: PCOS patients with higher PSS in spite of having equivalent BMI, dietary habits, and age may have higher WHR, dyslipidemia, and fasting sugar as compared to normal individuals. Stress management programs are need of the day for the highly stressed modernized global population.
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Rural-Urban differentials in predicting tobacco consumption pattern among males above 15 years: A cross-sectional community survey p. 143
Bhaskar Shahbabu, Aparajita Dasgupta, Ishita Sarkar, Kaushik Sarkar
Introduction: Globally, every year, more than 6 million people die because of tobacco use. 20% of all global deaths attributed to tobacco occur in India. The behavioral difference in the rural and urban communities is an important aspect of tobacco problem in the country. In this context, we conducted a community-based cross-sectional study to determine the effect of area (rural-urban) in predicting tobacco consumption pattern. Materials and Methods: A community-based observational, cross-sectional study was conducted in a rural and an urban community of West Bengal from May 2014 to April 2015. A predesigned pretested schedule adapted from the Global Adult Tobacco Survey India Questionnaire was used for data collection. Males above 15 years of age, residing in the study areas, were interviewed during house-to-house visit. Results: Data obtained from the interview of 704 males (352 each from urban and rural area) above 15 years revealed that the prevalence of current tobacco use in any form is significantly higher in rural area (75.6%) than in urban area (67.6%). This was related to the fact that awareness and perception of the people in rural areas are significantly less than their urban counterparts. In bivariate analysis satisfactory consumption pattern was significantly more in urban area but when adjusted with all potentially explanatory variables, the odds of satisfactory consumption pattern in urban area was attenuated significantly. Conclusion: An appropriate intervention strategy, based on local area-wise behaviors of people to curb out the menace of tobacco use, is the need of the hour.
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Clinicopathological profile of Waldenström's macroglobulinemia: Experience from a tertiary care center p. 151
Gautam Kumar Vasnik, S Venkatesan, Sanjeevan Sharma, Ajay Malik
Background: Waldenstrom macroglobulinemia (WM) is a rare mature B cell Neoplasm, characterized by monoclonal Immunoglobulin M (IgM) in the serum and lymphoplasmacytic infiltration in the bone marrow. It accounts for approx 2% of Non Hodgkin Lymphomas. The disease is slightly more common in elderly males, the median age at diagnosis being 63 years. The disease is very infrequent in India and only a few studies have been published on the disease. Hence, we bring out this study on Clinico-Pathological Profile of WM. Aims and Objectives: To study clinico-pathological profile of WM cases and to distinguish them from other plasma cell neoplasms as both the diseases have different treatment protocols and prognosis. Materials and Methods: A cross sectional observational study was conducted at tertiary care center over a period of two years. Six cases of WM were encountered and enrolled for the study due to their rarity and morphological overlap with plasma cell neoplasms. The WHO criteria were followed and patients fulfilling those criteria were included in the study. The diagnosis of WM was based on the morphologic and immunohistochemistry findings of biopsy specimens, the presence of a monoclonal IgM, and the presence of distinctive clinical characteristics. Results: Median age of patients was 60.5 years with a male preponderance. 33% of cases presented with B symptoms and 100% cases presented with moderate to severe anaemia. 50% of the cases had thrombocytopenia and hepatomegaly. All cases had albumin:globulin ratio reversal. Peripheral smear showed background staining, rouleaux formation, relative lymphocytosis. Plasmacytoid cells were present in two cases. Bone marrow aspirate smears showed features of lymphoplasmacytic infiltration with suppression of other lineages. BM biopsies were hypercellular and showed a diffuse pattern of marrow infiltration by lymphoplasmacytic cells. The immunostaining of the infiltrating lymphocytes were CD 20+ and plasma cells were CD138+. Serum protein electrophoresis and immunofixation electrophoresis confirmed IgM type of monoclonal gammopathy. Conclusion: WM is relatively a rare mature B cell neoplasm which at times can have morphological overlap with other plasma cell neoplasms. We conclude that correlation with clinical laboratory test results while making diagnostic decision is an integral part of recognition of WM due to low grade indolent course of the disease and better outcome.
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The effect of sitagliptin on hepatic ischemic reperfusion injury in rats p. 156
Song-Chol Mun, Hye-Sun Hong
Background: Dipeptidyl peptidase-4 (DPP4, DPPIV, CD26, EC was found out more than four decades ago as a serine protease that severs N-terminal dipeptides from peptide substrates. DPP-4 inhibitors have been used in many animal models of lung and heart illness, in which injury was obtained by an ischemic attack followed by the following reperfusion. Here, we present the large body of experimental study that now gives irresistible evidence for the useful impact of DPP-4 targeting in ischemia/reperfusion injury. In this study, we discuss the effect of DPP-4 inhibitor (Sitagliptin) on DPP-4 expression in the rat model. Materials and Methods: We made a rat model of liver ischemia (90 min)-reperfusion (180 min), collected blood and liver samples after reperfusion. The possible inhibitory effect of Sitagliptin on DPP-4 in a rat model of hepatic ischemia-reperfusion (IR) damage was evaluated. Hepatic malondialdehyde (MDA) levels were evaluated spectrophotometrically to know the degree of oxidizing reaction in the liver. We evaluated the expression of tumor necrosis factor (TNF)-α and interleukin (IL)-6 in the model. We used hematoxylin and eosin (H and E) staining to remark the change of liver morphologically. Results: Significantly, the expression of DPP-4 levels was declined after treatment with Sitagliptin in the IR group. MDA, TNF-α, and IL-6 levels were significantly increased in the IR group but decreased in the groups treated with Sitagliptin, 5 mg/kg. H and E staining show exact edema and necrosis were remarked in the IR group, but in the Sitagliptin pretreatment group, they were decreased. Conclusion: The study showed that pretreatment with Sitagliptin might inhibit DPP-4 activation and reduce hepatic IR damage.
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The prevalence of hypertension and prehypertension among children in schools of rural health training area of a tertiary care hospital in Nagpur, Maharashtra p. 161
Arshiya Rehman Sheikh, Chaitanya R Patil, Sushama Subhash Thakre
Context: Chronic diseases such as diabetes, hypertension, and respiratory diseases are affecting the younger age groups occurring across the world. Raised blood pressure in children is increasing at an alarming rate. Aims: The aim was to study the prevalence of hypertension and prehypertension among children of schools in rural health training center area of a tertiary care hospital in Nagpur, Maharashtra, and to find any association between generalized obesity and central obesity with hypertension/prehypertension. Settings and Design: A cross-sectional study was conducted in the schools under the administrative cover of Indira Gandhi Government Medical College, Nagpur. Materials and Methods: Schoolchildren who had completed 10 years and not more than 13 years, whose parents gave consent, who gave assent, and apparently healthy were included in the study. The demographic particulars such as age and gender were collected using the case record form. Anthropometric measurements and blood pressure were measured using the standard guidelines. Statistical Analysis Used: Qualitative variables expressed in terms of percentages and quantitative in terms of mean and standard deviation. Chi-square test for trend and Student's t-test were used. Results: The prevalence of hypertension and prehypertension was 3.57% and 6.25%, respectively. We found a significant association between hypertension/prehypertension with waist-to-hip ratio of the children (P < 0.05). Conclusions: We found a higher prevalence of hypertension and prehypertension among the schoolchildren in rural areas, and we found a significant association between central obesity and hypertension/prehypertension.
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Varied ocular manifestations of Goldenhar syndrome p. 166
Rashi Verma, NP Singh
Goldenhar syndrome, also known as oculo-auriculo-vertebral syndrome, is a rare congenital disorder due to defect in the development of the first and second branchial arches during blastogenesis. This syndrome consists of epibulbar dermoids, eyelid coloboma, auricular abnormalities, preauricular appendages, and mandibular hypoplasia. There can also be associated cleft palate, malocclusion of teeth, and involvement of the axial skeleton (vertebrae and ribs). Congenital heart disease and anomalies of the genitourinary system are some rare manifestations of this syndrome. We report two cases of Goldenhar syndrome with varied ocular manifestations. The first patient was an 18-year-old female who presented with an inferotemporal limbal dermoid with protruding hair involving the inferotemporal cornea. She also had external ear malformation, preauricular skin tag, and mandibular hypoplasia. The second patient was a 3-year-old boy with low intelligence who presented with an upper eyelid coloboma and a temporal limbal dermoid in the left eye with telecanthus and epicanthal folds. There were associated mandibular hypoplasia and preauricular skin tag. Both the patients did not have any vertebral anomaly or congenital heart defect.
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Cranial Manifestations of Neurofibromatosis Type 2: A Rare Case Demonstrating 15 Intracranial Lesions p. 169
Amit Kharat, S Sneha, Ela Sharma, Vishva Chauhan
Neurofibromatosis type 2 (NF-2) is a rare autosomal dominant disorder characterized by multiple neoplasms which include meningiomas, schwannomas, and ependymomas. The most common tumors associated with NF-2 are bilateral vestibular schwannomas. We report the case of a 20-year-old female who presented with headaches and decreased vision. She had classical clinical presentation and imaging findings, which led to the diagnosis of NF-2.
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Quite uncommon entity: Gynecomastia as an initial manifestation of thyrotoxicosis p. 173
Akhilesh Kumar Singh, Divakar Verma, Ashwini Kumar Nigam
Gynecomastia can be seen in about 10%–40% of cases of thyrotoxicosis, but thyrotoxicosis presented with gynecomastia as an initial manifestation is extremely uncommon. Only few case reports are found in the literature. Here, we present a case of a 27-year-old male of hyperthyroidism who presented with painful left-sided gynecomastia.
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Dry lung syndrome: The positive end of the oligohydramnios spectrum p. 175
Simrita Kaur Khurana, Krishna Revanna Gopagondanahalli, Victor Samuel Rajadurai, Suresh Chandran
Oligohydramnios secondary to mid-trimester preterm premature rupture of the membranes can result in a range of abnormalities from functional hypoplasia of the lungs to structural hypoplasia and fetal compression syndrome. Here, we discuss two infants born at 24-week gestation with a history of severe oligohydramnios requiring extensive resuscitation with high ventilation pressures at birth. One had dry lung syndrome (DLS) and after adequate resuscitation did well. The second case had severe pulmonary hypoplasia complicated by recurrent air leaks and succumbed to it. Management of DLS is primarily supportive; these neonates require adequate respiratory support to open the collapsed airway at birth and optimal ventilation in the early neonatal period to facilitate smooth recovery.
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Sublingual ranula: A case study and management modalities p. 179
M Arun Kumar, Rama Gupta, S Anjana
Ranula is a mucus extravasation cyst of the oral cavity, the incidence of which peaks in the second decade of life. In this case report, a young male presented with a slowly progressive swelling at the floor of the mouth which was diagnosed clinically as ranula. He underwent excision of the ranula. Three-month follow-up revealed no recurrence.
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Reducing the intake of trans fat in the global food supply: World Health Organization p. 182
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
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Eye as a window to glioblastoma multiforme: A series of case reports p. 184
Shalesh Rohatgi
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Hepatitis and Novel Wuhan Coronavirus Infection: Observation p. 184
Pathum Sookaromdee, Viroj Wiwanitkit
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Novel Coronavirus: Concern over health-care professionals Highly accessed article p. 185
Nilofur Banu
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Support for health-care professionals during Wuhan Coronavirus infection outbreak p. 187
Viroj Wiwanitkit
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