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El Mednifico Journal
  This is an Open Access Journal Open Access journal
     ISSN (Print) 2307-7301
     Published by Mednifico Publishers Homepage  [1 journal]
  • A new comprehensive method for treatment of severe intra-uterine adhesions

    • Authors: Sefa Kelekci, Serpil Aydogmus, Emine Demirel, Mustafa Sengul
      Abstract: Background: The aim of this paper is to describe a special comprehensive approach to women with severe intra-uterine adhesions and oligo-amenorrhea.Case Presentation: A 40 year old woman was admitted with oligo-amenorrhea. After estradiol (E2) levels reached 200 pg/dl, we did transabdominal ultrasound directed hysteroscopic adhesiolysis. We inserted a triangle balloon for a week. The Intra-uterine device was left in place for 1–3 months, while the intrauterine catheters were removed after 1–2 weeks. We treated patient with 2 x 2 mg estradiol hemihidrate and azitromycin daily.Conclusion: The patıent has been eumenorrheic and she had a 7 week intra-uterine pregnancy one year after the operation.
      PubDate: 2014-03-30
      Issue No: Vol. 2 (2014)
  • Novel anticancer agents in clinical and preclinical trials

    • Authors: Adnan Salim
      Abstract: [No abstract available]
      PubDate: 2014-03-30
      Issue No: Vol. 2 (2014)
  • Research knowledge and behavior of health workers at Federal Medical
           Centre, Bida: A task before learned mentors

    • Authors: Ibrahim Taiwo Adeleke, Adedeji Olugbenga Adekanye, Abdullahi Daniyan Jibril, Fausat Fadeke Danmallam, Henry Eromosele Inyinbor, Sunday Akingbola Omokanye
      Abstract: Background: Clinical research has been acknowledged to have positive impacts on healthcare systems. However, health workers at Federal Medical Centre, Bida (FMCB) were presumably adjudged as indisposed to research. Thus, a scientific study became imminent. The present study sought to determine research knowledge and behavior of health workers at FMCB.Methods: A 25-point questionnaire was administered to 247 stratified randomly selected employees of the hospital.Results: Most participants (99.4%) believed that research is relevant to healthcare services. A good number (73.1%) of them selected abstract as the first section of journal articles, but not many (32.5%) selected research idea as the first step in research methodology. In terms of knowledge about tools for health related research, most participants (83.8%) said they could operate computer system, but only few (25.6%) could recognize SPSS as software for data analysis.Conclusion: Health workers at FMCB acknowledged the impacts of health services research. However, not many possessed adequate knowledge of research methodology and the right computing skills. Evolving a better research culture would require the few researchers in the hospital to play continuous mentorship role along with the need for the hospital management to provide an enabling environment promoting a positive research culture.
      PubDate: 2014-03-30
      Issue No: Vol. 2 (2014)
  • Flexural and tensile strengths of three restorative materials used in
           pediatric dentistry

    • Authors: Marcia Pereira Alves Dos Santos, Lucianne Cople Maia
      Abstract: Background: This in vitro study aimed to compare the flexural strengths (FS) by using the three-point method as well as the uniaxial tensile strengths (TS) of three restorative materials commonly used in pediatric dentistry: Freedom/SDI (Group I), Vitremer/3M (Group II), and TPH Spectrum/Dentsply (Group III).Methods: For FS and TS, five samples of each material were specifically made upon black Teflon matrices according to ISO 4049. The materials were incrementally inserted, lightcured (40s – 500mW/cm2), and stored in moist and dark environment at 37oC for 12 hours. A universal testing machine was used at crosshead speed of 0.5 mm/min and 50 kgf load. All results were analyzed with ANOVA and Tukey tests at 5% significance. For FS, the mean values (± SD) (in MPa) were: GI = 111.00 ± 43.49, GII = 114.80 ± 42.60 and GIII = 344.90 ± 68.90.Results: For TS, the mean values obtained from GI, GII, and GIII were, respectively, 12.51 ± 4.59, 9.93 ± 3.98, and 33.09 ± 10.69. The performance of GIII was statistically better regarding both FS and TS than GI and GII (P<0.05). No statistical difference was found between GI and GII regarding both FS and TS (p>0.05). Descriptive analysis showed that GI and GII were brittle compared to the GIII, which had suffered plastic deformation before fracture.Conclusion: The TPH material was more resistant than the Freedom and Vitremer ones, whose flexural and tensile strengths were found to be similar.
      PubDate: 2014-03-29
      Issue No: Vol. 2 (2014)
  • Magnetic resonance imaging cholangiographic evaluation of normal common
           bile duct size

    • Authors: Mustafa Fatih Erkoç, Sevil Alkan, Sinan Soylu, Aylin Okur
      Abstract: Background: Regardless of the etiology of biliary diseases, intrahepatic or extrahepatic biliary dilatation is usually observed as a result. To investigate the possible reasons, primarily, we have to determine the dilatation. At this point, the most important question is what is the limit of a normal common bile duct (CBD) size and does it really differ after cholecystectomy' The size of normal CBD has been measured and reported in previous studies by various imaging methods but to our knowledge, it has not been measured by MRI cholangiography before. The aim of this study was, therefore, to determinate the normal diameter of CBD and to compare with post-cholecystectomy patients by MRI cholangiography.Findings: MRI data was acquired for a six month period retrospectively. A total of 104 patients who had undergone MRI cholangiography due to any reason were divided into two groups: with cholecystectomy (31 patients) and without cholecystectomy (73 patients). The mean diameter of normal CBD in those without and with cholecystectomy patients was 4.28 mm and 7.92 mm respectively. Mean of CBD diameters of post-cholecystectomy patients was significantly greater than the control group (p<0.001).Conclusion: In conclusion, the mean diameter of normal CBD shows a significant increase in cholecystectomized patients.
      PubDate: 2014-03-29
      Issue No: Vol. 2 (2014)
  • Microalbuminuria: An early marker of diabetic kidney disease

    • Authors: Zahra Ali, Muhammad Adnan, Saira Bashir, Iffat Shabbir, Tayyaba Rahat
      Abstract: Background: Diabetic nephropathy is the leading cause of end-stage renal disease globally and contributes to the total disease burden. The study was carried to estimate the occurrence of microalbuminuria in type II diabetics and to find its association with blood pressure, duration of disease and anthropometric measurements.Findings: The cross-sectional study was conducted for six months in Pakistan Medical Research Council Research Centre, Fatima Jinnah Medical College, Lahore. A total of 91 subjects who met the inclusion criteria were selected. A comprehensive questionnaire including age, education, socio-economic status, medical history, blood pressure and anthropometric measurements was used as a study tool. Random blood sample was used for the estimation of plasma glucose, blood urea and serum creatinine, while first morning urine sample was collected for the qualitative screening of microalbuminuria. Data analysis was done using Statistical Package for Social Sciences version 15 (SPSS-15).The mean age of 91 selected subjects was 50 ± 9 years and male to female ratio was 2:1. 80.2% subjects were diabetic hypertensive and remaining 19.8% had only diabetes. The overall prevalence of microalbuminuria was 58.2%. Prevalence of microalbuminuria among males was 30.2% and among females 69.8%. Correlation analysis showed that plasma glucose level, duration of diabetes and systolic blood pressure correlated with microalbuminuria at P<0.05. While age, BMI, waist to hip ratio were not statistically correlated with microalbumin. Among the 53 patients having microalbuminuria, serum urea and creatinine was found to be raised in 13.2%.Conclusion: Microalbumin has associations with systolic blood pressure, elevated plasma glucose level and duration of diabetes. Hence, diabetic patients should be subjected to routine screening for microalbuminuria at least once in a year.
      PubDate: 2014-03-29
      Issue No: Vol. 2 (2014)
  • Atypical mesothelial hyperplasia mimicking mesothelioma in patient with
           metastatic papillary carcinoma of thyroid

    • Authors: Mutahir A Tunio, Mushabbab AlAsiri, Syed Azfer Husain, Nagoud Mohamed Omar Ali, Shomaila S Akbar
      Abstract: Background: Atypical mesothelial hyperplasia (AMH) is characterized by rapid proliferation of mesothelial cells with cellular atypia secondary to pleural irritation. AMH is a diagnostic challenge and it is not always easy to differentiate from mesothelioma and metastatic carcinoma to pleura. Only few related case reports have been published so far.Case Presentation: Herein we present a case of an 80 year old Saudi woman, who was treated one year ago with total thyroidectomy and radioactive iodine ablation twice for metastatic papillary carcinoma of thyroid, presented with right pleural effusion which was positive for mesothelial cells and computed tomography of chest showed right pleural masses suspected for mesothelioma or metastatic papillary carcinoma, which turned out to be AMH on immunohistochemistry.Conclusion: AMH is rare benign manifestation which can be associated with underlying malignancy. Radioactive iodine therapy could be a possible cause. The radiological features of AMH resemble that of mesothelioma or metastatic carcinoma to pleura and immunohistochemistry is confirmatory.
      PubDate: 2014-03-28
      Issue No: Vol. 2 (2014)
  • Lipoma of retromandibular space

    • Authors: Anand Gupta, Varun Chopra, Gurvanit Lehl, Shivani Jindal
      Abstract: Background: Lipomas are a common tumor of skin but less common in the head and neck accounting for only 1-4.4% of all benign tumors. Of the variety of lipomatous benign tumors that occur, over 80 percent are ordinary lipomas and only about 13 percent of these occur in the head and neck region, most commonly in the posterior neck. Rarely, lipomas can occur in the antrerior neck, infratemporal fossa, oral cavity, pharynx, larynx and parotid gland. Lipomas involving submandibular and parapharayngeal spaces have been reported. To the best of our knowledge after searching the English Literature on MEDLINE database, no case has been reported involving this region (retromandibular space).Case Presentation: We report a case of 40 year old male who presented with solitary swelling over left retromandibular region which confirmed to be lipoma on histopathological examination after surgical excision. Postoperatively patient developed a sialocele after 2 weeks which was managed successfully by aspiration and antisialagogues. Patient recovered completely after two weeks and no recurrence was seen till follow up of two years.Conclusion: Lipomas are common tumors of the head and neck region. They commonly occur at the site where fat is present and which is not required for metabolic needs of the body. Untreated lipomas can result in aesthetic and functional disease.
      PubDate: 2014-03-28
      Issue No: Vol. 2 (2014)
  • Primary eosinophilic granuloma presenting as bilateral otitis media and

    • Authors: Purnima Aggarwal, Uma Debi, Geetanjli Jindal
      Abstract: Background: Simultaneous bilateral involvement of the temporal bones is a rare manifestation of eosinophilic granuloma, a disease characterized by solitary or multiple foci of osteolytic damage.Case Presentation: A young child initially presented with bilateral otitis media, with subsequent rapidly developing bilateral masses in the mastoid region. Computed tomography demonstrated extensive bony destruction which, after a course of vinblastine, methotrexate and prednisolone improved dramatically on follow-up scans.Conclusion: We present an unusual case of bilateral temporal bone destruction due to eosinophilic granuloma in a young child along with the literature review.
      PubDate: 2014-03-28
      Issue No: Vol. 2 (2014)
  • Peripheral ossifying fibroma

    • Authors: S V S G Nirmala, Ramasub Bareddy, Sivakumar Nuvvula, Swetha Alahari, Sandeep Chilamakuri
      Abstract: Background: Peripheral ossifying fibroma is a solitary growth on the gingiva which is thought to arise from the periodontal ligament. We report a case of peripheral ossifying fibroma in the maxillary anterior region of a 13 year old girl.Case Presentation: The patient presented with a gingival lesion in the maxillary left anterior region of the mouth since 2 weeks. Following thorough full mouth scaling, an excisional biopsy was done and the specimen was sent for histopathological examination. Healing of the surgical site was uneventful. Based on the clinical and histopathological findings a final diagnosis of peripheral ossifying fibroma was made.Conclusion: The diagnosis warrants for frequent recall interval for monitoring recurrence. This report highlights the importance of definitive diagnosis in order to provide appropriate treatment.
      PubDate: 2014-03-28
      Issue No: Vol. 2 (2014)
  • Extra-abdominal breast fibromatosis: A rare breast pathology in medical

    • Authors: Mehmet Yildirim, Nükhet Eliyatkın, Hakan Postaci, Nazif Erkan
      Abstract: Fibromatosis is a rare entity of the breast. Ultrasound and mammography are not helpful for diagnosis. The ideal treatment is complete excision of the mass with clear margins.
      PubDate: 2014-03-27
      Issue No: Vol. 2 (2014)
  • Sarcomatoid lung cancer: a rare, aggressive form of non-small cell lung
           cancer with an initially indolent presentation in one of the youngest
           documented patients

    • Authors: Arpan Patel, Joshi Sumendra, Dinesh Ananthan, Hayas Haseer Koya
      Abstract: Background: Sarcomatoid lung cancer is a very infrequent form of aggressive non-small cell lung cancer accounting for less than 1 percent of all lung cancers. Due to its rarity, no set standard of treatment has been devised. This cancer has a median age of diagnosis around 60. Our patient is the youngest documented case of sarcomatoid carcinoma.Case Presentation: A 31-year-old African American male with a history of HIV, CD4 of 25 came in for evaluation of anemia and chronic dry cough. Upon initial workup he had a left lower lung mass on chest x-ray. Follow-up CT scan confirmed 6 x 3.4 cm mass next to the left ventricle of the heart, another mass posterior to the LV (8.5 cm) and a third one in the lingula (5 cm). Brain MRI did now show any metastatic lesions. The lingulal mass was biopsied and was shown to be pleomorphic type of sarcomatoid cancer. Reimaging two weeks later showed an increase in size of all lesions and direct extension into the upper abdomen, diaphragm, pericardium and liver metastasis. The patient was seen a month later for palliative radiation to the left lower lung.Conclusion: This case serves illustration of the aggressive nature of sarcomatoid lung cancers and rapid progression. Due to rarity and chemo-resistant nature of this histology of lung cancer, standard of care is not established. Patient in discussion underwent palliative radiotherapy of his left lung, though due to significant decline in performance status and pulmonary decomposition he chose to undergo comfort measures and subsequently died shortly after.
      PubDate: 2014-03-27
      Issue No: Vol. 2 (2014)
  • Therapeutic spectrum of diuretics in different diseases

    • Authors: Muhammad Majid Aziz, Ikram Ur Rehman, Muhammad Wajid, Muhammad Ali Raza, Javed Ahmad
      Abstract: Diuretics have major role in numerous disorders such as congestive heart failure, nephrosis, respiratory acidosis and in hypertension. Diuretics not only decrease the severity of the disease, but also cure the disease. This essay highlights some of their uses
      PubDate: 2014-03-27
      Issue No: Vol. 2 (2014)
  • Stem cells from gynecological tissue: Trash to treasure

    • Authors: S Indumathi, B Padmanav, D Sudarsanam, B Ramesh, M Dhanasekaran
      Abstract: Stem cell research has opened new avenues for developing therapeutic options for targeting disease as well to understand the underlying principles of several pathological conditions when these stem cells go awry. This has increased the quest for identifying ideal stem cells and their role in regeneration. The gynecological redundant sources such as endometrium and fallopian tube seem to have been neglected as a source of stem cell for therapeutic application. The present essay unravels the potency of stem cells derived from these sources, thereby bringing into light their therapeutic application from trash to a treasure. With their immense potency, these stem cells can also be banked for off-the-shelf allogeneic stem cell therapy.
      PubDate: 2014-03-27
      Issue No: Vol. 2 (2014)
  • Evolutionary context of hypertensive disorders in human pregnancy

    • Authors: Abhay Kumar Pandey, Anjali Rani, Shripad B Deshpande, B L Pandey
      Abstract: The erect posture and bipedalism in humans has evolved at cost of compromise of abilities in meeting some challenging demands of physiology. Counter adaptive mechanisms have emerged and keen understanding of their pliability is crucial to health and management of disease. Several features of human placenta are distinctive in providing advantage for uteroplacental blood supply. The depth and extent of rooting of fetal trophoblastic cells in the maternal tissues and timing of implantation are particularly of scientific interest. Stressors upon such system and their impact at molecular level constitute risk for unique diseases of human pregnancy, the hypertension and preeclampsia. The study of such mechanisms is crucial to advance diagnostic and therapeutic strategies, and calls for very natural experimentation. Reproduction at high altitude implies particular stress and strain on mechanisms toward ensuring high uteroplacental blood flow for feto-maternal wellbeing. The context deserves intense examination toward medical advance in dreaded disease of pregnancy-induced hypertension and preeclampsia.
      PubDate: 2014-03-27
      Issue No: Vol. 2 (2014)
  • Antidepressants in the management of bipolar depression - An appraisal

    • Authors: Siddharth Sarkar
      Abstract: The issue about whether and when to use antidepressants in bipolar depression is a clinical question that has generated a lot of passionate debate. There seems to be a discrepancy in the opinions of experts across the Atlantic Ocean about the pros and cons of using antidepressants for management of bipolar depression. This is amply reflected by the greater volume of discussion and opinion related scientific literature, rather than hardcore clinical data in the form of randomized controlled trials. The debate as of present exists with no final winner still as the use of antidepressants in bipolar depression has both pros and cons. This essay attempts to offer evidence to either of the viewpoints and offer some suggestions based on literature.
      PubDate: 2014-03-27
      Issue No: Vol. 2 (2014)
  • Rectopopliteal fecal fistula developed through an intra-abdominal adhesion

    • Authors: Mustafa Emiroglu, Ismail Sert, Abdullah Inal, Cem Karaali, Cengiz Aydın
      Abstract: Background: A number of etiological factors may result in an enterocutaneous fistula formation. Some fistulas may drain from long and unexpected tracts.Case Presentation: A 58-year-old female patient who had undergone radical cystectomy with ileal pouch reconstruction surgery two years earlier for urinary bladder carcinoma was admitted for septic clinical condition and a rectopopliteal fecal fistula formation. Patient was improved with a diversion surgery with Hartmann closure and proper wound care. This case is unique by being the sole enterocutaneous fistula which is developed through an intra-abdominal adhesion. Rectopopliteal enteroatmospheric fistulas are rare clinical conditions.Conclusion: Enterocutaneous fistulas may complicate any intra-abdominal condition, especially in comorbid patients who have had a major abdominal surgery. A septic clinical presentation with erythema and subcutaneous emphysema is suggestive of enteric fistula formation. 
      PubDate: 2014-03-27
      Issue No: Vol. 2 (2014)
  • Phocomelia – A case study

    • Authors: Soniya B Parchake, Nilesh Keshav Tumram, A P Kasote, M M Meshram, Pradeep G Dixit
      Abstract: Background: Phocomelia syndrome is a rare birth defect especially of the upper limbs. The bones of the upper arm and in some cases other appendages may be extremely shortened and even absent. In rare cases, there is absence of the upper bones of both the arms and legs so that the hands and feet appear attached directly to the body. Here we present a rare case of phocomelia.Case Presentation: A newly born female infant was brought to the orphanage in our city in very weak condition. She had pansystolic murmur in parasternal region and was diagnosed with ventricular septal defect. Both upper limbs showed single forearm with rudimentary phalyngeal bones. Lower limbs shows rudimentary phalyngeal bones with long femur, spine normal. The child did not survive and died shortly after presentation. Autopsy was done within 24 hours of the death of the female infant, and no significant abnormality other than rudimentary upper and lower limbs was noted. Evidence of bronchopneumonia was observed in both lungs. Cause of death was attributed to bronchopneumonia.Conclusion: The present case had only deformity of the upper and lower limbs with acyanotic heart disease with small muscular ventricular septal defect. The case highlights the morphological defect in such individuals and challenges that may exist due to the neglect of such a child by their parents and the need for special care for such individuals having congenital defects if they survives.
      PubDate: 2014-03-26
      Issue No: Vol. 2 (2014)
  • Anesthetic considerations and implications for non-cardiac surgery in a
           patient presenting with aorto-occlusive disease

    • Authors: Teena Bansal, Manish Bansal, Sarla Hooda
      Abstract: Patients with peripheral vascular disease continue to challenge anesthesiologists as these patients often have associated coronary artery disease. There is always a danger of myocardial ischemia and cardiac morbidity both intra-operatively and postoperatively in this group of patients. Here we report a patient posted for emergency laparotomy for intestinal obstruction presenting with aorto-occlusive disease.
      PubDate: 2014-03-25
      Issue No: Vol. 2 (2014)
  • Plasma myeloperoxidase enzyme assay in cases of neonatal sepsis

    • Authors: Eman Abdel Ghany, Hannah Abul Ghar, Eslam Madbooly, Rania Mohamed Samy
      Abstract: Background: Myeloperoxidase (MPO) is a heme enzyme of azurophilic granules in neutrophils that has a strong oxidative activity. MPO has been demonstrated to be a major pathway for O2-dependent microbicidal activity.Methods: This study was conducted on 84 neonates. 41 with culture proven sepsis and 43 healthy neonates who served as control. Complete blood count, C-reactive protein quantitative assay and blood gases were done in cases group, MPO enzyme level measured by ELISA was done and compared in both groups.Results: MPO enzyme level was statistically higher in case group compared to control group (P-value < 0.001). There was no statistically significant difference in whether the infected were pre-term or full term. MPO enzyme levels were statistically higher in cases with sepsis without septic shock compared to cases with septic shock (P-value < 0.001). MPO level showed positive correlations with total leukocyte count and absolute neutrophil count. MPO assay (using the cutoff value of 146.5 ng/ml) had a sensitivity of 80% and specificity of 83.9% with a positive predictive value of 92.9%, negative predictive value of 61.5% and accuracy of 82.9%.Conclusion: MPO enzyme level increases significantly in neonates with sepsis. MPO assay is not affected by gestational age but can be affected by deterioration to septic shock. Early diagnosis of sepsis cannot rely on a single laboratory test and clinical decision remains to have the upper hand in diagnosis.
      PubDate: 2014-02-28
      Issue No: Vol. 2 (2014)
  • Adverse neonatal and maternal outcomes in Pakistani tertiary care
           hospitals: A prospective, observational study

    • Authors: Sarah Saleem, Elizabeth M McClure, Janet Moore, Samina Iqbal, Syed Hasan Ala, Fariha Khawaja, Omrana Pasha, Robert L Goldenberg
      Abstract: Background: Neonatal and maternal death rates remain high in low-income countries, with little improvement with increasing facility births. We sought to examine risks for neonatal mortality/morbidity among low-risk hospital deliveries in a low-resource setting.Methods: Deliveries at tertiary hospitals in Karachi, Pakistan from 2005-2008 were prospectively enrolled with follow-up to 42 days postpartum.Results: Of 5,008 women enrolled, 98% were followed 28 days post-delivery. 4.3% of infants had severe illness or neonatal death. 28-day neonatal mortality rate was 19.1/1,000 births. Newborn death/severe illness was associated with being unbooked, low birth weight, newborn intensive care, and lack of cord/neonatal skin cleansing and hand-washing before handling the baby.Conclusion: Although most were low-risk and all were hospital deliveries, maternal and perinatal morbidity and mortality rates were high. Lack of cord care and maternal hand washing was significantly associated with adverse outcomes. Results suggest that in addition to improving hospital care, simple interventions such as hand-washing may reduce maternal and newborn morbidities. 
      PubDate: 2014-02-27
      Issue No: Vol. 2 (2014)
  • The expression of scavenger receptor B2 in enterovirus 71-infected mice

    • Authors: Jian Li, Zongbo Chen
      Abstract: Background: Scavenger receptor class B, member 2 (SCARB2) participates in early innate immune responses to infection. Our aim in this study was to explore the expression and role of mouse SCARB2 (mSCARB2) in different tissues in EV71-infected mice.Methods: ICR mice were inoculated intraperitoneally (i.p.) with EV71 0.1 ml 107.5 TCID50 /ml. The control mice were injected i.p. with the same volume RD cell lysate. Mice were sacrificed by aether anesthesia at day 4, 8 and 12 post infection (p.i.). Their brain, brainstem, spinal cord, cerebellum, lung and heart were dissected out for determining the number of copies of viral RNA by quantitative real-time PCR (qRT-PCR). Detection of expression of mSCARB2 was performed by immunohistochemistry, qRT-PCR and Western-blotting. Cytokines quantification was done by ELISA.Results: The viral loads in central nervous system (CNS) were higher than in lung or/and heart. The expression of mSCARB2 increased in tissues of EV71-infected mice. However, the levels of mSCARB2 increased in CNS were higher than in lung or/and heart within a certain period of time, particularly in brain stem and brain. In addition, local TNF-α, IL-6 and IL-1β levels of production were consistent with mSCARB2 levels of expression in tissues of EV71-infected mice. However, it presented a positive correlation between relative mSCARB2 mRNA level and TNF-α, IL-6 and IL-1β levels in local tissues at day 4 and 8 p.i.Conclusion: Our data revealed that the elevated local mSCARB2 may modulate pro-inflammatory cytokines induction in local tissues, particularly, in CNS of EV71-infected mice.
      PubDate: 2014-02-24
      Issue No: Vol. 2 (2014)
  • Dorsal hippocampus histaminergic and septum GABAergic neurons work in
           anxiety related behavior: Comparison between GABAA and GABAB receptors

    • Authors: Leila Chodari, Shahrbanoo Oryan, Ramesh Ahmadi, Ghorbangol Ashabi
      Abstract: Background: Integration of septum and hippocampus has an important role in anxiety modulation and inhibition. Our previous studies indicated that GABAergic system blockade in the medial septum (MS) attenuates anxiety-like behavior. Herein, we aimed to investigate the histaminergic and GABAergic associations between dorsal hippocampus and MS, respectively. Moreover, the present study compares the power of two kinds GABA receptors, GABAA and GABAB receptors, in MS in anxiety related behavior of male rats.Methods: In the present study we investigated the intrahippocampal CA1 (intra-CA1) microinjection of histamine and intra-septal GABAergic agents on anxiety-related behavior in rats, using elevated plus-maze test of anxiety.Results: Intra-CA1 administration of histamine increased open arm time (%OAT) and open arm entry (%OAE). Intra-septal administration of the GABAA agonist muscimol (10 ng/rat) increased %OAE and %OAT but not locomotor activity. Administration of muscimol (2.5 and 5 ng/rat) had no effect on anxiety, while co-administration of sub-effective dose of histamine (1 µg/rat) into CA1 and sub-effective dose of muscimol (2.5ng/rat) into medial septum area increased %OAE and %OAT. Administration of GABAA receptor antagonist confirmed GABAA function in the medial septum. In contrast, injection of GABAB receptor agonist decreased OAT and OAE percentage. Microinjection of GABAB receptor antagonist revealed that this GABA receptor increased the anxiety in the rats by a different mechanism.Conclusion: The effect of histamine on anxiety in CA1 may be modulating through septal GABAergic system and GABAA receptor is involved in the process
      PubDate: 2014-02-22
      Issue No: Vol. 2 (2014)
  • Examination of bone marrow mesenchymal stem cells seeded onto
           poly(3-hydroxybutyrate-co-3-hydroxybutyrate) biological materials for
           myocardial patch

    • Authors: Junsheng Mu, Hongxing Niu, Fan Zhou, Jianqun Zhang, Ping Hu, Ping Bo, Yan Wang
      Abstract: Background: The implantation of bone marrow mesenchymal stem cells (BMSCs) into the heart has been reported to be effective for myocardial infarction. However, it is unknown as to what methods are most suitable for supporting stem cell growth in a myocardial patch. We used a new polymer material composed of poly(3-hydroxybutyrate-co-3-hydroxybutyrate) [P(3HB-co-3HB)] co-cultured with BMSCs to create a myocardial patch.Methods: BMSCs were obtained from healthy male BSL-C57 mice. The cells were treated with 5-azacytidine to investigate their differentiation into cardiomyocytes. The cells were seeded for 24-hours onto P(3HB-co-3HB) biological material films (n=8). Cell-biomaterial constructs were fixed and analyzed using different methods. BMSCs were CD34-, CD45-, CD90+ (low) and CD73+. The cells were stained with anti-cardiac troponin T (cTnT) and anti-connexin 43 (CX43) antibodies after 5-azacytidine treatment.Results: Scanning electron microscopy showed that BMSC morphology was normal and cell numbers were more abundant on the P(3HB-co-3HB) material surfaces. The growth curve of BMSCs on the biomaterial patches showed the P(3HB-co-3HB) material permitted good stem cell growth.Conclusion: Owing to its excellent biocompatibility and biodegradability properties, in particular its porosity, P(3HB-co-3HB) is highlighted as an optimal material to support myocardial cell growth and myocardial patch formation in patients with myocardial infarction.
      PubDate: 2014-02-21
      Issue No: Vol. 2 (2014)
  • A dermatological approach to the feet of soccer players

    • Authors: Asli Feride Kaptanoğlu, Hasan Ulaş Yavuz, Kaya Süer
      Abstract: Background: Soccer is a sport in which the feet are very susceptible to injuries and dermatological diseases. Present literature does not have much data about the possible dermatologic conditions occurring in soccer players and the associated factors. Therefore, the aim of this study was to evaluate the dermatologic foot problems and associated factors in soccer players.Findings: We evaluated forty young soccer players and recorded dermatologic conditions localized to their feet. The skin and nail lesions were recorded by the site of occurrence, symmetry and diagnosis. Further mycological, bacteriological or other screening tests were done to clarify the diagnosis. Diagnoses were classified into 4 groups: bacterial infections, fungal infections, dermatoses and traumatic lesions. Associated factors were also evaluated in detail. The results of our study revealed that there were at least two dermatological problem in the feet of soccer players and the commonest problems were foot odor, fungal infections and traumatic lesions, respectively.Conclusion: As dermatological foot lesions are common in soccer players, regular evaluation of soccer players’ feet should be essential so as to identify skin problem, to treat them early and effectively in order to avoid deficits in performance.
      PubDate: 2014-02-13
      Issue No: Vol. 2 (2014)
  • Comparison of squash smears and frozen sections versus paraffin sections
           in the intra-operative diagnosis of central nervous system lesions

    • Authors: Hephzibah Rani, Padmaja Kulkarni, Udupi Shastry Dinesh, Sateesh Melkundi
      Abstract: Background: Utility of squash cytology is well established in the intra-operative diagnosis of brain tumors, thereby guiding the neurosurgeon in the surgical management. A comparative study between squash smears, frozen sections and paraffin sections was done with an aim to study the diagnostic accuracy as well as limitations of these techniques. The present study was also undertaken to evaluate the discordant cases in intraoperative consultation of central nervous system (CNS) lesions.Methods: A total of 221 neurosurgical specimens were received in the Department of Pathology over three years duration, of which intra-operative consultation was requested in 110 cases. Both frozen and squash preparation was performed on all cases and stained with hematoxylin and eosin. An intra-operative diagnosis was made after examination of the squash smears and frozen section slides. The diagnosis given on squash smears and frozen section were then compared with final diagnosis given on paraffin-embedded sections. Immunohistochemistry was performed in a few diagnostically challenging cases.Results: This study compares the diagnostic accuracy of squash smears and frozen sections from 110 surgical specimens. The 110 cases included thirty six astrocytomas (32.7%), twenty four meningiomas (21.8%), twelve schwannomas (10.9%), two hematolymphoid tumors (1.8%), eight medulloblastomas (7.3%), three oligodendrogliomas (2.7%), four pituitary adenomas (3.6%), four ependymomas (3.6%), four metastatic tumors (3.6%), one paraganglioma (0.9%), two pineal parenchymal tumors (1.8%) and ten infections (9.1%). The accuracy of squash smears was 93.6%, and when combined with frozen sections the accuracy increased to 97.3%.Conclusion: Squash smears are simple, rapid, economical and very effective tool in the diagnosis of brain tumors. However, in few matrix rich/fibrous tumors like meningiomas and schwannomas, frozen sections are more useful.  Hence, overall the combined use of squash smear and frozen section study increases the intra-operative diagnostic accuracy of CNS lesions.
      PubDate: 2014-02-12
      Issue No: Vol. 2 (2014)
  • Comparison of linear, logarithmic and mel-frequency filter-bank energy
           cepstra in automatic seizure detection using radial basis function neural

    • Authors: Chandrakar Kamath
      Abstract: Background: Epilepsy is a neurological disorder affecting a very large number of people worldwide. A large fraction of the epilepsy patients have poorly controlled epilepsy. The conventional method relies on experienced neurophysiologists, who visually examine the continuous long-term inpatient/ambulatory electroencephalogram (EEG) signal. This is a tedious and time-consuming, and not a cost effective procedure. Several automated epileptic detection and classification systems have been proposed and such systems facilitate the neurologist to diagnose and treat more patients in a given time. There are not many studies that have explored to an adequate depth the features used in other areas of signal processing, for example, the seldom used feature such as filter-bank energy cepstrum (FBE-CEP), being tried for seizure detection.Methods: Epileptic seizures are abnormal transient recurrent discharges in the brain with signatures manifesting in the EEG recordings by frequency changes and increased amplitudes. We employed static and dynamic features derived from FBE-CEP to capture these changes in amplitude and frequency. We compared the diagnostic performance of the linear, logarithmic, and mel-frequency, baseline FBE-CEP and its two composite vectors in epileptic seizure detection on a standard publicly available EEG database. The comparison was tried on eight different classification problems in the medical field related to epilepsy, using radial basis function neural network.Results: All the three FBE-CEP methods, irrespective of frequency scaling, showed excellent overall performance.Conclusion: The static and dynamic features derived from FBE-CEPs outperform those derived from CEP, suggesting their suitability in epilepsy seizure detection.
      PubDate: 2014-02-03
      Issue No: Vol. 2 (2014)
  • Evaluation of foramen magnum in sex determination from human crania by
           using discriminant function analysis

    • Authors: Deepali Jain, O P Jasuja, Surinder Nath
      Abstract: Background: Many studies have been conducted on different populations on sexual dimorphism with respect to the cranial base. The present research was undertaken to study the accuracy and reliability of the foramen magnum in sex determination by using discriminant function analysis.Methods: 140 adult skulls (70 of either sex) were included in the study. Length, breadth index and area of foramen magnum were subjected to discriminant function analysis.Results: The accuracy of sex classification was up to 75.7% using a single variable. The least value was obtained from the index of the foramen magnum i.e. 57.9%. Three discriminant function equations were calculated based on these measurements. In stepwise analysis, breadth of foramen magnum was found to be more discriminating variable providing an accuracy of 75.7%.Conclusion: It can be concluded from the results that the measurements of foramen magnum of cranium provides valuable results and suitable for sex determination when other methods are inconclusive.
      PubDate: 2014-02-02
      Issue No: Vol. 2 (2014)
  • Mineral content analysis and investigation of antimicrobial activities of
           Evolvulus alsinoides (L.) L. against clinical pathogens

    • Authors: Duraisamy Gomathi, Manokaran Kalaiselvi, Ganesan Ravikumar, Kanakasabapathi Devaki, Chandrasekar Uma
      Abstract: Background: Medicinal plants are the richest bio-resource of drugs of traditional systems of medicine, modern medicines, nutraceuticals, food supplements, folk medicines, pharmaceutical intermediates and chemical entities for synthetic drugs. Use of herbal products as antimicrobial agents may provide the best alternative to the wide and injudicious use of synthetic antibiotics. Trace elements play a vital role in the medical value of plants as curative and preventive agents in combating disease, nutritive and catalytic disorders. The aim of the study was to investigate the trace element analysis by energy-dispersive x-ray spectrometer (EDX) and antimicrobial activity of ethanolic extract of Evolvulus alsinoides.Methods: Elemental analysis of Evolvulus alsinoides whole plant sample was done by using scanning electron microscope (SEM) with an EDX and for the antimicrobial activity was done by using standard procedures.Results: Our results showed the presence of carbon, oxygen, chloride, potassium and calcium in whole plant material of Evolvulus alsinoides. The ethanolic extract of plant material showed significant antibacterial activity against Bacillus, Pseudomonas, Proteus, Klebsiella, Streptococcus, Staphylococcus and Escherichia coli and also showed the good antifungal activity against all the fungi (Aspergillus flavus, Candida albicans, Candida tropicans, Rhizopus and Fuserium) tested.Conclusion: The data obtained in elemental analysis and antimicrobial activity of this plant indicates the promising potential in the treatment of various diseases as a medicine
      PubDate: 2014-02-02
      Issue No: Vol. 2 (2014)
  • Comparative effect of antiplatelet drugs in streptozotocin-induced
           diabetic nephropathy in experimental rats

    • Authors: Taruna Katyal, Jitender Negi, Monika Sachdeva, R D Budhiraja
      Abstract: Background: Platelets have been reported to play a role in the progression and development of diabetic nephropathy (DN). The present study has been designed to investigate the comparative effect of some antiplatelet drugs in streptozotocin (STZ) induced nephropathy in rats.Methods: Diabetic nephropathy was induced by administering single dose of streptozotocin in wistar rats. DN was clinically assessed by estimation of various biochemical parameters and histopathological studies of renal tissue. DN was assessed by measuring serum creatinine, blood urea nitrogen, proteinuria, renal cortical collagen content, lipid profile, serum nitrite/nitrate ratio, renal TBARS, reduced glutathione levels.Results: Administration of these antiplatelet drugs (aspirin, dipyridamole, cilostazol) did not treat the diabetic induced nephropathy, but did retard the progression of the disease to a great extent. Treatment with high dose of cilostazol (25mg/kg, i.p.) shows significant improvement in (BUN, serum creatinine, total urine protein, ratio of kidney wt/body wt, TBARS, reduced glutathione) renal parameters studied for DN.Conclusion: It may be therefore concluded that renoprotective effect of cilostazol is due to its antiplatelet property and through the inhibition of various intracellular pathways.
      PubDate: 2014-02-01
      Issue No: Vol. 2 (2014)
  • Pre-treatment evaluation: Setting a foundation in the management of
           drug-resistant tuberculosis

    • Authors: Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava, Jegadeesh Ramasamy
      Abstract: The emergence of resistance to the first-line anti-tuberculosis (TB) drugs has posed a significant threat to the global mission of reducing the magnitude of TB. Considering the life-threatening nature of the multidrug-resistant TB (MDR-TB), in addition to the poor cure rate/success rate, high default rate/ incidence of complications and the potential risk of transmission of the disease to a susceptible contact, early diagnosis and initiation of the patient on second-line anti-TB drugs is of prime public health importance. The first step in ensuring a good outcome is to initiate the MDR-TB treatment regimen based on the pre-treatment evaluation (PTE) done at the drug resistant TB center by an expert committee. PTE is the crucial foundation in ensuring a favorable outcome to the treatment of drug-resistant forms of TB, as a good PTE can detect and avert the possible drug induced adverse effects at the earliest.
      PubDate: 2014-01-25
      Issue No: Vol. 2 (2014)
  • Organophosphate poisoning presenting as bradycardia

    • Authors: Hari Krishan Aggarwal, Deepak Jain, Shivraj Goyal, Shaveta Dahiya, Ashima Mittal
      Abstract: Organophosphate poisoning is very common in India. Its presentations are very vivid. Here we present a case of organophosphate poisoning in a young male with only bradycardia as sole manifestation of poisoning.
      PubDate: 2014-01-25
      Issue No: Vol. 2 (2014)
  • Ileoileal intussusception in a young adult secondary to a mucinous

    • Authors: Archana Shetty, Mudasser Rehan, Chowdappa Vijaya
      Abstract: Background: Intestinal intussusceptions represent a rare cause of intestinal obstruction in adults, with the most frequent localization being the ileocecal region. The initial diagnosis is often missed or delayed as the presentation is non-specific.Case Presentation: A 23 year young female presented to our surgical OPD with 5 days history of colicky pain in the right lower abdominal quadrant, aggravated by food intake and associated with vomiting. Emergency midline laparotomy was performed, and it revealed ileoileal intussusception for which segmental ileal resection was done with end to end anastomosis.Conclusion: In adults, majority of the intussusceptions are secondary to an underlying pathology, with approximately 65% due to malignant or benign neoplasms. The incidence of malignancy is particularly high with colonic intussusceptions
      PubDate: 2014-01-23
      Issue No: Vol. 2 (2014)
  • Bilateral mucoepidermoid carcinoma of parotid

    • Authors: Mayank Baid, Vikram Chaturvedi, Jayesh Jha
      Abstract: Background: Mucoepidermoid carcinoma (MEC) is the most common malignant neoplasm of parotid. Bilateral mucoepidermoid carcinoma is extremely rare. We report here a case of synchronous bilateral mucoepidermoid carcinoma of parotid.Case Presentation: A 65 years old female presented at the outpatient department of our surgical oncology unit with bilateral swelling in the parotid region for 1 year with sudden increase in the size of left sided swelling for 3 months. She underwent left sided radical parotidectomy with excision of left facial, hypoglossal and spinal accessory nerve en-block with the tumor and modified neck dissection followed by cervical flap coverage. On the right side, facial nerve preserving superficial parotidectomy was done. Histopathology revealed it to be high grade MEC and patient received adjuvant radiotherapy. At 1 year follow up she has no evidence of recurrence or metastasis.Conclusion: Bilateral mucoepidermoid carcinoma is a rare tumor of the parotid for which, surgery forms the mainstay of therapy, although postoperative radiation is thought to be effective. Radiation is reserved for primary treatment of malignant tumors in patient who are poor surgical candidates, or who do not want to undergo surgery.
      PubDate: 2014-01-23
      Issue No: Vol. 2 (2014)
  • Unusual presentation of a case of fallopian tube carcinoma

    • Authors: Latika Sahu, Gouri Gandhi, Krishna Agarwal, Sunita Dubey, Preeti Yadav, Richa Gupta
      Abstract: Background: Primary fallopian tube carcinoma (PFTC) accounts only for <1% of all female genital cancers. The diagnosis of PFTC is rarely considered preoperatively and is usually first appreciated at the time of operation or by a pathologist.Case Presentation: Here we are presenting a case report of 45 years old lady with fallopian tube carcinoma, who presented to us with features of advanced ovarian malignancy. FNAC from tumor showed epithelial malignancy and she received neo-adjuvant chemotherapy followed by staging laparotomy and interval debulking surgery. She developed a non-healing ulcer at FNAC site which was excised during laparotomy. On laparotomy, 200cc ascitic fluid was drained. Uterus, right ovary and tube appeared normal. Left side tube showed growth of 3cm x 2cm. Total abdominal hysterectomy, bilateral salpingo-oophorectomy and infracolic omentectomy was done. Histopathological examination revealed left side poorly differentiated primary fallopian tube carcinoma. Uterus and right tube with ovary were free of tumor. She was advised to get 3 cycle of chemotherapy postoperatively.Conclusion: In our patient, FNAC gave a positive diagnosis of malignancy and we were able to operate her malignancy properly following chemotherapy.
      PubDate: 2014-01-23
      Issue No: Vol. 2 (2014)
  • Bilateral granulomatous mastitis after local nandrolone injection

    • Authors: Sadaf Alipour, Akram Seifollahi
      Abstract: Background: Granulomatous mastitis is a rare inflammatory disease of the breast. Several theories have been postulated for the etiology of the disease.Methods: In the present article, a case of bilateral granulomatous mastitis after intramammary injections of nandrolone decanoate in a 32 years woman is introduced. The clinical and radiologic pictures are presented. Pathogenesis, presentation, diagnosis, imaging, histopathology and treatment of granulomatous mastitis as available in the present literature are briefly discussed.Conclusion: The present case is in favor of a positive association between granulomatous mastitis and the anabolic steroid. This new topic warrants further studies.
      PubDate: 2014-01-23
      Issue No: Vol. 2 (2014)
  • Pattern of deliveries during three calendar years in rural India

    • Authors: Rajiv Mahendru, Sunita Siwach, Richa Kansal, Vijayata Sangwan, Ritika Kaur, Pooja Gupta
      Abstract: Background: Seasonal variation of various obstetric events has been reported by certain studies. The objective of this study was to understand the delivery pattern during the calendar months in rural India.Findings: The study was carried in a retrospective manner by collecting month-wise delivery data for three calendar years from registration center in a rural area of Ambala District of Haryana Province (India). This included deliveries occurring after viable period of 28 weeks gestation conducted in (i) a teaching Institute; (ii) government set-up hospital; and (iii) domiciliary environment of that particular area. During the study period, 43,191 deliveries were recorded with an average monthly rate of 1,199 births. Sinusoidal pattern was observed in the monthly distribution of deliveries peaking during August-October and decline in January and April-May. There was a statistically significant difference between the highest and lowest rates.Conclusion: Results of this study may be beneficial in health system planning and in the interpretations of seasonal variations in other reproductive parameters.
      PubDate: 2014-01-23
      Issue No: Vol. 2 (2014)
  • Do socioeconomic inequalities lead to deceptive measurement of obstetric
           morbidity in India'

    • Authors: Kshipra Jain, Mayank Prakash
      Abstract: Background: The extent of maternal mortality is an indicator of disparity and inequity in access to appropriate health care and nutrition services throughout a lifetime, and particularly during pregnancy and childbirth. According to WHO (2005), 99% of maternal deaths occur in developing countries. Three quarters of maternal mortalities result from the direct obstetric complications. However, the ambiguity and variability in existing literature on the magnitude of socio-economic inequality in obstetric morbidity is leading to complexity for priority setting in health policy. The present study aims at assessing how far self-reported obstetric morbidity misleads measurement of socio-economic inequalities in India and to assess whether refined inequality measures can help to overcome this problem.Methods: The study has used data from the most recent round of National Family Health Survey (NFHS-3). We have used concentration indices to access the socio-economic inequalities in self-reported obstetric morbidity and later implied regression based decomposition analysis to find out the contributions of socio-economic predictor.Results: Findings reveal that self-reporting obstetric morbidity survey data is potentially misleading in measuring socio-economic differentials with simple bivariate analysis as greater number of obstetric complications persists in socio-economically advantaged groups which may be not true in reality. However, application of sophisticated regression based decomposition analysis demonstrates that, to some extent, we can overcome the problem of measuring socio-economic inequality, as decomposition analysis shows incidence of obstetric complication are greater among disadvantaged groups.Conclusion: Primarily, the inequalities arise from poverty, education and residing in rural areas. However, the contribution of education to the incidence of obstetric morbidity is negative. This could be because of differences in the educational level of women that potentially affects their awareness and understanding about obstetric complications. The findings thus suggest that education is a key determinant of bias in self-reporting obstetric morbidity. Finally, we conclude that logical explanations of the results are needed when we infer these results for health policy interventions, as decomposition analysis has also failed to overcome the problem of self-reporting morbidities among illiterate women.
      PubDate: 2014-01-11
      Issue No: Vol. 2 (2014)
  • Medical students' perception about teaching-learning and academic
           performance at Nobel Medical College, Biratnagar, Nepal

    • Authors: Mukhtar Ansari, Attique ur Rahman Mufti, Salman Khan
      Abstract: Background: Effective teaching-learning is an important prerequisite for academic excellence. The study was aimed at determining students’ perception about the effectiveness of teaching-learning methods and improving the academic performance.Methods: This cross-sectional study was carried out among 385 medical students of Nobel Medical College, Biratnagar, Nepal during February and March, 2012. The instrument used was a self-administered pretested questionnaire containing both closed and open ended questions. The questionnaire was distributed among the students and their responses were collected and entered in SPSS 11.5 for windows (Chicago Inc) for analyses.Results: Nearly two third (64%) of the students were male and majority (61%) of the students were from three zones such as Bagmati, Koshi and Janakpur of Nepal. Small group interactive discussions (64%), Problem Based Learning classes (65%) and use of multimedia were found the most effective approaches for improving the academic performance. Burden of multi-subjects (53.5%), lack of seriousness (28%), irregular study habit (17.4%) and fears of examinations (85%) were found the major causes of students’ poor performance in examinations. There were statistically significant association between gender and fortnightly class test as a factor for improving academic performance (p<0.001), use of transparency projector and power point projector as important means of teaching methods (p=0.010, 0.009) and studying many subjects as a reason for poor performance (p=0.030).Conclusion: Multimedia combined with Problem Based Learning and small group interactive discussions were found the most efficient approaches for better academic performance.
      PubDate: 2014-01-10
      Issue No: Vol. 2 (2014)
  • Incidental gallbladder carcinoma in laparoscopic cholecystectomy: five
           years local experience

    • Authors: Wagih Mommtaz Ghnnam, Turki Maed Al Salem Elbeshry, Jaweed Rafiq Malek, Emad Shebl Emarra, Mohammed Eid Alzahrany, Ahmad Ali Alqarni, Ammar Ahmad Khattab
      Abstract: Background: Carcinoma of the gallbladder is the most common malignancy of the biliary tract. Most of the cases are diagnosed as an incidental case among patients undergoing cholecystectomy. The objectives of this study were to report the rate of incidental carcinoma of gallbladder in patients undergoing cholecystectomy and to study the demographic profile and prognosis of these patients in our locality.Methods: A retrospective study was carried out in our general hospital during 2007-2012. The hospital records and histopathology reports of 1982 patients who had undergone elective laparoscopic cholecystectomy were studied.Results: Out of 1982 cases of cholecystectomy, gallbladder cancer was detected in 10 (0.5%) cases and was more common in females (M:F ratio = 2:8) .The mean age of occurrence was 73.6 years. Most of the cases diagnosed, were at their early stages and only two of them were in pT3 pathological stage. Five of those patients survived to date with a mean follow up duration of 26 months.Conclusion: The rate of incidental carcinoma of gallbladder is 0.5% in our locality and nearly half of patients were early stage with acceptable five year survival rates. Routine postoperative histopathology of gall bladder is mandatory.
      PubDate: 2014-01-10
      Issue No: Vol. 2 (2014)
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