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   Table of Contents - Current issue
Coverpage
January-June 2022
Volume 8 | Issue 1
Page Nos. 1-93

Online since Friday, July 8, 2022

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EDITORIAL  

Pedestrian fatality: Price paid for zero individual travel carbon footprint!! p. 1
Angeline Neetha Radjou, Muthandavn Uthrapathy, S Sevel, G Sriramulu
DOI:10.4103/2455-3069.350137  
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INVITED REVIEW Top

Gender dysphoria in adults: Concept, critique, and controversies Highly accessed article p. 4
Abdul Faheem, Ilambaridhi Balasubramanian, Vikas Menon
DOI:10.4103/jcrsm.jcrsm_33_22  
Gender dysphoria (GD) is a condition where one feels distressed about one's assigned gender at birth. The construct has undergone successive revisions in understanding and terminology in contemporary classificatory systems. Currently, the terms “GD” and “gender incongruence” are used in the Diagnostic and Statistical Manual of Mental Disorders-5 and International Classification of Diseases-11, respectively. However, there continues to be a lack of clarity on terminologies used in describing related concepts. Sex is an inflexible categorical concept, whereas gender is a social construct. It is vital to understand and distinguish between sexual orientation and gender identity. Clarity in understanding and usage of these and other related terms in the field is central to addressing the issue of stigma faced by the members of the lesbian, gay, bisexual, transgender, queer, intersex, asexual+ (LGBTQIA+) community, an umbrella term used to denote individuals with nonconformative gender identity and orientation. Several clinical and ethical issues exist with diagnosing and managing GD such as optimal treatment of minors, fertility after gender affirming treatments, and dissatisfaction following gender reassignment. To clarify these issues and facilitate access to care for LGBTQIA+ individuals, the GD category has been retained in the classificatory systems despite activists calling for dropping the term from diagnostic manuals to minimize associated stigma. Other controversies in the area include inclusion of childhood GD diagnosis on the grounds of uncertainty of longitudinal trajectory of the clinical phenomenon and use of nonevidence-based, potentially harmful, treatments such as “conversion therapies.” There is a need to sensitize clinicians about these issues and mainstream them in the assessment and management of GD. Such an approach would aid development of culturally sensitive and evidence-based treatments for gender variance.
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REVIEW ARTICLE Top

Gut dysbiosis: A pathway to glucose dysregulation? p. 12
Yakubu Lawal
DOI:10.4103/jcrsm.jcrsm_48_21  
Various reports have emerged on the possible nature of the complex and dynamic cause-effect relationship between gut dysbiosis and abnormal glucose homeostasis. These reports have suggested or experimented with diverse therapeutic strategies to tackle gut dysbiosis and glucose intolerance caused thereof. This review is aimed at re-aligning reports of pathophysiology and treatment modalities of gut dysbiosis and suggesting focal points of future research that will fast-forward a more encompassing clinical applications in the management of glucose intolerance. Literature search was done using databases including Pubmed, Pubmed Central, Embase, and Google scholar. The search terms used were (“glucose intolerance” OR “glucose dysregulation” OR “diabetes” OR “dysglycemia” OR “prediabetes”) AND (“gut dysbiosis” OR “abnormal gut microbiota” OR “gut microbiota” OR “gut microflora” OR “abnormal gut microflora”). On Initial search, the titles and abstracts of 632 literatures returned were checked for relevance to the review topic. Subsequently, 88 literatures that fulfilled the set criteria were critically reviewed and relevant contents extracted for this review. In conclusion, the treatment of gut dysbiosis can help to ameliorate glucose intolerance. These treatments include prebiotics, probiotics, synbiotics, postbiotics, antibiotics, and even antidiabetics.
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ORIGINAL ARTICLES Top

Vitamin D levels among adults in a tertiary care hospital in Wayanad p. 20
Aiswarya Raj, Shreya Cherian, Shuba Srinivasan
DOI:10.4103/jcrsm.jcrsm_81_21  
Background: Vitamin D insufficiency affects nearly 50% of the population worldwide. Inadequate serum Vitamin D levels are associated with multiple conditions such as secondary hyperparathyroidism and increased fracture risk. Multiple studies carried out also showed a correlation between Vitamin D deficiency and occurrence of diabetes and hypertension (HTN) in these deficient individuals. This study aimed to determine the serum levels of Vitamin D among patients frequenting a tertiary care hospital in Wayanad and the associations with sunlight exposure, gender, dietary factors, and diabetes and HTN. Settings and Design: Cross-sectional study. Materials and Methods: Hundred patients were randomly selected from the outpatient department over 6 months and asked to fill up a questionnaire. Vitamin D analysis was done by Elecsys Vitamin D total assay. Statistical analysis used was IBM SPSS statistics for Windows, version 20.0: Association between continuous data was determined using t-test/Mann–Whitney test depending on normality of data and association between categorical variables was determined using Pearson's Chi-square test. Results: Fifty-seven percentage of patients had Vitamin D deficiency. Significantly lower values of Vitamin D were seen among women. Conclusions: The median Vitamin D levels in men were 22.785 ng/ml and 17.81 ng/ml in women. No association was established between >1 h of daily sunlight exposure, the prevalence of diabetes and HTN, and daily consumption of dairy products and Vitamin D deficiency.
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Assessment of risk-taking behavior, leadership effectiveness, intelligence, ability to handle stress in college-going students, and effect of self-control on these parameters p. 25
Mohita Singh, Sunil Sachdev, Amrita Singh
DOI:10.4103/jcrsm.jcrsm_92_21  
Background: Human intelligence is the intellectual prowess of humans, which is marked by high cognition, motivation, and self-awareness. Leadership is the art of motivating a group of people to achieve common goals. Risk-taking is conscious or nonconscious controlled behavior with perceived uncertainty about its outcome. The present study was designed to assess the risk-taking ability of an individual that is required to be a good leader along with intelligence, ability to handle stress, and the effect of self-control on these parameters. Materials and Methods: The study was performed in two phases. In the first phase, the subjects were asked to fill risk-taking questionnaire, and their leadership effectiveness and intelligence levels were assessed. Their basal level of stress parameters and Stroop test were assessed. A stressor was introduced and stress parameters, Stroop test were again assessed. In the second phase of the study, the subjects were asked to practice moderate-intensity physical activity for 15 days and its effect was seen on all the above parameters. Results: Statistically significant and nonsignificant differences were obtained on comparison between baseline and poststress values; and also between baseline and postexercise values in all the three groups namely high-risk takers, moderate risk-takers and nonrisk takers at different level of significance. Comparison between first phase and second phase of the study yielded significant and non-significant results. Conclusion: Self-control improves leadership effectiveness. Exercise helps reduce stress response that aids in better decision-making quality required for being a leader.
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Efficacy of periodic acid–Schiff stain in the diagnosis of onychomycosis – A cross-sectional study p. 32
Mohamed Salahudeen, Anita Ramdas, Arthi Elumalai, Kandasamy Ravichandran, Sheela Kuruvila
DOI:10.4103/jcrsm.jcrsm_3_22  
Background: Onychomycosis is the fungal infection of the nail which needs to be differentiated from other causes of dystrophic nails due to its long-term treatment. Direct microscopic examination with potassium hydroxide (KOH) mount along with fungal culture shows inconsistent sensitivity. Thus, there is a need of more accurate and efficient method to detect onychomycosis. Aims and Objectives: This study aims to compare periodic acid–Schiff (PAS) stain with KOH and nail fungal culture in the diagnosis of onychomycosis. Materials and Methods: This was a cross-sectional study conducted in the dermatology outpatient department of a tertiary care center in South India from July 2019 to July 2021. A total of 93 patients with clinical suspicion of onychomycosis were included in the study and evaluated for the following three methods: KOH mount, nail fungal culture, and PAS stain. Results: Of the 93 patients, PAS was positive in 82 (88%) cases, KOH mount was positive in 32 (34%) cases, and nail fungal culture showed positive results in 49 (53.2%) patients. The percentage of positivity of combined PAS and culture was 89 (95.7%) and combined KOH and culture was 63 (65.7%). The culture yielded growth in 49 patients showing dermatophytes in 2, yeasts in 35, and nondermatophyte molds (NDMs) in 12 specimens The most common isolated species was Candida tropicalis found in 11 (22.4%) followed by Candida species in 8 (16.3%), Candida albicans in 7 (14.2%), and Trichosporon species in 6 (12.2%) specimens. Among the NDMs, Fusarium oxysporum was the most isolated found in 5 (10.2%). Conclusion: The importance of this study is to highlight the utility of PAS stain in the diagnosis of onychomycosis which otherwise may be missed with KOH and culture. PAS can be performed as an additional test to KOH mount and nail fungal culture to close the diagnostic gap.
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Knowledge, attitude, and Practices of telemedicine among the health-care practitioners during COVID pandemic: A cross-sectional study p. 37
Mahalaxmi S Petimani, Nagapati P Bhat, P Preethishree, Prabhakar Adake
DOI:10.4103/jcrsm.jcrsm_59_21  
Introduction: COVID pandemic created a difficult situation for the medical fraternity. Many health-care practitioners achieved their work through telemedicine. For delivering better patient care, especially during the pandemic, the present study was conducted to assess the Knowledge, Attitude, and Practices (KAP) of telemedicine among healthcare practitioners of our institution. Materials and Methods: A prevalidated questionnaire form containing 13 questions on KAP of telemedicine was circulated to health-care practitioners through Google Form by snowball technique. A total of 96 responses were collected. Descriptive statistical method was applied and results are expressed in percentages. Results: Out of 96 responses, 61 (63.5%) were from men and 35 (36.5%) from women. About 63.5% of health-care practitioners were aware of the term telemedicine, 22.9% were aware but not practising, and 13.5% were aware and currently practising telemedicine. Regarding the mode of telemedicine, 42.7% preferred video calling (Skype/hangout/WhatsApp), followed by 27.1% personalized website (HODO/Healzapp), 17.7% by text message (SMS/Email/Fax), and 12.5% for an audio phone call. With respect to taking consent, 59.4% expressed that consent is required and 40.6% expressed that consent is implied when the patient initiates the call. Regarding challenges in telemedicine, 83.3% expressed that clinical examinations cannot be done, 76% for connectivity issues, 55.2% worried about patient safety, and 54.2% for medico-legal issues. 53.1% of health-care practitioners would like to charge the same fees for telemedicine, followed by 27.1% lower fees, 12.5% no fees, and 7.3% would like to charge higher fees than routine. Conclusion: Telemedicine is essential for patient care, especially during a pandemic. Hence, National Medical Commission should incorporate telemedicine modules in the undergraduate curriculum for better patient care.
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A randomized, open-label, multicentered parallel-group clinical study to evaluate the efficacy and safety of Joint Core™ compared to Jointace DN™ in osteoarthritis patients p. 44
Ramesh Kannan, Sriram Bakthavatchalam, Sakthibalan Murugesan, B Aravinda Kumar, Bijoy Deb, Chandramohan Marimuthu, Priya Rajendran
DOI:10.4103/jcrsm.jcrsm_21_22  
Background: Osteoarthritis (OA) is one of the most common musculoskeletal diseases worldwide, with pain, joint stiffness, fatigue associated with disability, and loss of physical activity. There is a need for an effective and safer alternative medication for the management of OA knee in elderly patients as the current medications possess severe risks to the patient compromising the quality of life. Methodology: The study design and setting were phase 3, randomized, open-label, multicentered, active-controlled parallel-group interventional trial conducted at secondary care centers in Puducherry. Fifty patients (50) patients with OA knee were enrolled as per study criteria and randomized to receive Joint Core™ and Jointace DN™ for 12 weeks. The outcomes were assessed using various pain scales and subscales, Short-Form Health-12 (SF-12) questionnaire, and inflammatory markers. The data obtained at baseline and weeks 4, 8, and 12 were compared and statistically analyzed. Results: Joint Core™ showed continuous reduction in the Visual Analog Scale pain scores at 4, 8, and 12 weeks and improvement in Western Ontario and McMaster Universities OA Index subscale and pain global assessment scales and good response rate in the Outcome Measures for Rheumatology Committee and OA Research Society International Standing Committee for Clinical Trials Response Criteria Initiative scores proving it to be efficacious in the treatment of OA knee compared to Jointace DN™. The safety assessed showed that Joint Core™ produces minimal gastrointestinal side effects and does not affect any organs as assessed by the laboratory parameters. Conclusion: Joint Core™ is effective and safe in the treatment of OA knee when compared to its comparator Jointace DN™. Joint Core™ can be an alternative treatment option in the patients with OA knee who are intolerant to diacerein-based combinations available to treat OA.
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A comparative study of students' perception of flipped classroom teaching and traditional classroom teaching among final-year medical students p. 52
Kavitha Balasubramanian, Vinoth Kumar Sethuraman, Balasubramanian Ramachandran
DOI:10.4103/jcrsm.jcrsm_69_21  
Introduction: Recently, flipped classrooms (FCs) have emerged as a new pedagogical method in which students are given study resource material to develop a basic understanding of the topic before class, and in-class precious time is used for learner-centric activities. Accordingly, the study objective was to determine the student's perception of flipped and traditional teaching methods. Materials and Methods: In this analytical cross-sectional study, students attending medicine clinics were divided into two groups of roughly forty students each. One group received FC teaching and the other traditional lecture on hypo- and hyperthyroidism topics. A structured questionnaire on students' perception of FC teaching and traditional teaching technique was used for both groups. Different parameters related to the learning process about hypothyroidism and hyperthyroidism were considered as primary outcome variables. Coguide software was used for statistical analysis. Results: The students' age range was between 21 and 23 years. The majority were males (>55%). Among the students who attended FCs, the majority (>60%) agreed to follow the same method in future. Majority (>75%) of the students agreed that the reading materials were useful. Overall, a positive perception was observed in the FCs compared to that of the traditional classroom method. Conclusion: FC compared with traditional teaching methods had a good response from the medical students. Students' perception of FC method was positive.
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The prophylactic antimalarial activity of Combretum nigricans hydromethanol crude extract in mice p. 59
Chinedu Enegide, Charles C Ofili, Uzuazokaro M Agatemor, Dabum L Jacob
DOI:10.4103/jcrsm.jcrsm_18_21  
Background: Malaria has maintained its historic threat to global health, with nearly 40% of the world's population being at risk of its mayhem. The increasing cases of resistance by Plasmodium parasite to the currently available antimalarial agents have led to increased scientific screening of medicinal plants for the possible development of newer agents, both for treatment and chemoprophylaxis against malaria. This study was designed to evaluate the prophylactic antimalarial activity of Combretum nigricans hydromethanol crude leaf extract in mice. Materials and Methods: The prophylactic activity of C. nigricans hydromethanol crude leaf extract was evaluated using the method illustrated by Peters. Six groups containing five mice each were used for the study. Group 1 (control) received distilled water 10 ml/kg b.w. p.o., Groups 2–4 were treated with 200, 400, and 800 mg extract/kg b.w. p.o., respectively, Group 5 mice were treated with chloroquine 10 mg/kg b.w. p.o., whereas Group 6 mice were treated with artesunate 10 mg/kg b.w. p.o. Results: The result showed significant (P < 0.05) chemoprophylactic activity in all treated groups compared with the control group. The chemoprophylactic activity of the extract was 55.4, 61.6, and 79.5% for 200, 400, and 800 mg/kg, respectively. A dose-related increase in mice body weight was also observed in the extract-treated groups. Phytochemical screening of the extract revealed the presence of several important active principles, including alkaloids, saponins, and flavonoids. Conclusion: The present study revealed that C. nigricans hydromethanol crude leaf extract possesses significant chemoprophylactic activity against malaria.
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Utility of biomarkers in predicting the severity and mortality of coronavirus disease 2019 infection: A retrospective observational study p. 64
Sapna S Deshpande, Namrata Mestri, Mohasin J Halgale, Pradnya M Chimankar
DOI:10.4103/jcrsm.jcrsm_72_21  
Context: The clinical course of Coronavirus Disease 2019 (COVID-19) infection is variable and subjective. Hence, there is a dire need for objective interpretation of severity. The utilization of biomarkers categorizes these patients into nonsevere, severe, or critical categories. Aim: This study aims to assess the role of different biomarkers in predicting the severity and mortality of COVID 19. Materials and Methods: Case records of 247 patients of a designated COVID center in Kolhapur, Maharashtra, India, were included in this observational study. Biomarkers such as total leukocyte count, C-reactive protein, lactate dehydrogenase, D-Dimer, interleukin-6 (IL-6), procalcitonin, and serum ferritin were studied in different categories of severity of the disease. Results: The median serum ferritin levels among nonsevere cases, severe, and critical cases were 187.95 ng/mL (interquartile range [IQR] = 93.05 ng/mL to 382.50 ng/mL), 230 ng/mL (156 ng/mL to 670 ng/mL), and 412.33 ng/mL (234 ng/mL to 689 ng/mL), respectively and this difference was statistically significant (P < 0.001). The average values of IL-6 were significantly higher (P < 0.001) among the patients who died (19.12 pg/mL) when compared to those which were alive (3.74 pg/mL). Based on the receiver operating characteristic analysis, the interpretation of the severity of the disease was excellent through the evaluation of levels of serum ferritin (Area under curve = 0.755 [95% confidence interval = 0.635–0.875; P = 0.001]). Conclusions: Serum ferritin among the biomarker panel studied was the best test that predicted the severity of COVID-19 infection. The IL-6 levels were significantly higher among the patient who succumbed when compared to those who survived the disease.
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CASE REPORTS Top

Erroneous display of inhalational agent..! p. 69
Anamika Agnihotri, Minal C Mali, Sunil Kumar Valasareddy
DOI:10.4103/jcrsm.jcrsm_65_21  
A well-equipped anesthesia workstation is a boon for better anesthesia practice. Advancement in technical aspects such as respiratory gas analysis made perioperative care better and safer. Any kind of equipment troubleshoot can contribute to morbidity and mortality; however, the magnitude of these is not established.
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Anesthetic challenges in a case of hydatid cyst of liver posted for laparoscopic-assisted excision of the cyst p. 72
Ramyavel Thangavelu, Vikasini Raman, RV Ranjan, Sampath Kumar Poral
DOI:10.4103/jcrsm.jcrsm_73_21  
Hydatid cyst caused by Echinococcus granulosus is a common health problem in developing countries. The rupture of hydatid cyst can cause anaphylactic shock or even death during the surgical treatment. We present a report regarding anaphylactic reaction due to surgery to the liver for a hydatid cyst. Clinical examination and contrast-enhanced computed tomography preoperatively revealed a large hydatid cyst measuring 18 cm × 13 cm × 11 cm with few thin septations in the right lobe causing mass effect and splaying of intrahepatic vessels. Intraoperatively, the patient was successfully managed with antihistamines, steroids, crystalloids, and a small dose of vasopressor. After the surgery, she was transferred from the Intensive care unit to the surgical ward on the first postoperative day. The possibility of anaphylactic reactions should be kept in mind, and close monitoring for early diagnosis and appropriate management of anaphylaxis is essential for a favorable perioperative outcome in the case of hydatid cyst surgery.
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Anesthetic challenges in a case of Sheehan's syndrome posted for open reduction and internal fixation and nailing following fracture femur p. 75
Abinaya Ramachandran, Nagalakshmi Palanisamy, Pradeesh T Johny, RV Ranjan
DOI:10.4103/jcrsm.jcrsm_78_21  
Sheehan's syndrome is postpartum hypopituitarism caused by necrosis of the pituitary gland due to severe hypotension or shock caused by massive hemorrhage during or after delivery. Patients with Sheehan's syndrome have varying degrees of pituitary hormone deficiency. There is increased sensitivity to barbiturates and opiates in patients with Sheehan's syndrome. They are more prone to hypotension, hypoxia, and hypothermia which must be addressed intraoperatively. Herein, we report successful anesthetic management of a patient with Sheehan's syndrome with distal third femoral shaft fracture for fixation who had numerous hormonal and electrolyte abnormalities. This case report emphasizes the importance of meticulous preanesthetic assessment, optimization, and perioperative management of patients with Sheehan's syndrome for successful management of the case.
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Perioperative management of a rare case of severe polycythemia vera with gout coming for an emergency minor surgery – A concern for the anesthesiologists p. 78
Ganapathysubramanian Manujkumar, Amoolya Kamalnath, Ethirajulu Ruthrendra, Venkatesh R Ranjan
DOI:10.4103/jcrsm.jcrsm_88_21  
Polycythaemia Vera is a chronic myeloproliferative neoplasm with an unknown etiology and is a rare occurrence. The erythrocytosis and thrombocytosis along with the hypercoagulable state as a direct result of surgery predispose these patients to thrombosis and hence haemorrhage. Here, we report the anaesthetic issues concerning an elderly male patient presenting with complaints of difficulty in passing stools, fever, and cough with mucoid sputum and diagnosed to be having low anal fistula and perianal abscess with presence of haemorrhoids along with polycythaemia and gout, who was not on any treatment, and posted for an emergency perianal abscess drainage and fistulectomy. With a hematocrit of 63.3% and normal arterial oxygen saturation, the anesthetic management included a thorough preoperative evaluation of associated comorbidities, proper positioning, conducting regional anesthesia meticulously and prevention of acute thrombotic or hemorrhagic episodes. The uneventful perioperative period resulted in the smooth recovery of the patient.
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A case of enteric fever complicated by hemophagocytic lymphohistiocytosis probably induced by ChAdOx1 nCoV-19 COVID-19 vaccine p. 81
Mathew Cherian, Siddhant Jeevan Thampi
DOI:10.4103/jcrsm.jcrsm_94_21  
Although enteric fever is a relatively common disease in countries mainly belonging to South Asia (incidence of around 100/100,000 persons per year) where there is poor hygiene, its complications in the form of hemophagocytic lymphohistiocytosis (HLH) are rare but have been documented before. Here, we present the case of a 19-year-old boy diagnosed with enteric fever with secondary HLH possibly induced by the COVID-19 vaccine (COVISHIELD ChAdOx1 nCoV-19 coronavirus vaccine [Recombinant]). Although there is no proof that the vaccine could have induced secondary HLH, its possibility cannot be ruled out simultaneously. Early identification and diagnosis of HLH are of extreme importance. If not treated correctly, mortality can reach up to 40%. In this article, we would like to press upon the clinical presentation, diagnosis, and management of such a case and the possibility of this presentation being induced by the COVID-19 vaccine.
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LETTERS TO EDITOR Top

The role of copeptin in the prognosis of ischemic stroke p. 85
Jamir Pitton Rissardo, Ana Letícia Fornari Caprara
DOI:10.4103/jcrsm.jcrsm_91_21  
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Cerebral mucormycosis as a new phenotype of post-COVD-19 neurological syndrome p. 87
Alberto José Sanjuanelo-Fontalvo, Juan Santiago Serna-Trejos, Diego Gerardo Prado-Molina, Ivan David Lozada-Martinez
DOI:10.4103/jcrsm.jcrsm_63_21  
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Mental health issues among Indian women during the COVID-19 pandemic driven lockdown p. 89
Sahanaa Chandar, Abhilasha Nair
DOI:10.4103/jcrsm.jcrsm_89_21  
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Framing standard operating procedure for infection control and prevention during COVID pandemics p. 91
Haritha Madigubba, R Deepashree, Apurba Sankar Sastry
DOI:10.4103/jcrsm.jcrsm_50_20  
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REVIEWERS Top

Reviewers p. 93

DOI:10.4103/2455-3069.350146  
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