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   Table of Contents - Current issue
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July-September 2022
Volume 20 | Issue 3
Page Nos. 123-211

Online since Monday, August 1, 2022

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EDITORIAL  

Antimicrobial resistance in India – “A silent pandemic within the pandemic” Highly accessed article p. 123
Karthik Gunasekaran
DOI:10.4103/cmi.cmi_47_22  
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ORIGINAL ARTICLES Top

Clinicoetiological profile of acute ischemic stroke patients in the therapeutic window in a tertiary care hospital in Northern India Highly accessed article p. 125
Amit Chandra, Maqbool Wani, Adnan Firdous Raina, Hilal Ahmad Ganie, Waseem Dar, Arjimand Yaqoob, Ravouf Asimi
DOI:10.4103/cmi.cmi_20_22  
Background: A stroke is defined by the rapid emergence of clinical symptoms and focuses on evidence (applicable to individuals in a deep coma and those with subarachnoid hemorrhage) or widespread brain damage. The study aimed to evaluate the clinical characteristics of patients with acute ischemic stroke in a tertiary care hospital in North India. Methods: By analyzing case files and conducting patient interviews, information on the patients was gathered and evaluated. The study's inclusion and exclusion criteria were based on the 2018 American Heart Association and American Stroke Association (AHA/ASA) thrombolysis guidelines for acute ischemic stroke. Recent major trauma or major surgery within 14 days not involving the head, seizure at the onset of stroke, systemic malignancy, and pregnancy were excluded. Results: The study enlisted the participation of 76 patients who were divided into two groups. Patients in the one group were given tenecteplase, whereas the other group were given alteplase. Patients in the tenecteplase and alteplase groups were of different ages and had various other risk factors for hypertension, atrial fibrillation, diabetes, smoking, and previous stroke or transient ischemic attack. The risk factor distribution in both the groups was statistically significant for variables such as hypertension and diastolic blood pressure (P < 0.05). Stroke in internal carotid artery territory was present in 3 out of 42 in the tenecteplase group and 2 out of 32 in the alteplase group. Most patients in both the groups had a stroke of undetermined cause. Small vessel and large vessel strokes were found in 9.5% and 14.7%, respectively. Conclusion: In the development of stroke, there is a definite relationship between age and gender. A sedentary lifestyle, food, and obesity are risk factors for stroke. According to an AHA/ASA drug utilization analysis, most medicines were appropriate for stroke patients.
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Outcomes of supraflex Sirolimus-eluting coronary stents p. 130
Vishal Virendra Singh, Sheikh Mohamad Tahir, Sanjiv Sharma
DOI:10.4103/cmi.cmi_28_22  
Background: The development of a sirolimus-eluting coronary stent (SES) was a big step forward in interventional cardiology. SES has been demonstrated in large, randomized clinical studies to reduce angiographic restenosis and target vessel revascularization (TVR) when compared to bare-metal stents and other drug-eluting stents (DESs). However, there is little information on the outcomes of Indian patients treated with Drug-eluting stents (DES). As a result, the study's goal was to assess the efficacy of Supraflex sirolimus-eluting coronary stents in the treatment of coronary artery disease and to identify severe adverse cardiovascular and cerebrovascular events. Methods: This single-center, observational, nonrandomized study enrolled unselected real-world patients at a tertiary care center who had undergone implantation with Supraflex sirolimus-eluting stents. The primary endpoint of the study was major adverse cardiovascular and cerebrovascular events (MACCE), which is a conglomeration of cardiac death, target lesion revascularization, TVR, cerebrovascular accident (CVA), and heart failure at 1-year follow-up. Results: A total of 100 patients were intervened successfully with sirolimus-eluting stents. Out of total patients, diabetes and hypertension were observed in 38% and 35% of patients, respectively. According to the American College of Cardiology/American Heart Association classification, there were 68% of type B lesions and 32% of type C lesions. At 1-year follow-up, major adverse cardiovascular events were 11%, a composite of 4% target lesion revascularization, 3% target vessel revascularization, 1% CVA, and 5% heart failure. Diabetes (P = 0.02), hypertension (P = 0.01), kidney dysfunction (P = 0.002), and left ventricular (LV) function (P = 0.01) strongly correlated with outcome (MACCE). Conclusion: There was an acceptable rate of adverse events after implantation of the Supraflex sirolimus-eluting stents, although slightly higher than in other studies. Diabetes, hypertension, kidney dysfunction, and LV function strongly correlate with the outcome (MACCE).
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The incidence of trauma with the use of glidescope in anticipated difficult airway cases – A prospective observational study p. 138
Mary Benita Jeyakumar, Melvin Alex Abraham, Georgene Singh, Tony Thomson Chandy
DOI:10.4103/cmi.cmi_94_21  
Background: Glidescope video-laryngoscope (GVL) is an invaluable equipment for patients with anticipated difficult intubations that aids in visualizing the vocal cords out of line-of-sight. However, despite the ease in the visualization and shortening of the time taken to visualise the cords, the intubation time is often prolonged and is associated with trauma. This study aims at identifying incidence of trauma with glidescope in anticipated difficult airway scenario and whether correct practice by experienced anesthesiologist can reduce trauma. Methodology: Eighty-nine adult patients with anticipated difficult airway who were intubated using GVL by experienced anesthesiologists in a tertiary care setting were studied. The time to visualize, the time to intubate, the difficulties encountered at intubation were documented, the incidence of trauma was reported. The factors associated with trauma were analyzed using PSPP software (psppire. exe 0.8.4-g012d99). Results: The incidence of airway trauma was 11.2%. It was higher in the group with technical difficulties (Gtd) (P < 0.001) and was less in the hands of an experienced anesthesiologist (P = 0.02). Conclusion: GVL intubation in anticipated difficult airway cases by experienced anesthesiologists using the right technique has lesser incidence of trauma, lesser than that is seen with Macintosh intubations in anticipated difficult airway scenario. Knowledge on techniques to troubleshoot technical difficulties with GVL may reduce the incidence of trauma further and needs to be studied more.
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Prevalence of undiagnosed diabetic retinopathy among inpatients with diabetes at a tertiary care hospital in Jammu Region (Jammu and Kashmir), India p. 143
Arjumand Nazir, Fayaz Ahmed Wani, Asma Jabeen
DOI:10.4103/cmi.cmi_16_22  
Background: One of the most devastating consequences of diabetes is diabetic retinopathy (DR), a condition that poses significant financial and health-care burdens on individuals, health-care systems, and the global economy. This study aims to estimate the prevalence of DR in the inpatient diabetic population in the tertiary care hospital of the Jammu region (Jammu and Kashmir). Methods: This cross-sectional study had men and women over 18 years admitted to Government Medical College, Jammu with type 1 or type 2 diabetes based on a previous physician diagnosis or hemoglobin A1C ≥6.5% (48 mmol/mol) and were eligible to participate. The exclusion criteria included type 1 diabetes diagnosed within the past 5 years. In addition, data on secondary risk factors for retinopathy were collected, such as duration, hemoglobin A1C, and associated comorbidities. Results: Seventy-eight patients with a known diagnosis of diabetes mellitus were included in this study. The majority of the study participants, 56.4% (44/78) were male and were in the age group of 40–60 years. The majority, 57.7% (45/78) participants, were unaware that DR could affect their vision. The prevalence of proliferative DR and clinically significant macular edema was 3.8% (3/78 each). Conclusion: Our study suggests an increased prevalence of DR in the study population, which seems to be a concern.
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Microbial contamination on mobile phones of health-care workers at a tertiary care hospital of Northern India p. 149
Shujauat Hussain Dar, Gulnaz Bashir, Qounser Nisar, Iqra Majid, Muzaffar Ahmad Khandi
DOI:10.4103/cmi.cmi_22_22  
Background: The use of mobile phones (MPs) in hospital halls, laboratories, intensive care units, and operating rooms is a common practice. There are no proper guidelines for the disinfection of MPs that meet hospital standards. This study investigated the bacterial contamination on MPs of health-care workers employed in tertiary healthcare Sher-i-Kashmir Institute of Medical Sciences (SKIMS) Srinagar, Jammu and Kashmir.” Materials and Methods: One-hundred and fifty-five health-care workers (57 doctors, 50 nurses, 35 technical staff, and 21 other employees) were included in a cross-sectional study performed from January 2018 to June 2018 at the SKIMS, Srinagar, Jammu and Kashmir. Social demographic characteristics (such as gender and occupation) and cell phone-related questions were gathered through a self-administered questionnaire (e.g., frequency of MP disinfection and use of the MP at work). Sample collection and processing were done correctly to avoid any bias. Results: Majority (79%) were working in different wards of the institute, followed by (51%) working in different laboratories and (8%) working in intensive care settings. The majority of the participants (42%) said they used their phone less than ten times per day; 33% said they used it 10–20 times/day. In terms of disinfection, 107 (69%) of the participants cleaned their MP occasionally, 31 (20%) never cleansed their phone, and just 17 (11%) regularly disinfected their phone. Out of 155 MPs sampled, 125 (80.6%) showed microbial growth, and 30 (19.4%) were free of microbial growth. Out of the total 125 positive samples, 51 (40.8%) were Gram-positive bacilli (which was considered as airborne contamination), 36 (28.8%) were Gram-positive cocci (GPC), 25 (20%) Gram-negative bacilli, 11 (8.8%) were mixed growth, and 2 (1.6%) were yeasts. Out of 36 GPC, Staphylococcus aureus was predominant, i.e., 15 (41.6%), followed by Enterococcus spp. 12 (33.3%), Coagulase-negative Staphylococci spp. 7 (19.4%), and Streptococci spp. 2 (5.5%). Conclusion: Almost all MPs were contaminated, with more than half of them harboring pathogenic microorganisms. It could pose a significant risk to both health-care personnel and patients in the form of nosocomial infections.
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Magnetic resonance imaging downstaging, pathological response, and microsatellite instability status in patients with signet-ring cell carcinoma rectum undergoing preoperative long-course chemoradiation p. 154
B Rajkrishna, Saikat Das, Dipti Masih, Tharani Putta, Rajat Raghunath, Thomas Samuel Ram
DOI:10.4103/cmi.cmi_23_22  
Aim and Objective: To assess the magnetic resonance imaging (MRI) downstaging, pathological response, and the relationship between microsatellite instability (MSI) and radiotherapy response in signet-ring cell carcinoma rectum. Materials and Methods: Twenty two patients were recruited prospectively and retrospectively in this observational study. Six weeks following radiotherapy, the response was assessed using an MRI pelvis, and patients who were operable underwent total mesorectal excision followed by adjuvant chemotherapy. The outcome of radiotherapy was correlated with post radiation MRI downstaging, pathological response, and MSI status. Results: The post radiotherapy response assessment MRI showed tumor regression grading (TRG) 5 in 5 patients. TRG 4 seen in 12, TRG 3 in 3, and TRG 2 in 1 patient. Fifteen patients were operable and post-operativ histopathology showed that 40% had pathological complete response (pCR) and 26.7% had near-complete response. Even those who had no response in MRI had pCR. MSI done 17 patients were stable. Of the 6 patients who had complete pathological response, two were MRI TRG 5, three were MRI TRG 4, and one was MRI TRG 3. The median survival was 23 months. The 2-year and 3-year disease-free survival was 46% and 38%, respectively. Conclusion: The predictive value of MRI downstaging in these tumors following neoadjuvant long-course chemoradiation therapy is not often in concurrence with the histopathological response and needs to be interpreted carefully. Even though the pCR rate seen in this cohort is encouraging, this needs to be evaluated in studies with large cohorts.
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Prevalence of type 2 diabetes among persons with disabilities in the South-East Asian region: A systematic review and meta-analysis p. 161
Rajeswaran Thiagesan, Vijayaprasad Gopichandran, Sudharshini Subramaniam, Hilaria Soundari, Kalpana Kosalram
DOI:10.4103/cmi.cmi_27_22  
Background: Type 2 diabetes is a major public health burden in the South-East Asian region. Persons with disabilities have a higher predilection for developing type 2 diabetes. Objective: The objective of this study was to estimate the prevalence of type 2 diabetes among persons with physical, development, sensory, and psychiatric disabilities in the South-East Asian regional countries. Methods: The Medline database was searched through PubMed using a specifically developed search strategy to identify observational studies that looked at the prevalence of type 2 diabetes among persons with various types of disabilities. Specific inclusion–exclusion criteria were used to shortlist the most relevant studies. The AXIS tool was used to assess the risk of bias in the identified studies. Data were extracted from the final list of studies and meta-analyzed using a random-effects model. Forest plot was used to study the pooled estimate and funnel plot was studied to assess publication bias. Subgroup analysis of prevalence of diabetes among persons with psychiatric and physical disabilities was performed. Results: A total of 771 papers were identified for screening. Of them, 740 were excluded and 31 were included in the full-text review. Finally, 12 studies were included in the meta-analysis. The prevalence of type 2 diabetes among persons with disabilities was 12.8% (95% confidence interval [CI]: 8.8%–16.8%). The studies showed a wide heterogeneity. The funnel plot did not show any publication bias. Subgroup analysis showed that while the prevalence of type 2 diabetes in persons with psychiatric disabilities was 14.0% (95% CI: 9%–18.9%), it was 10.6% (95% CI: 3.6%–17.6%) among persons with other forms of physical disabilities. Conclusion: The prevalence of type 2 diabetes is high among persons with disabilities. There is a need for well-conducted systematic studies in the South-East Asian region on prevalence of type 2 diabetes among persons with disabilities.
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BRIEF REPORTS Top

The impact of COVID-19 pandemic on caustic ingestion at a tertiary care center in South India p. 168
Nicholas Vijay Rao, Ebby George Simon
DOI:10.4103/cmi.cmi_118_21  
Background: The COVID-19 pandemic has had a significant impact on the mental health of individuals which has sometimes led to attempts at deliberate self-harm including the ingestion of caustic substances. This study was aimed to compare the rates of caustic substance ingestion during the pandemic to a similar period in the preceding year at our center. Methodology: We carried out a retrospective analysis, in which patients' details (demographic, clinical, endoscopic, and outcomes) were collected and compared between April 2019 and December 2019 (pre-COVID-19 pandemic) and from April 2020 to December 2020 (during the COVID-19 pandemic). Results: A total of 41 patients were included in this study, 26 (63.4%) in the pandemic period and 15 (36.5%) in the prepandemic period. The majority were female in both the prepandemic (60%) and pandemic periods (53.9%). More adolescents (<18 years of age) were seen in the pandemic period (15.3%) than in the prepandemic period (6.7%). The proportion of patients admitted with caustic substance ingestion in the pandemic period (3.53%) was significantly higher than in the prepandemic period (1.57%) (P = 0.0094). Conclusion: Caustic substance ingestion almost doubled in our center during the COVID-19 pandemic highlighting the burden of mental health issues during a pandemic.
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Effect of a hydrogen peroxide gas-plasma sterilization on physical integrity and quality of N95 respirators: An experimental study during the COVID-19 pandemic p. 172
Malathi Murugesan, Sneha Radha, Bhagteshwar Singh, Prasad Mathews, Suresh Devasahayam, Priscilla Rupali
DOI:10.4103/cmi.cmi_9_22  
Background: N95 respirators have prevented transmission among health-care workers during the COVID-19 pandemic. During times of intense shortage of respirators and border closures during the pandemic, re-use strategies with available decontamination methods were necessitated. This in-house experimental study evaluated the effect of hydrogen peroxide gas-plasma sterilization on respirators and helped establish an evidence-based protocol for their re-use in a resource-poor setting. Materials and Methods: A three-dimensional experimental model using saline nebulization as the aerosol exposure and a particle counter to measure the filtration of particles through the mask pre- and post-sterilization was used. Multiple cycles of plasma sterilization were done till the physical integrity/fit was lost. Total filtration volume was used as a surrogate marker to assess the filtration efficiency (FE). Results: The total volume of particles filtered on a 3M respirator was 99.9%. Unused Halyard and Venus respirators were compared against 3M and found to have FE of 99.9% and 60.5%, respectively. After repeated sterilization cycles, the total volume of particles filtered was 59.3% for Halyard in the seventh cycle and 36.2% for Venus in the fifth cycle. When the physical integrity and fit was tested, the appropriate fit was lost after eight cycles of sterilization for Venus and was not lost for Halyard even after the tenth cycle. Conclusion: This low-cost experimental study helped implement an effective and safe decontamination strategy for safe re-use of N95 respirators in an emergent situation with no access to commercial testing in a resource poor health-care setting during the pandemic.
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SYSTEMATIC REVIEW Top

Undergraduate medical education in India during COVID-19 pandemic p. 177
AY Nirupama, Sirshendu Chaudhuri, Chandra Sekhar Chittooru, K Yashaswini Vani, Sravana Deepthi Chittem
DOI:10.4103/cmi.cmi_38_22  
Introduction: The COVID-19 pandemic led to the disruption of medical teaching nation-wide and pushed the institutions to explore the probable role of online teaching methods. The aim of this review is to identify the untested perspectives and help in strategizing based on evidence generation for the preparation for future. Methods: We followed the Preferred Reporting Items for Systematic and Meta-Analysis guidelines for reporting the present review. We searched PubMed, Scopus, and Embase databases for the articles published between April 2020 and October 2021 for studies on online medical education in India during the COVID-19 pandemic. Results: We initially screened a total number of 1412 articles and finally recruited 45 articles for the analysis. Majority of the articles were from single institution, and reported the experience of the students and teachers on online teaching. The common teaching platform used such as Zoom and Google Meet were enumerated. Internet connectivity was the most reported challenge of online teaching. None of the selected articles reported on ethical issues related to online teaching. Conclusion: Even though there were some strong points reported for the successful implementation of e-learning, a more sustainable and well-informed plan should be devised for the future on online teaching.
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CASE SERIES Top

Management of symptomatic posterior circulation flow aneurysms associated with agenesis of the internal carotid artery p. 182
Aswin Padmanabhan, Vinu Moses, Munawwar Ahmed, Krishna Prabhu, Bijesh Ravindran Nair, Baylis Vivek Joseph, Shyamkumar Nidugala Keshava
DOI:10.4103/cmi.cmi_114_21  
Internal carotid artery agenesis, unilateral or bilateral is a rare congenital anomaly. Cerebral circulation challenged by this lack of anterior supply is compensated by increased flow through the posterior circulation and circle of Willis. This hyperdynamic circulation results in flow-related aneurysms, especially along the branching segments. We present the clinical, imaging and endovascular management of three symptomatic patients with discussion of relevant literature.
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CASE REPORTS Top

Dimethoate self-poisoning–Induced severe hypotension p. 187
Anand M Tiwari, Kapil G Zirpe, Rustom S Wadia, Sushma K Gurav, Abhijit M Deshmukh
DOI:10.4103/cmi.cmi_12_22  
Intentional ingestion of organophosphorus compound (OP) poisoning continues to be a frequent reason for critical care admission in India. For the past 6 decades, the OP compounds used in India for the poisoning had effects on cholinergic and neurogenic fibers producing the respiratory and neurologic presentation. Recently, a less frequent OP poison has appeared which acts on cardiac sympathetic fibers with bradycardia and hypotension as presenting features. The shock which was nonresponsive to dopamine/dobutamine was identified as a major cause of death in patients with dimethoate poisoning in a large prospective cohort study. Severe dimethoate poisoning in contrast to other OP compounds has a high case fatality rate. There have been case reports from outside India. We report the first two cases with successful treatment of this toxicity in India.
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Resolve or refer? A difficult choice in the management of neonatal refractory hypoglycemia p. 191
Vinod Kumar Palaparthy, Karen Edith Kiruba, Monica Thapwal
DOI:10.4103/cmi.cmi_17_22  
Hypoglycemia is the most common metabolic abnormality in the neonatal period. Refractory hypoglycemia is challenging to manage in resource-limited settings. We aim to report the challenges faced and the lessons learnt while managing a neonate with refractory hypoglycemia.
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Chemotherapy-induced acute reversible toxic leukoencephalopathy p. 194
AK Vishnu, Thara Pratap, Dhanya Jacob, Muhammed Jasim Abdul Jalal, Anupama Gopalakrishnabhakthan
DOI:10.4103/cmi.cmi_24_22  
Acute toxic leukoencephalopathy can be due to a variety of endogenous and exogenous agents. Chemotherapy-induced toxic leukoencephalopathy is often encountered in clinical practice with the widespread use of various chemotherapeutic agents. Since initial clinical findings may be nonspecific, magnetic resonance imaging can be useful in the pattern recognition of white matter injury as well as to rule out its close differentials. Early diagnosis is important since prompt removal of the inciting agent and supportive therapy can reverse this condition, while delay can result in a poor prognosis. Here, we report a case of chemotherapy-induced toxic leukoencephalopathy in a patient with metastatic adenocarcinoma of the rectum from an imaging perspective.
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MEDICAL EDUCATIONS Top

Experiential learning: How pedagogy is changing in medical education p. 198
Debkumar Pal, Manish Taywade, Kumbha Gopi
DOI:10.4103/cmi.cmi_35_22  
Kolb's cycle of experiential learning is the new method of pedagogy for medical education. It is helpful in the integration of book knowledge and practical knowledge, which is an essential component in competency-based medical education. Experiential learning is helpful for students and more interesting also for them.
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Ensuring training of medical students in bioethics competencies as an integral part of medical curriculum p. 201
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/cmi.cmi_52_22  
Ethics has been considered an integral and indispensable part of the health-care profession for multiple decades. The term “bioethics” generally refers to the study of ethical issues arising because of the development made in the field of medicine, biology, and technology, which might become a cause of concern for humans or detrimentally affects the association between human and their environment. In order to streamline the training process of medical students in bioethics, there is an indispensable need to define the competencies that need to be covered during the training period. We must understand that teaching bioethics is way more than covers a theoretical topic, rather it requires exposure of medical students to a number of practical and clinically relevant scenarios. In conclusion, training medical students in bioethics have to be acknowledged as an important need, as it will eventually determine the safety and well-being of the current and future generations of people. It is high time that specific steps are taken to define specific bioethics competencies and integrate them with the existing medical curriculum to benefit both medical students and the general population.
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OPINION Top

Physiotherapy and behavioral techniques in management of posttraumatic stress disorder in health-care workers amid COVID pandemic p. 205
Srishti Bipul Banerjee
DOI:10.4103/cmi.cmi_33_22  
Since the outbreak of coronavirus in 2019, the health-care workers (HCWs) are tirelessly battling through these unprecedented times. Although the pandemic has shaken the health-care systems globally due to its unpredictable course and spread, HCWs continue to remain on the frontline. the focus is always on patient care and limiting the spread amidst which the mental health and challenges faced by HCWs takes a back seat, the purpose of this opinion is to focus on the mental health issues HCWs are facing globally while fulfilling their duties. The article discusses the clinical features and risk factors and also provides evidence-based management strategies for posttraumatic stress disorder in HCWs.
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LETTERS TO THE EDITOR Top

Monitoring treatment outcomes among tuberculosis patients: Implications for practice and policy p. 209
Anugraha John, Hari Teja Avirneni, Sinthu Sarathamani Swaminathan
DOI:10.4103/cmi.cmi_45_22  
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Is it one or two? p. 210
Ramya Iyadurai, OC Abraham
DOI:10.4103/cmi.cmi_48_22  
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