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   Table of Contents - Current issue
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July-September 2021
Volume 19 | Issue 3
Page Nos. 129-219

Online since Monday, July 5, 2021

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EDITORIAL  

Second wave of COVID-19: Unrelenting rampage of the SARS CoV-2 variants Highly accessed article p. 129
Kundavaram Paul Prabhakar Abhilash
DOI:10.4103/cmi.cmi_44_21  
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ORIGINAL ARTICLES Top

Perception of noncommunicable diseases among the tribals of the Gudalur Valley, Nilgiris, Tamil Nadu p. 132
Royson Jerome Dsouza, Roshina Sunny, Pooja B Sambhalwar, Saranya Hariharan, Smitha Mohanraj, Nandakumar Menon
DOI:10.4103/cmi.cmi_17_21  
Introduction: Noncommunicable diseases (NCDs) pose a significant burden on global health with the increasing prevalence in rural and tribal communities. Although several studies show an alarming trend in adverse outcomes in Indian tribes, there have been only a few reports assessing their perception of NCDs. This study was conducted to address this gap to design better health strategies to reduce the burden of NCDs among the tribal communities. Methodology: This was a hospital-based cross-sectional descriptive study done in Gudalur Adivasi Hospital in The Nilgiris district, Tamil Nadu. The study participants included the five tribal communities belonging to the Particularly Vulnerable Group (formerly Primitive Tribal Group) living in the Gudalur and Pandalur Taluks. After approval from the Ethics committee of the Association for Health Welfare in the Nilgiris (ASHWINI), the data were collected using a predesigned, semi-structured, interviewer-administered questionnaire. The results were entered into an Excel sheet and exported to SPSS software (version 19) for the analysis. Results: The interviewed tribals belonged to the Paniya tribe (54%), Bettakurumba tribe (25%), Moolakurumba tribe (7%), Kattunayakan tribe (6%), and Irula tribe (8%) of whom 43% were illiterate. Seventy-eight percent of the tribals were aware of the presence of NCDs in their community. The most common source of information is ASHWINI and the other health care facilities. The association of unhealthy diet and family history with NCDs was reported by 72% and 25% of the interviewed tribals, respectively. However, the other risk factors like lack of physical activity (7%), old age (2%), and environmental factors (3%) were poorly understood. Similarly, the association between alcohol, tobacco, and NCDs was acknowledged by only 10% and 4% of the interviewed tribals. The importance of screening was understood by 72% of the interviewed tribals. Conclusion: This study showed that there is a severe lack of awareness of NCDs among the tribal population of the Gudalur and Pandalur taluks of the Nilgiris district in Tamil Nadu. The importance of health promotion in reducing the burden of NCDs is well recognized. There is an urgent need for implementing adequate strategies to correct the knowledge, attitude, and practices of the tribal communities towards NCDs.
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Impact of Coronavirus Disease 2019 crisis on families of children with congenital heart disease and knowledge, attitude, and practices assessment: A hospital-based study p. 137
Shruti Atul Prabhu, Manokamana Shaiju, P Shiv Patel, Priti Sahu, Kiran Verma
DOI:10.4103/cmi.cmi_18_21  
Background: The current coronavirus disease 2019 (COVID-19) pandemic has disrupted the spectrum of health care, including delaying diagnoses and treatment, particularly for complex health conditions, such as pediatric patients with congenital heart disease (CHD). Objectives: The objective of this study is to assess the impact of COVID-19 crisis and lockdown on families of children with CHD and to study knowledge, attitude, and practices (KAP) regarding COVID-19 among them. Methodology: The purposive sampling was used, all patients (173) who consulted in the cardiology outpatient department during the study period and 190 CHD patients whose the date of surgery was previously scheduled during April and May 2020, but delayed due to the national lockdown were included in this study. Hence, the sample size of the study was 363. Phone calls were made to all patients' families. This study design was used due to current COVID-19 crisis to minimize contact with patients, in line with safety precautions mandated by the government. Results: 54.2% were male patients, 43.3% in the age group of 1–5 years, predominant diagnosis (37.3%) was ventricular septal defect. Majority of parents of CHD patients (78.2%) answered that primary source of information about COVID-19 was social media. Twelve percent patients had worsening of symptoms related to existing heart condition during this period. Parents of 26 patients (8.3%) faced difficulty in getting medicines due to lockdown. The KAP assessment found that a high proportion of parents possessed basic knowledge about the disease at the early stage of the pandemic. The average KAP score was 10.2 (Range 2–16). Conclusion: This is the first study to investigate the impact of COVID-19 on children with CHD during the pandemic. This group had faced considerable difficulty like the general population. KAP assessment showed that they had good knowledge about the pandemic; they were following precautionary measures, especially because of the child's condition, to ensure the child's safety.
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Study of exposure to dexamethasone among children with acute lymphoblastic leukemia and effect on intellectual function – A pilot study p. 144
Shumraa Aminath, Gurpreet Kaur Dhillon, Shifla Abdul Latheef, Harpreet Singh Dhillon, Shibu Sasidharan, Babitha Manalikuzhiyil, Suneeta Singh
DOI:10.4103/cmi.cmi_19_21  
Background: There has been significant increase in the remission rates for childhood acute lymphoblastic leukemia (ALL) with addition of corticosteroids to chemotherapy regimens. However, with increase in survivors, there has been increase in the incidence of neurocognitive dysfunction as a 'long term sequelae. The present study was undertaken with the aim to study the effect of a chemotherapy regimen with dexamethasone on intellectual abilities in children with ALL. Methodology: This was a prospective, observational, and descriptive study conducted at a tertiary care hospital over a period of 18 months. Sixty children aged between 6 and 12 years diagnosed with B cell ALL and belonging to the standard risk ALL group on treatment protocol Pediatric Berlin-Frankfurt-Munster (1–10 years) (standard risk), initiated and maintained on oral dexamethasone as part of their chemotherapy regimen were recruited. All the patients were followed up for 6 months and assessed for intellectual ability using Raven's standard progressive matrices (SPM), which was carried out before starting oral dexamethasone, at 3 months and after 6 months of starting oral dexamethasone. Results: The scores obtained at three intervals were compared by one-way repeated analysis of variance and the results showed a significant increase in raw scores of SPM. The difference between the mean scores at the three specified intervals was statistically significant (P < 0.001). The overall maximum improvement (mean raw scores of 5.5) was seen over 6 months period in older age group (12 years). Gender-wise comparison of performance revealed an overall better scores in males, though the differences were not significant. Conclusion: The current study revealed a significant increase in raw scores of SPM in children with standard risk B cell ALL undergoing chemotherapy along with dexamethasone. However, randomized control studies with larger sample size followed up longitudinally for a longer period of time are needed for specific recommendations of using dexamethasone over other corticosteroids.
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Effect of direct-acting antiviral treatment on decompensated Hepatitis C Virus cirrhosis p. 151
Neha Jakhete, Rati Deshpande, Mary G Bowring, Jessica Shay, Jennifer Katzianer, Shanti Seaman, Ahmet Gurakar, Christine M Durand, Brittany Barnaba, Kirti Shetty
DOI:10.4103/cmi.cmi_35_21  
Goals: The goal of the study is to assess the effect of direct-acting antivirals (DAAs) on the model for end-stage liver disease-sodium (MELD-Na) score and on specific decompensations related to hepatitis C virus (HCV) cirrhosis. The aim of our study was to identify a specific cohort of patients with cirrhosis, if any, that should be targeted for treatment with DAAs. Background: The development of DAAs has provided safe and well-tolerated treatment options for patients with advanced liver disease. However, controversy remains in terms of optimal timing of treatment and whether this treatment should be offered before or following liver transplantation. Methods: We identified all patients with HCV cirrhosis who initiated treatment with DAA therapy at Johns Hopkins Hospital between July 2014 and June 2016. We identified a subset of patients who had decompensated cirrhosis and recorded their MELD-Na scores and decompensations pre- and post-treatment. Results: Fifty-six patients achieved sustained virologic response with decompensated HCV cirrhosis. The group demonstrated a significant decrease in median MELD-Na score following treatment from 12 to 10.5. Furthermore, a significant percentage of patients experienced resolution of ascites following DAA therapy with 19 patients (35.2%) clearing their ascites posttreatment. Of the 19 patients who cleared ascites, MELD-Na score decreased from a median of 12 (interquartile range [IQR] 11–18) to 11 (IQR 8–14), P = 0.01. Conclusions: Our findings suggest that patients with ascites as their main decompensation should be considered for the treatment with DAAs, while awaiting liver transplant given that the MELD-Na score showed only modest improvement and thus would not affect liver transplant (LT) listing priority.
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Prevalence and psychosocial correlations of COVID-19-related worries in people with diabetes mellitus seeking services from East Indian tertiary care center: A cross-sectional survey results p. 157
Suravi Patra, Swati Priyadarshini Acharya, Manish Taywade, Debapriya Bandyopadhyay, Binod Kumar Patro
DOI:10.4103/cmi.cmi_39_21  
Context: Patients with diabetes are more prone to psychosocial problems which are known to adversely impact clinical outcomes of diabetes. COVID-19 is understood to further worsen the psychosocial problems of patients with diabetes. Aims: We carried out this cross-sectional telephonic survey of COVID-19-related worries in patients with diabetes mellitus to understand the prevalence and correlates of COVID-19-related worries. Settings and Design: This was a telephonic survey of patients seeking care from noncommunicable disease clinic of a tertiary care medical center. Subjects and Methods: We used a structured questionnaire to assess sociodemographic, clinical, psychological variables and COVID-19-related worries. Statistical Analysis Used: We used SPSS 20.0 for descriptive statistics keeping significance levels at 0.05. Between-group comparisons of continuous variables were made with independent t-test and two-way ANOVA; correlations were carried out with Pearson correlation test. Results: Two hundred and nine patients completed the telephonic survey conducted from September to November 2020. The prevalence of diabetes-related worries in our sample was 80%. Younger age (P < 0.001), unemployment (P = 0.029), and the presence of mental disorder (P < 0.001) were associated with higher diabetes-related worries. Poor glycemic control (0.008) and symptoms of COVID-19 (0.03) were associated with diabetes-related worries. Diabetes-related worries correlated with diabetes distress (ρ =0.441, P < 0.001), social isolation (ρ =0.401, P < 0.001), and perception of social support (ρ = −0.158, P < 0.001). Conclusions: A large proportion of our patients with diabetes are at high risk to experience COVID-19-related worries especially, younger people, unemployed and those with mental illness. Furthermore, the presence of diabetes distress and the perception of social isolation increase COVID-19 worries.
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How safe is Covishield (ChAdOx1nCoV-19) Vaccine? Experience from a Tertiary Care Hospital in South India p. 162
Leeberk Raja Inbaraj, Carolin Elizabeth George, Nirupama Navamani Franklyn
DOI:10.4103/cmi.cmi_50_21  
Background: Coronavirus disease vaccine has been recently rolled out for health care workers in India. We aimed to determine the incidence of adverse events following immunization (AEFI) among healthcare workers (HCWs) after their first dose of the ChAdOx1nCoV-19 vaccine. Methodology: We recruited 218 HCWs for this cross-sectional study. We circulated a google form on the hospital and asked them to self-report their vaccination experience. Results: Two-thirds (69.7%, 95% confidence interval [CI]: 63.1–75.7) had minor AEFI, and none had severe AEFI. Body ache (46.8%, 95% CI: 40–53.6) was the most common symptom followed by headache (30.3%, 95% CI: 24.2–36.8). Most of them (39.4%, 95% CI: 32.9–46.2) experienced symptoms within 4–24 h after taking the vaccine. Majority (78.9%) were anxious before the vaccination. The younger age group and female gender were significantly associated with AEFI. Conclusion: HCWs experienced minor, self-limiting AEFI with the first dose of ChAdOx1nCoV-19. The hospital reported no serious AEFI following the vaccination.
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REVIEW ARTICLES Top

The management of hyperthermia and exercise-associated hyponatremia in low-resource and prehospital settings Highly accessed article p. 165
Daniel Grace
DOI:10.4103/cmi.cmi_15_21  
Between 2000 and 2016, the number of people exposed to heat waves worldwide increased by around 125 million. As global warming increases, there is growing concern regarding the effect of heat stress on health outcomes, particularly in low- and middle-income tropical countries. The likelihood of developing heat-related injury depends on three factors: an individual, their environment, and their workload. Both exertional hyperthermia and exercise-induced hyponatremia are potentially life-threatening conditions that may develop in environments with increased heat stress. These can present with vague and overlapping symptoms such as confusion, headache, vomiting, and in severe cases, coma. The management of these two conditions is extremely different, and making a correct diagnosis can be challenging, particularly for health-care professionals who are working in low-resource or prehospital settings.
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Attendance norms in undergraduate medical education in India: Issue worth considering? p. 171
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/cmi.cmi_34_21  
Medical education has been recognized as a challenging professional course as a lot is expected from the medical students during their training period. An extensive search of all materials related to the topic was carried out in the PubMed search engine and National Medical Council Website, and a total of 15 studies similar to the current study objectives were selected based on the suitability with the current review objectives. In order to ensure that students actively participate in their learning and eventually progress from one professional year to the next one, the regulatory body has formulated eligibility criteria for the students to appear in summative assessments. Although attendance policy tends to have a significant influence on reducing the unnecessary absenteeism in the class, it cannot be conclusively said that the best learning occurs while students are physically attending the class. A student can be asked to mandatory attend those sessions wherein the content cannot be perfected by reading material. To conclude, the clause of meeting attendance norms for being eligible for the summative assessment is a must in many ways to ensure that students remain involved in their learning process. However, there is a definite scope to modify the attendance norms depending on the type of sessions and whether the proposed knowledge or skills can be acquired within the four walls of a class or by the students on their own.
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Acute pain management p. 175
Premranjan Mohanty
DOI:10.4103/cmi.cmi_38_21  
Pain has been described as one of the leading causes of morbidity worldwide and is one of the most significant contributors to absence from work and thereby a decrease in productivity. Acute pain is frequently neglected and undertreated both in the emergency department (ED) and in the postoperative period. The management of acute pain is very often inconsistent and inadequate relative to the degree of pain perceived by the patient. This also results in reduced patient satisfaction, readmissions, and delayed recovery in postoperative patients. Suboptimal analgesia is frequently a result of certain barriers, at the physician level as well as patient level. In the setting of an ED, the key to solving the problem of oligoanalgesia starts with the acknowledgment and assessment of pain, involving the treating physicians, nurses, and the other emergency medical service providers.
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Aspiration during emergency intubation in the emergency department: A review p. 179
Ramgopal Roshan
DOI:10.4103/cmi.cmi_40_21  
Endotracheal intubation is considered the gold standard airway management in the Emergency department (ED) for patients requiring definitive airway. It is one of the most commonly performed invasive procedures in the ED. Due to limited time for preparation, unstable condition of the patient, and urgency of the situation, it is always considered a high-risk procedure. The risk of aspiration is high in patients with low sensorium while the intubation process itself is associated with an increased risk of aspiration. It is therefore important to take preventive steps and recognize early signs of aspiration as treatment is difficult and could prolong and complicate hospital stay. Until a gold standard definition and a reliable diagnostic marker for aspiration pneumonia (AP) is available, it would always be a challenging task for clinicians to diagnose AP.
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OPINIONS Top

COVID-19 pandemic and role of behavior change communication p. 185
Manish Taywade, Pradnya Dilip Chandanshive, Somen Kumar Pradhan
DOI:10.4103/cmi.cmi_5_21  
Since the onset of the COVID-19 pandemic, various public health interventions have been employed due to the lack of an effective vaccine or treatment against the disease. Despite various global and national initiatives, there is still a lack of compliance among the general public. Hence, there is a need for behavior change communication (BCC) for individuals as well as communities to effectively combat the disease spread. This article attempts to address the issues in implementing public health measures and the role of BCC in controlling the pandemic situation.
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COVID-19 pandemic in India: Should rural secondary care hospitals stop surgical care? p. 188
Royson Dsouza, Nandakumar Menon
DOI:10.4103/cmi.cmi_52_21  
The COVID-19 pandemic has been a real test to the healthcare system of India ever since the first reported case in December 2019. Surgical illnesses amongst other diseases have taken a severe brunt during the pandemic due to restriction in operative procedures, lockdown and travel restrictions. The tertiary care centers located in tier three cities are burdened with managing patients with COVID-19 infections. The impact due to cancellation and postponement of surgical illnesses will be tremendous. It is imperative to make rural secondary care hospitals part of the solution in this crisis. In this article, the authors have summarized how best this can be achieved in a manner that protects the patients without putting the health workers at risk.
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CASE REPORT Top

Ludwig's angina – Is management possible in a resource-limited rural surgical setup? p. 191
Royson Jerome Dsouza, M Venkatesan, John H Stephen, Mrudula Rao
DOI:10.4103/cmi.cmi_22_21  
Ludwig's angina is a rapidly progressive gangrenous cellulitis of the soft tissues of the neck and floor of the mouth which can cause airway compromise. The management involves a multidisciplinary approach consisting of intensivists, otolaryngologists, head-and-neck surgeons, and anesthesiologists. Consequently, the patients with Ludwig's angina are mostly managed at tertiary care centers. Although early surgical intervention for drainage of the abscess and securing the airway is recommended, many subsets of these patients can be managed conservatively. These include hemodynamically stable patients, without stridor and respiratory distress. A 41-year-old lady with no known comorbidities presented with a rapidly progressive swelling over the submandibular region following dental extraction. There were severe trismus and dysphagia but without clinical evidence of airway compromise. She was successfully managed in a rural secondary tribal health-care center with intravenous antibiotics, analgesics, and serial clinical examination. The patient improved symptomatically and recovered well. Through this case report, the authors would like to highlight that Ludwig's angina can be managed in resource-limited rural surgical centers through early intervention along with adequate monitoring and surgical drainage if required.
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MEDICAL EDUCATIONS Top

Considering medical education research: Selection into medical school p. 194
Jennifer Cleland, Vinay Oommen, Amudha Poobalan
DOI:10.4103/cmi.cmi_28_21  
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Medical education challenges during remote learning: Open book assessments p. 197
Ambarish Das, R Akshaya, Siva Santosh Kumar Pentapati, Manish Taywade, Swayam Pragyan Parida
DOI:10.4103/cmi.cmi_12_21  
Teaching, learning, and assessment methods have changed during the COVID-19 pandemic. The teacher and student need to be acquainted with various options available in such a crisis. The need of the hour is to avoid crowding in medical schools. Open book and virtual assessments are suitable, compelling options. The COVID-19 pandemic has resulted in a transformation from conventional teaching-learning methods to online platform along with other options. Open book examination and assessment are likely to be one of the keys to the new medical education during the pandemic. Loss of professional years can be minimized using the open book examination.
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Connecting with spiritual intelligence in medicine p. 202
Vijayaraghavan Padmanabhan
DOI:10.4103/cmi.cmi_21_21  
While diagnosing and treating patients, the physician makes use of cognitive intelligence (IQ) and emotional intelligence (EQ). Coming up with a concept or treatment that is completely new and yet suitable for a clinical situation requires not only IQ and EQ but also a connection with the physician's own creative “inner self” or “soul,” which is spiritual intelligence (SQ). Such an individual can function from the level of “self” or ego as well as from “inner self” and can move between ego and “soul” with ease. The physician can utilize the unbiased instinctive wisdom of SQ while making use of IQ and EQ. He (or she) will be comfortable in dealing with uncertainties. Individual insights corroborated by studies in neuroscience have helped to understand how IQ and EQ relate to SQ, making it comprehensible to all. Connecting with SQ benefits the physician in patient care as well as in medical education.
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Resuming conventional medical teaching after reopening of medical colleges in India p. 205
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/cmi.cmi_156_20  
The coronavirus disease 2019 (COVID-19) pandemic has accounted for a significant disruption in each and every sector, including medical education. However, to avoid interruption in learning, all the medical colleges have adopted one or the other form of online teaching–learning and assessment to benefit the students. After a wait of more than 8 months, it was decided by the Indian government authorities that all the medical colleges should re-open from December 2020 onward. The regulatory body has proposed a framework and instructed the medical colleges to delay the summative assessments by 2–3 months, so that students are not deprived of learning opportunities, especially pertaining to the practical and clinical interactions. In conclusion, the COVID-19 pandemic has resulted in a major disruption in the effective delivery of medical education in the entire nation. Nevertheless, it is our responsibility to utilize the available time and focus more on teaching practical and clinical skills to benefit the students to the optimal extent.
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Redefining “Health”: A critical reflection exercise for 1st year MBBS students Highly accessed article p. 207
Vijayaprasad Gopichandran
DOI:10.4103/cmi.cmi_30_21  
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Employing situational judgment tests during the medical training: Need of the hour p. 211
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/cmi.cmi_142_20  
In the field of medicine, the assessment of medical students conventionally has been carried out on the basis of academic performance alone. However, it is a fact that a medical professional should possess much more than medical knowledge alone and that's the reason why other core competencies have been defined by the regulatory bodies across the world. This translates to the immense need to assess the professional characteristics of a medical student, as they are equally important attributes in the making of a competent health care professional. Situational judgement test is a tool to assess the non-academic attributes in a medical student and has been acknowledged as an effective method for teaching, training and practicing medicine. In conclusion, the situational judgment test is an extremely cost-effective, valid and reliable approach to assess the non-academic attributes of the medical students in their workplace. This calls for the need to introduce them in all the medical institutions for both undergraduate and postgraduate courses, as it will definitely prepare them for the challenges of clinical practice.
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HISTORY OF MEDICINE Top

A gift in time p. 213
Reena George
DOI:10.4103/cmi.cmi_45_21  
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LETTERS TO THE EDITOR Top

Is high-dose zinc supplementation effective in reducing the symptoms of severe acute respiratory syndrome Coronavirus 2 infection? p. 216
Chidiebere Emmanuel Okechukwu
DOI:10.4103/cmi.cmi_37_21  
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The downregulation of angiotensin-converting enzyme 2 expression may be associated with depression and anxiety among patients with severe acute respiratory syndrome Coronavirus 2 p. 218
Chidiebere Emmanuel Okechukwu
DOI:10.4103/cmi.cmi_47_21  
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