Indian Journal of Critical Care Medicine

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2023 | June | Volume 27 | Issue 6

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EDITORIAL

Ajith Kumar AK, N Nikhil

Innovations with Validation: An Ingenious Way Forward?

[Year:2023] [Month:June] [Volume:27] [Number:6] [Pages:2] [Pages No:377 - 378]

Keywords: Fit Test, Innovations, N95 respirators, Validation

   DOI: 10.5005/jp-journals-10071-24478  |  Open Access |  How to cite  | 

246

EDITORIAL

Sachin Wali, Shreyas Hanumantrao Gutte

Towards Achieving Nutrition Goal in Critically Ill Patients: Need a Simple Yet Effective Bedside Tool

[Year:2023] [Month:June] [Volume:27] [Number:6] [Pages:2] [Pages No:379 - 380]

Keywords: Caloric target, Clinical outcomes, Critically ill patients, Nutrition, Nutritional support, Nutrition delivery, Proteins, Protocol

   DOI: 10.5005/jp-journals-10071-24480  |  Open Access |  How to cite  | 

327

Original Article

Sulakshana Sulakshana, Dipanjan Chatterjee, Arpan Chakraborty

Extracorporeal Membrane Oxygenation for Severe COVID-19 in Indian Scenario: A Single Center Retrospective Study

[Year:2023] [Month:June] [Volume:27] [Number:6] [Pages:5] [Pages No:381 - 385]

Keywords: Acute respiratory distress syndrome, COVID-19, Extracorporeal membrane oxygenation

   DOI: 10.5005/jp-journals-10071-24469  |  Open Access |  How to cite  | 

Abstract

Background: Initial reports from Wuhan (China) suggested poor outcomes for severe COVID-19 patients treated with Extracorporeal Membrane Oxygenation (ECMO). Extracorporeal Life Support Organization (ELSO) interim 2019 guidelines also recommended using ECMO only when all conventional therapies are exhausted. However, later studies showed that delayed ECMO initiation may lead to longer ECMO runs, offsetting any benefit from resource conservation by delaying the initiation. Hence, this study was intended to analyze the sociodemographic characteristics, type of ECMO, and complications of its outcome in the Indian scenario. Materials and methods: Demographic and patient clinical outcome data of all the patients of severe ARDS due to COVID-19 being treated with ECMO from 1st June 2020 to 31st May 2021 at Medica Super-specialty Hospital (Kolkata, India), were retrospectively compiled and analyzed. Results: Total number of patients treated was 79 with 10% female representation. The mean age was 43 ± 3.2 years and the mean body mass index 37 ± 4.3. Fifty percent of the patient survived. The mean duration of the ECMO run was 17 ± 5.2 days. Sepsis (65%) was the commonest complication observed followed by acute kidney injury (39%). Conclusion: This study provides significant insight into the outcomes of patients of COVID-19 treated by ECMO in the Indian scenario. Mortality rates of COVID-19 patients on ECMO were comparable to the non-COVID-19 patients, although the ECMO run time was relatively longer. Our study concluded that ECMO should be considered as a treatment option in appropriate COVID-19 cases. However, if the capacity diminishes in a pandemic situation, ECMO consideration should be based on more stringent criteria.

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Original Article

Mohamed Kamal, Mominah Bhatti, Warren Christopher Stewart, Moira Johns, David Collins, Yahya Shehabi, Solomon Rajesh Thambiraj, Sumesh Arora

Safety Goggles with Elastic Headband to Improve N95 Fit Following Failed Quantitative Fit Test

[Year:2023] [Month:June] [Volume:27] [Number:6] [Pages:6] [Pages No:386 - 391]

Keywords: COVID-19, Eye protection, Fit Test, Goggles, N95 respirators, Personal protective equipment

   DOI: 10.5005/jp-journals-10071-24473  |  Open Access |  How to cite  | 

Abstract

Introduction: N95 respirators, together with eye protection, form vital elements of personal protective equipment (PPE) for healthcare workers (HCW) caring for patients with respiratory infections, such as COVID-19. Duckbill N95 respirators are widely used but have a high failure rate when Fit Tested. The commonest site for inward leaks is the region between the nose and maxilla. Safety goggles with an elastic headband may press the upper rim of the respirator against the face, thereby reducing inward leaks. We hypothesized that the use of safety goggles with an elastic headband will improve the overall fit-factor of a duckbill N95 respirator and increase the proportion of users who pass a quantitative Fit Test. Methods: About 60 volunteer HCWs, who had previously failed quantitative Fit Testing with a duckbill N95 respirator, participated in this before-and-after intervention study. A PortaCount® 8048 was used for quantitative Fit Testing. The test was first performed with a duckbill N95 respirator only. It was then repeated after participants donned a pair of safety goggles (3M Fahrenheit, ID 70071531621). Results: Before the intervention, i.e., with the respirator only, 8 (13.3%) participants passed their Fit Test. This increased to 49 (81.7%) after the application of safety goggles (OR 42, 95% CI 7.14–1697.9, p < 0.0001). The adjusted mean overall fit factor, using Tobit regression analysis, increased from 40.3 to 193.0 (t = 12.32, p < 0.001). Conclusion: The use of safety goggles with an elastic headband significantly increases the proportion of users who pass a quantitative Fit Test and improves the fit-factor of a duckbill N95 respirator.

293

Original Article

Seongpyo Mun, Seran Kook

Impact of Visual Nutritional Indicator on the Nutritional Therapy in Intensive Care Unit

[Year:2023] [Month:June] [Volume:27] [Number:6] [Pages:5] [Pages No:392 - 396]

Keywords: Clinical outcome, Nutritional support team, Nutritional therapy, Visual nutritional indicator

   DOI: 10.5005/jp-journals-10071-24474  |  Open Access |  How to cite  | 

Abstract

Background: We wanted to evaluate if a visual nutritional indicator (VNI), which shows the total amount of calories and protein, can improve the quality of nutritional therapy (NT) and result in better clinical outcomes prospectively. Materials and methods: We randomly assigned patients to VNI or non-VNI (NVNI) groups. In the VNI group, VNI was attached to the patient's bed for the attending physician. The primary goal was a higher supply of calories and proteins. The secondary goals were the shorter length of intensive care unit (ICU) stay, mechanical ventilation, and renal replacement therapy. Results: The total calorie supply was 18.6 kcal/kg and 15.6 kcal/kg in the VNI and NVNI groups, respectively (p = 0.04). The total protein supply was 0.92 g/kg and 0.71 g/kg, respectively (p = 0.05). The length of ICU stay was 5.6 days and 5.3 days in the VNI and NVNI groups, respectively (p = 0.09). The length of mechanical ventilation was 3.6 days and 3.8 days, respectively (p = 0.07). The length of renal replacement therapy was 5.7 days and 6.3 days, respectively (p = 0.13). The mortality on the seventh day was 14.6% and 16.1% in the VNI and NVNI groups, respectively (p = 0.08). The mortality on the thirtieth day was 20 and 20.8%, respectively (p = 0.87). Conclusion: Visual nutritional indicator, indicating the total amount of calories and protein provided, can improve the quality of NT but fail to obtain a better clinical outcome.

275

Original Article

Asisha Janeela Mathansingh, Arun Jose, Jude Joseph Fleming, Kundavaram Paul Prabhakar Abhilash, Vignesh Kumar Chandiraseharan, Audrin Lenin, Samuel George Hansdak, Ramya Iyyadurai, Thenmozhi Mani, Michael Eddleston

Quantification of Organophosphorus Insecticide Removed by Gastric Lavage in Acutely Poisoned Patients: An Observational Study

[Year:2023] [Month:June] [Volume:27] [Number:6] [Pages:6] [Pages No:397 - 402]

Keywords: Efficacy, Gastric lavage, Insecticide poisoning, Organophosphorus

   DOI: 10.5005/jp-journals-10071-24475  |  Open Access |  How to cite  | 

Abstract

Introduction: The effectiveness of gastric lavage in organophosphorus (OP) poisoning has not been established. We assessed the ability of gastric lavage to remove OP insecticides as a preliminary stage in assessing effectiveness. Patients and methods: Organophosphorus poisoning patients presenting within 6 hours were included, irrespective of prior gastric lavage. A nasogastric tube was placed and gastric contents aspirated, followed by at least three cycles of gastric lavage with 200 mL of water. Samples from the initial aspirate and the first three lavage cycles were sent for identification and quantification of the OP compounds. Patients were monitored for complications of gastric lavage. Results: Around 42 patients underwent gastric lavage. Eight (19.0%) patients were excluded from the study because of a lack of analytical standards for ingested compounds. Insecticides were detectable in the lavage samples of 24 of 34 (70.6%) patients. Lipophilic OP compounds were detected in 23 of 24 patients, while no hydrophilic OP compounds could be detected in six patients with reported ingestion of hydrophilic compounds. For chlorpyrifos poisoning (n = 10), only 0.65 mg (SD 1.2) of the estimated ingested amount (n = 5) of 8,600 mg (SD 3,200) was recovered by gastric lavage. The mean proportion of the compound removed by initial gastric aspirate was 79.4% and subsequent three cycles removed 11.5, 6.6, and 2.7%. Conclusion: Lipophilic OP insecticides could be quantified in the stomach contents of OP poisoning patients with the first aspiration or lavage being most effective. The amount removed was very low; hence, routine use of gastric lavage for OP poisoning patients arriving within 6 hours is unlikely to be beneficial.

571

Original Article

Dineshbabu Sekar, Mohamed Rameesh, Jayaram Saibaba, Divya Raman

Clinical Profile, Corticosteroid Usage and Predictors of Mortality in Near-hanging Patients: A Five-year, Single-center Retrospective Study

[Year:2023] [Month:June] [Volume:27] [Number:6] [Pages:8] [Pages No:403 - 410]

Keywords: Dexamethasone, Glasgow outcome score, Hanging-induced cardiac arrest, India, Intensive care, Near hanging, Steroids

   DOI: 10.5005/jp-journals-10071-24477  |  Open Access |  How to cite  | 

Abstract

Background: Hanging is the most common method of suicide in India. When near-hanging patients reach the hospital for treatment, their neurological outcome ranges from full recovery to severe neurological impairment or death. This study looked at the clinical profile, usage of corticosteroids and predictors of mortality in near-hanging patients. Materials and methods: This retrospective study was conducted from May 2017 to April 2022. Demographic, clinical, and treatment details were collected from case records. Neurological outcome at discharge was assessed using the Glasgow Outcome Scale (GOS). Results: The study involved 323 patients, 60% of men with a median (interquartile range) age of 30 (20–39). At the time of admission, the Glasgow Coma Scale (GCS) ≤8 in 110 (34%) patients, hypotension was present in 43 (13.3%) of patients, and 21 (6.5%) had hanging-induced cardiac arrest. About 101 patients required intensive care unit care. Corticosteroid therapy was given to 219 patients (67.8%) as part of anti-cerebral edema measures. Good neurological recovery was found (GOS-5) in 84.2% of patients, and the death rate (GOS-1) was 9.3%. Univariate logistic regression showed that usage of corticosteroids is significantly associated with poor survival (p < 0.02, odds ratio 4.7). In the multivariable logistic regression analysis, GCS ≤8, hypotension, need for intensive care, hanging-induced cardiac arrest, aspiration pneumonia, and severe cerebral edema were found to be significantly associated with mortality. Conclusion: The majority of near-hanging patients had a good neurological recovery. Corticosteroids were used in two-thirds of the study population. There were multiple variables associated with mortality.

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Original Article

Anitha Gunalan, Apurba Sankar Sastry, Venkateswaran Ramanathan, Sujatha Sistla

Early- vs Late-onset Ventilator-associated Pneumonia in Critically Ill Adults: Comparison of Risk Factors, Outcome, and Microbial Profile

[Year:2023] [Month:June] [Volume:27] [Number:6] [Pages:5] [Pages No:411 - 415]

Keywords: Healthcare-associated infections, Intubation, Ventilator, Ventilator-associated pneumonia

   DOI: 10.5005/jp-journals-10071-24465  |  Open Access |  How to cite  | 

Abstract

Background: Ventilator-associated pneumonia (VAP) is one of the most frequent hospital-acquired infections, which develops in mechanically ventilated patients after 48 hours of mechanical ventilation. The purpose of this study was to determine the incidence rate, various risk factors, microbiological profile, and outcome of early- vs late-onset ventilator-associated pneumonia (VAP) in medical intensive care unit (MICU). Materials and methods: This prospective study was conducted on 273 patients admitted to the MICU in JIPMER, Puducherry, from October 2018 to September 2019. Results: The incidence of VAP was 39.59 per 1000 ventilation days of MICU patients (93/273). Of these, 53 (56.9%) patients had early-onset VAP and 40 (43.1%) had late-onset VAP. Multiple logistic regression analysis showed that steroid therapy, supine head position, coma or impaired unconsciousness, tracheostomy, and re-intubation were found to be independent predictors of early- and late-onset VAP, respectively. Most cases of VAP were caused by Gram-negative bacteria (90.6%), with nonfermenters contributing to 61.8%. The most frequent pathogens causing early-onset VAP were Acinetobacter baumannii (28.9%) and Pseudomonas aeruginosa (20.6%), while in late-onset VAP, A. baumannii (32.9%) and Klebsiella pneumoniae (21.9%) were the most common. Maximum death rate was seen in patients infected with Escherichia coli (50%) and Stenotrophomonas maltophilia (38.5%). There was no significant association between the presence of VAP and mortality among the studied population. Conclusion: The incidence of VAP in our study was high. There were no significant differences in the prevalence of pathogens associated with early-onset or late-onset VAP. Our study shows that early-onset and late-onset VAP have different risk factors, highlighting the need for developing different preventive and therapeutic strategies.

707

Original Article

Benyamin Hoseini, Seyyed Mohammad Tabatabaei

Comparison of Six Scoring Systems for Predicting In-hospital Mortality among Patients with SARS-COV2 Presenting to the Emergency Department

[Year:2023] [Month:June] [Volume:27] [Number:6] [Pages:10] [Pages No:416 - 425]

Keywords: COVID-19, Emergency department, Mortality prediction, Performance measures, Scoring system

   DOI: 10.5005/jp-journals-10071-24463  |  Open Access |  How to cite  | 

Abstract

Background: The study aimed to compare the prognostic accuracy of six different severity-of-illness scoring systems for predicting in-hospital mortality among patients with confirmed SARS-COV2 who presented to the emergency department (ED). The scoring systems assessed were worthing physiological score (WPS), early warning score (EWS), rapid acute physiology score (RAPS), rapid emergency medicine score (REMS), national early warning score (NEWS), and quick sequential organ failure assessment (qSOFA). Materials and methods: A cohort study was conducted using data obtained from electronic medical records of 6,429 confirmed SARS-COV2 patients presenting to the ED. Logistic regression models were fitted on the original severity-of-illness scores to assess the models’ performance using the Area Under the Curve for ROC (AUC-ROC) and Precision-Recall curves (AUC-PR), Brier Score (BS), and calibration plots were used to assess the models’ performance. Bootstrap samples with multiple imputations were used for internal validation. Results: The mean age of the patients was 64 years (IQR:50–76) and 57.5% were male. The WPS, REMS, and NEWS models had AUROC of 0.714, 0.705, and 0.701, respectively. The poorest performance was observed in the RAPS model, with an AUROC of 0.601. The BS for the NEWS, qSOFA, EWS, WPS, RAPS, and REMS was 0.18, 0.09, 0.03, 0.14, 0.15, and 0.11 respectively. Excellent calibration was obtained for the NEWS, while the other models had proper calibration. Conclusion: The WPS, REMS, and NEWS have a fair discriminatory performance and may assist in risk stratification for SARS-COV2 patients presenting to the ED. Generally, underlying diseases and most vital signs are positively associated with mortality and were different between the survivors and non-survivors.

421

Original Article

Sonu Sama, Ritika Abrol, Renu Dhasmana, Neha Sharma, Sushant Khandhuri, Rahul Chauhan, Prateek Dwivedi

Effect of Implementation of an Eyecare Bundle on Incidence of Exposure Keratopathy in Intensive Care Unit of Tertiary Care Center in North India

[Year:2023] [Month:June] [Volume:27] [Number:6] [Pages:7] [Pages No:426 - 432]

Keywords: Exposure keratopathy, Eyecare bundle, Ocular surface diseases

   DOI: 10.5005/jp-journals-10071-24470  |  Open Access |  How to cite  | 

Abstract

Background: Lack of eyecare protective measures especially in unconscious and sedated critically ill patients, make them prone to ocular surface diseases (OSDs), e.g., exposure keratopathy. This study is aimed to frame an algorithm-based approach to eyecare via eyecare bundle to bring down the burden of OSDs in critically ill patients especially in resource-limited settings. Materials and methods: After clearance from institutional ethical committee, a quasi-experimental single center study was conducted over a period of 6 months. Incidence of exposure keratopathy was calculated before and after induction of eyecare bundle and was compared. Statistical analysis was done using SPSS software v20. p-value of less than 0.05 was considered significant. Results: A total of 218 patients were enrolled in the study after obtaining informed written consent and after fulfilling inclusion criteria. Patients were divided into control and experimental groups, with baseline characteristics similar in both the groups, respectively, in terms of gender, age (40 years), APACHE II score, and specialty distribution except predominantly medical patients in experimental group. In control group (n = 99), total 69 patients (41 medical and 28 surgical) developed exposure keratopathy, while in experimental group (n = 109) only 15 patients (6 medical and 9 surgical) developed exposure keratopathy, hence a significant reduction was observed. Further follow-up of patients in the experimental group was also done on Days 5 and 7, respectively. Conclusion: The proposed protocolized algorithm-based eyecare bundle significantly reduced the incidence of exposure keratopathy in sedated, mechanically ventilated, and vulnerable critically ill patients.

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Original Article

Girish Kanna, Rajeev A Annigeri

Prevalence of Augmented Renal Clearance (ARC), Utility of Augmented Renal Clearance Scoring System (ARC score) and Augmented Renal Clearance in Trauma Intensive Care Scoring System (ARCTIC score) in Predicting ARC in the Intensive Care Unit: Proactive Study

[Year:2023] [Month:June] [Volume:27] [Number:6] [Pages:11] [Pages No:433 - 443]

Keywords: ARC score, ARCTIC score, Augmented renal clearance, Creatinine clearance

   DOI: 10.5005/jp-journals-10071-24479  |  Open Access |  How to cite  | 

Abstract

Objectives: We aimed to study the prevalence of augmented renal clearance (ARC) and validate the utility of ARC and ARCTIC scores. We also aimed to assess the correlation and agreement between estimated GFR (eGFR-EPI) and 8-hour measured creatinine clearance (8 hr-mCLcr). Study design and methodology: This was a prospective, observational study done in the mixed medical-surgical intensive care unit (ICU) and 90 patients were recruited. 8 hr-mCLcr, ARC, and ARCTIC scores and eGFR-EPI were calculated for all patients. ARC was said to be present if 8 hr-mCLcr was ≥ 130 mL/min. Results: Four patients were excluded from the analysis. The prevalence of ARC was 31.4%. The sensitivity, specificity, and positive and negative predictive values of ARC and ARCTIC scores were found to be 55.6, 84.7, 62.5, 80.6, and 85.2, 67.8, 54.8, and 90.9 respectively. AUROC for ARC and ARCTIC scores were 0.802 and 0.765 respectively. A strong positive correlation and poor agreement were observed between eGFR-EPI and 8 hr-mCLcr. Conclusion: The prevalence of ARC was significant and the ARCTIC score showed good potential as a screening tool to predict ARC. Lowering the cut-off of ARC score to ≥5 improved its utility in predicting ARC. Despite its poor agreement with 8 hr-mCLcr, eGFR-EPI with a cut-off ≥114 mL/min showed utility in predicting ARC.

449

Original Article

Sampada A Patwardhan, Shweta Panchakshari, Ramya Sambasivam, Surabhi Dhupad, Rajeev N Soman, Amrita P Prayag

Ceftazidime-avibactam with or without Aztreonam vs Polymyxin-based Combination Therapy for Carbapenem-resistant Enterobacteriaceae: A Retrospective Analysis

[Year:2023] [Month:June] [Volume:27] [Number:6] [Pages:7] [Pages No:444 - 450]

Keywords: Carbapenems, Carbapenem-resistant enterobacteriaceae, Ceftazidime-avibactam, Gram-negative sepsis, Polymyxin

   DOI: 10.5005/jp-journals-10071-24481  |  Open Access |  How to cite  | 

Abstract

Introduction: Gram-negative sepsis remains one of the most difficult to treat infections in intensive care units (ICUs). Carbapenems are often considered to be robust and reliable options for treating infections due to Gram-negative bacteria. The dominance of carbapenem-resistant enterobacteriaceae (CRE) has emerged as one of the greatest challenges faced by the medical community today. Carbapenem-resistant enterobacteriaceae may be resistant to all beta lactam antimicrobials including carbapenems and often, are even resistant to other classes of drugs. There are limited studies comparing polymyxin-based therapies with ceftazidime-avibactam (CAZ-AVI)-based therapies for treating infections caused by CRE. Methods: A retrospective study comparing outcomes between patients with bacteremia caused by CRE treated with polymyxin-based combination therapy and CAZ-AVI-based therapy (with or without aztreonam). Results: Of total 104 patients, 78 (75%) were in the CAZ-AVI group. There was no significant difference in the underlying comorbidities between the two groups. The incidence of nephrotoxicity was significantly higher in the polymyxin group (p = 0.017). Ceftazidime-avibactam-based therapy was 66% less likely to be associated with day 14 mortality (p = 0.048) and 67% less likely to be associated with day 28 mortality (p = 0.039) as compared with polymyxin-based therapy. Conclusion: Ceftazidime-avibactam-based therapy may be a superior option to polymyxin-based therapy for infections caused by CRE. This can have significant practical applications, in terms of optimizing therapy for the individual patient as well as sparing polymyxins and reducing the use of polymyxins in our hospitals.

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LETTER TO THE EDITOR

Parikshit Shirish Prayag

Author Reply: Therapeutic Drug Monitoring of Isavuconazole: Lessons Learnt from a Real-life Setting in a Tertiary Care Center in India

[Year:2023] [Month:June] [Volume:27] [Number:6] [Pages:1] [Pages No:451 - 451]

Keywords: Fungal infections, Isavuconazole, Therapeutic drug monitoring

   DOI: 10.5005/jp-journals-10071-24471  |  Open Access |  How to cite  | 

240

LETTER TO THE EDITOR

Jes Jose

Optic Nerve Sheath Diameter in Hyponatremia: A Closer Look

[Year:2023] [Month:June] [Volume:27] [Number:6] [Pages:1] [Pages No:452 - 452]

Keywords: Hyponatremia, Optic nerve sheath diameter, Ultrasonography

   DOI: 10.5005/jp-journals-10071-24454  |  Open Access |  How to cite  | 

390

LETTER TO THE EDITOR

Upendra Hansda, Ijas Muhammed Shaji, Sanjeed Uttanganakam

Reply: Optic Nerve Sheath Diameter in Hyponatremia: A Closer Look

[Year:2023] [Month:June] [Volume:27] [Number:6] [Pages:1] [Pages No:453 - 453]

Keywords: Hyponatremia, Optic nerve sheath diameter, Ultrasonography

   DOI: 10.5005/jp-journals-10071-24468  |  Open Access |  How to cite  | 

229

LETTER TO THE EDITOR

Ripenmeet Salhotra

Therapeutic Drug Monitoring of Isavuconazole—But What about the Critically Ill?

[Year:2023] [Month:June] [Volume:27] [Number:6] [Pages:2] [Pages No:454 - 455]

Keywords: Antifungal treatment, Isavuconazole, Pharmacokinetics in critically ill, Therapeutic drug monitoring

   DOI: 10.5005/jp-journals-10071-24450  |  Open Access |  How to cite  | 

Abstract

Data on therapeutic drug monitoring of novel, broad-spectrum, and promising antifungal agent Isavuconazole sheds light on factors associated with subtherapeutic drug levels, however, a few other parameters, which characterize the critically ill patients, if included in the analysis, would have improved the understanding of drugs pharmacokinetics in this subset.

250

LETTER TO THE EDITOR

BG Arun

High-flow Tracheal Oxygenation with Airway Exchange Catheter: A Novel Approach

[Year:2023] [Month:June] [Volume:27] [Number:6] [Pages:1] [Pages No:456 - 456]

Keywords: Airway exchange catheter, High-flow oxygen, High-flow tracheal oxygenation

   DOI: 10.5005/jp-journals-10071-24476  |  Open Access |  How to cite  | 

247

Erratum

Erratum to “Fogging of Protective Eyewear in Intensive Care Unit and A Comparative Study of Techniques to Reduce It”

[Year:2023] [Month:June] [Volume:27] [Number:6] [Pages:1] [Pages No:457 - 457]

   DOI: 10.5005/jp-journals-10071-24472  |  Open Access |  How to cite  | 

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