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   Table of Contents - Current issue
Coverpage
October-December 2019
Volume 6 | Issue 4
Page Nos. 199-275

Online since Thursday, November 21, 2019

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REVIEW ARTICLE  

Immunotherapy and its advances in the management of head-and-neck cancer Highly accessed article p. 199
Sajad Ahmad Buch, Laxmikanth Chatra
DOI:10.4103/cjhr.cjhr_155_18  
Head-and-neck squamous cell carcinoma (HNSCC) consists of biologically aggressive tumors of a heterogeneous group. Despite the advances made in the surgical and radiological treatment methods for HNSCC, the limitations in the control of the disease and the treatment-associated toxicity have kept the 5-year overall survival at a dismal rate. The multifactorial methods used for the treatment of HNSCC bring their deleterious effects on patient's quality of life due to lasting xerostomia, sensorineural hearing loss, and diminished swallowing function. The inadequate improvement in the survival rate and associated side effects with the existing treatments have shifted the attention in HNSCC research toward the finding of less toxic and more effective treatments. The outstanding improvements in the survival outcomes of certain advanced cancers treated with immunotherapy have encouraged extensive interest in the field. Cancer surveillance is maintained by a competent immune system, and hence, activation of immune system is included as an overall goal against the cancer. This review explores recent advances in the treatment of HNSCC focusing on immunotherapy describing briefly the developing areas of immunotherapy research, challenges, and future actions for the comprehensive application of immunotherapy in HNSCC.
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ORIGINAL ARTICLES Top

Talk to parents: Bridge the knowledge gap in parents with epileptic children Highly accessed article p. 204
Alexis Varghese, Monika Sharma
DOI:10.4103/cjhr.cjhr_5_19  
Introduction: Parents' attitudes toward children with epilepsy may be influenced by their knowledge of the condition. Parental knowledge regarding epilepsy, its long-term management, likely events, and outcomes is essential in appropriate care of their children. This study was undertaken to identify the level of and possible gaps in knowledge of parents. Methodology: This prospective cross-sectional study was carried out in a tertiary care center, in which 50 caregivers of children with epilepsy took part, after due consent. Data were on a predesigned questionnaire which included questions addressing the type of epilepsy, parents' knowledge of etiology, treatment, untoward events, drug side effects, and emergency care. Observations and Results: Of 50 caregivers, only half of the parents were able to mention the cause of seizures in their child. Half of the parents thought that epilepsy affects intelligence of the child. Most of the parents, i.e., 96% were okay with talking about their child's condition with the family. Most parents (55.93%) brought their children to hospital for emergency care, while 10.16% knew some first aid for acute seizure. Parents of children on polytherapy (41.67%) were more aware of side effects of medicines as compared to parents of children on monotherapy (10.53%) (P = 0.014). Conclusion: Even though a sizable proportion of parents know about the cause of epilepsy in children, very few were equipped with knowledge of first aid care during a seizure. Lack of awareness of drug side effects is another major gap that doctors dealing with epileptic children must address, while talking to parents.
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Knowledge and risk perception of oral cancer among rickshaw drivers in Karad City, Maharashtra, India Highly accessed article p. 207
Hitesh Patil, Nupura A Vibhute, Unnati Shah, Rajendra Baad, Uzma Belgaumi, Vidya Kadashetti, Sushma Bommanavar, Wasim Kamate
DOI:10.4103/cjhr.cjhr_72_18  
Introduction: Rickshaw drivers, who provide an important mode of public transport in urban and semiurban areas in India, are exposed to harmful environmental pollutants, unhealthy lifestyle, irregular meals, poor work posture, and most importantly habits such as tobacco and alcohol. Keeping all this in view, the present study was planned to analyze the knowledge and risk perception of oral cancer among rickshaw drivers in Karad city. Materials and Methods: This cross-sectional, descriptive study was carried out among 300 autorickshaw drivers of Karad city from Western Maharashtra, India. The questionnaire used consisted of various items including tobacco and alcohol consumption, their working hours, and more importantly their awareness toward oral cancer including its early symptoms as well as their self-perceived risk assessment. Results: Out of the 300 autorickshaw drivers studied in the present study, 260 (86.7%) were either smoking or chewing tobacco in some of its forms. Only 36 (12%) of 300 participants thought they should undergo regular screening for oral cancer. Conclusion: Thus, the findings of this study reflect a significant need of increasing cancer awareness among the population of rickshaw drivers. Targeted counseling programs and oral cancer screening programs would enable catching the early signs of cancer and nipping it in its bud.
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Evaluation of infrastructure and financial resources in the Midday Meal Program: An in-depth study in upper primary schools of Kolkata p. 210
Aparajita Dasgupta, Madhumita Dobe, Jayeeta Burman, Sembagamuthu Sembiah
DOI:10.4103/cjhr.cjhr_74_19  
Introduction: The Midday Meal (MDM) Program in India is for primary and upper primary school students. To continue an effective program, infrastructure and financial resources should be both maintained and sustained.Objectives: The objectives of this study are to assess the adequacy of infrastructures and fund support available for the MDM Program of upper primary schools of Kolkata. Methodology: An institutional-based observational study with a cross-sectional design was conducted in government and government-aided schools of Kolkata over a period of 2 years from November 2016 to October 2018. A sample of 52 schools from a total of 515 schools was selected by simple random sampling. Statistical Analysis Used: Data were analyzed using the Statistical Package for the Social Sciences software version 16.0 (IBM, SPSS Inc., Chicago, USA). Descriptive statistics and inferential statistics were performed. Results: Infrastructure was satisfactory in 29 (55.8%) schools and unsatisfactory in 23 (44.2%) schools. There was a statistically significant difference of infrastructure between government schools and government-aided schools (P = 0.043). Financial resource was satisfactory in 88.9% of government schools and 85.7% of government-aided schools and this difference was not statistically significant. Conclusion: This evaluation study showed more than half and most of the schools were satisfactory in terms of infrastructure and financial status of the mid-day meal programme of Upper Primary Schools of Kolkata respectively, still intensified efforts like proper allocation of resources and supervision were needed to fulfill the lacunae.
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A study on awareness of road traffic accidents and their basic management among medical students of Government Medical College, Maharashtra, India p. 216
Abhay Srivastava, Shruti Gaikwad, Pallavi Pagdal, Sudip Bhattacharya
DOI:10.4103/cjhr.cjhr_10_19  
Background: India contributes to one in every ten road traffic accident (RTA) deaths across the world. Aim: The present study was conducted to assess the knowledge and practice toward road safety protocol and the basic life support among medical students. Settings and Design: A descriptive, cross-sectional study was conducted among the undergraduate medical students of 5th and 7th semesters studying in Government Medical College, Maharashtra, India. Materials and Methods: A descriptive, cross-sectional study was conducted during May 2018 to September 2018 among 265 undergraduate medical students in Government Medical College, Maharashtra, India, using a pretested questionnaire. Statistical Analysis: Frequency analysis of data was done, and Chi-square test was applied for the categorical variables using Statistical Package for the Social Sciences(SPSS version-22) Chicago, USA. Results and Conclusion: Our participants belonged to the age group of 19 to 22 years, and 46% of students were female and 54% were male. Majority (57.35%) of the students commute to college by bikes. It was found that nearly half (48.67%) participants wore a helmet occasionally while riding. 9.43% of students admitted that they only carry it with for avoiding traffic police. Nearly one-third (35.84%) of participants were fined in the past for traffic rule violations. The most common traffic violation was driving without a helmet (7.16%). Most (94.33%) of the participants had a good knowledge of road traffic signs. 69.81% of participants responded that they should stop the vehicle and then attend the call. Nearly half (47.16%) of the study participants wrongly interpreted the traffic signals. Only 5.2% of participants knew the correct method to secure the airway in a road traffic accident. Young drivers are a vulnerable age group of drivers worldwide. Our study revealed that only 33 participants rode two-wheelers, who knew about wearing helmets, and practiced it regularly. This is not a good sign at all. About 35.84% of participants were fined in the past for traffic rule violations. These reflected poor practice of traffic rules. Only 5.2% of participants knew the airway management in an RTA. This poor knowledge may be due to the lack of induction training about basic life support. The overall knowledge about RTA and basic management was very poor.
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Impact of the positive deviance approach on breastfeeding practices among tribal pregnant women: A before – After intervention study p. 222
Abhay Srivastava, Kanchan Gwande, Sudip Bhattacharya, Vijay Kumar Singh
DOI:10.4103/cjhr.cjhr_165_18  
Introduction: Breastfeeding is very important for the infant and for the mother. Breastfeeding practices in India and abroad are not up to the mark, and they pose serious health risk to the mothers and the babies. Methodology: This single-group before–after intervention study was conducted to assess the impact of positive deviance (PD) approach on knowledge about exclusive breastfeeding (EBF) practices among tribal pregnant women. The sample size was 376. Data were collected using convenient sampling method. At first, we identified eight positive deviants from that area. They were trained by the investigator regarding EBF practices. They were also motivated to share their knowledge and practices in the community. Results: It was observed that knowledge regarding initiation of breastfeeding (<1 h of birth) increased from 181 (52.2%) to (67.1%) among 347 study participants. Only 81 (23.3%) knew that breastfeeding should be on demand before intervention, which increased by 21% after the intervention. The majority of the study participants, i.e., 286 (82.4%) knew the advantages of breast milk. The proportion of study participants who knew that breastfeeding should not be stopped during mother's illness was 171 (49.3%) before and 229 (66%) after intervention. Before intervention, around one-fourth, that is, 85 (24.5%), knew that if the mother is not producing enough milk, then she should visit a health center which increased to 130 (37.5%) after intervention. The majority of the participants, i.e., 145 (41.8%) knew that bottle feeding should not be done for the babies which increased in proportion to around 55% after intervention. A statistically significant (P < 0.001) increase in knowledge was observed. Conclusion: It is possible to increase the awareness and practice level among the lactating mothers for EBF using the positive deviant approach. Recommendation: The concept of PD approach can be further popularized as they can strengthen our existing health system for better health outcomes in future.
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Blood pressure control in treated hypertensive Nigerians in South-South Nigeria: Experience from Benin city p. 229
Odigie Ojeh-Oziegbe, Igboin Joseph Ikhidero
DOI:10.4103/cjhr.cjhr_160_18  
Background: Systemic hypertension is the most common noncommunicable disease in Nigeria with a plethora of associated clinical conditions and target organ damage. Adequate blood pressure (Bp) reduction with antihypertensive medication is expected to reduce mortality and morbidity. However, although Bp is easy to measure and hypertension responds well to therapy, a significant number of hypertensive patients on medication are not well controlled and hence remain at risk for the complications of hypertension, since a significant number of patients do not reach the goal Bp of ≤140/90 mmHg. Methods: Case notes of 826 hypertensive patients seen over the past 5 years, who have had a minimum period of treatment of 6 months at the Medical Outpatient Department of the University of Benin Teaching Hospital, were retrospectively evaluated. All had antihypertensive medication prescribed and subjectively reported compliance with medications. Adequate Bp control was defined as a systolic Bp of <140 mmHg and a diastolic Bp of <90 mmHg according to the JNC VII definition. Results: There were 826 patients: 353 males and 473 females. Age range was 18–96 years. Mean age was males – 56.54 (±17.34) years and females – 53.83 (±15.1) years. Bp levels of <140/90 mmHg were found in a total of 40.92% of treated patients. Males had a total of 126 controlled out of 353 (35.69%) and females had a total of 212 controlled out of 473 (44.82%). Conclusion: Despite pharmacologic treatment, less than half of our treated patients were able to achieve adequate Bp control. These poor Bp control rates tend to reflect global trends. There is a need to objectively assess factors involved in Bp control so as to achieve a better outcome.
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Burkholderia cepacia complex bacteremia in pediatric intensive care unit in a tertiary care hospital in North India p. 232
Samia Kirmani, Fatima Khan, Neha Kaushal, Mohd Shahid, Neelam Taneja, Ayesha Ahmed
DOI:10.4103/cjhr.cjhr_118_18  
Introduction: Burkholderia cepacia complex (BCC) is a nonfermentative Gram-negative bacillus, now increasingly recognized as an important human pathogen causing hospital-acquired infections. Furthermore, it is a rare cause of sepsis in pediatric age group. Objective: The study aimed to determine the pattern of BCC infection in pediatric intensive care unit (PICU), to explore the antibiotic sensitivity profile, and to identify the source of BCC if any within the PICU. Materials and Methods: The study was conducted in the Department of Microbiology and Pediatrics, JNMC, AMU, Aligarh, for a period of 8 months from January 2017 to August 2017. Matrix-assisted laser desorption/ionization-time-of-flight (MALDI-TOF) was done in the Department of Microbiology, PGI, Chandigarh. All the blood cultures received in the enteric laboratory were screened. The isolates were then identified by standard biochemical techniques, and antimicrobial sensitivity was determined by Kirby–Bauer disc diffusion method as per the Clinical and Laboratory Standards Institute guidelines. Identity was confirmed by MALDI-TOF. As the increasing number of BCC infections was being reported, additional samples were collected from the PICU to identify the source. Results: The study involved 35 cases of blood culture-proven septicemia due to BCC among patients admitted in PICU. The first clustering of cases was noted in January 2017 affecting 6 babies. Six months later in August 2017, a second cluster of cases was noted affecting 24 babies. BCC was isolated in 35 samples. Among 30 patients, 20 were infants (including 13 neonates). Ceftriaxone (100%), minocycline (95%), chloramphenicol (85%), and co-trimoxazole (84.6%) were the most effective drugs followed by levofloxacin (79.1%), meropenem (71.4%), and ceftazidime (48.3%). None of the isolates was found to be sensitive to colistin, polymyxin B, cefepime, and tobramycin. BCC was also isolated from samples of Diurese-Nierenszintigraphie (DNS) and injection fentanyl used in PICU which could have possibly served as a source for further infection. Conclusion: BCC is an important cause of bacteremia with high fatality. It possesses the intrinsic resistance to many potent antibiotics. Proper and timely identification can help reduce the mortality, and implementation of infection control measures is essential.
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Internet gaming disorder in undergraduate medical and dentistry students p. 237
Aishwarya Aggarwal, Jeyaraj Durai Pandian
DOI:10.4103/cjhr.cjhr_117_18  
Introduction: The number of mobile game users has increased considerably over the last few years globally. Medical students are no exception to the increasing trend of gaming. Aim: The aim of this study was to find the prevalence of internet gaming disorder (IGD) and associated behavioral problems in medical and dentistry students. Materials and Methods: This cross-sectional study was conducted on undergraduate medical and dentistry students of Christian Medical College and Christian Dental College, Ludhiana, from July 2016 to October 2016. The self-administered questionnaire was based on the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) criteria for diagnosing IGD. Comparison was made between the individuals with IGD and without IGD for sleep, headache, and cognition-related problems. Chi-square and Student's t-tests were used. P < 0.05 was considered statistically significant. Results: Four hundred students participated in the study, of which 314 (78.5%) were medical and 86 (21.5%) dentistry students. Females 265 (66.2%) were a majority, and the mean age was 20.2 ± 9 years. Thirty-six students (9%) had IGD. Males were more commonly affected (males 22 [61.1%] vs. females 14 [38.9%], P < 0.001). The IGD group was more likely to play the games during classes (IGD group 24 [66.7%] vs. non-IGD group 176 [48.4%], P = 0.036) and tended to skip classes to continue gaming (IGD group 8 [22.5%] vs. non-IGD group 9 [2.5%], P < 0.001). The mean score for sleep and cognition-related problems was higher for the IGD group. Conclusion: IGD is prevalent among professional college students and is associated with sleep, headache, and cognition-related problems.
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Midazolam is effective in controlling intracranial pressure in severe traumatic brain injury p. 242
Smitha Elizabeth George, Jacob Eapen Mathew
DOI:10.4103/cjhr.cjhr_111_18  
Context: Traumatic brain injuries present a grave public health problem in developing countries. Guidelines suggest that neuromuscular blockade (NMB) should be avoided in severe head injury. Midazolam is an affordable option for sedation when resources are limited. Aims: We proposed to study whether midazolam as a sedative agent in severe head injury achieved adequate control of intracranial pressure (ICP) and reduced the need for NMB. Settings and Design: A prospective observational study was conducted in 96 consecutive patients with severe head injury needing ventilation in the neurosurgical intensive care unit (ICU) of our hospital. Subjects and Methods: A modification of “Guidelines for the management of severe head injury, Brain Trauma Foundation” was used to control ICP in these patients. A ventricular catheter was inserted for ICP monitoring and an ICP <20 mm Hg was targeted by cerebrospinal fluid venting, mannitol and increasing the level of sedation with midazolam up to 0.15 mg/kg/h. It was planned to monitor the ICP for a minimum of 48 hours. Results: Mean duration of ICP monitoring was 35.80 ± 23.08 hours. In 63 of the 96 patients, the ICP remained ≤20 mmHG in patients on Midazolam infusion without NMB (65.6%). Conclusions: Sedation with midazolam can be used in a severe head injury to control ICP and to reduce the need for NMB, particularly in resource-poor settings.
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Low occurrence of “spot sign” on computed tomography angiography in acute intracerebral hemorrhage: A single-center prospective study from India p. 248
Vineeth Jaison, Paramdeep Kaur, Yashpal Singh, Uttam Braino George, Jeyaraj Durai Pandian
DOI:10.4103/cjhr.cjhr_102_18  
Background: Intracerebral hemorrhage (ICH) has high mortality and morbidity. The “spot sign” on three-dimensional computerized tomography angiography (3D-CTA) has been associated with hematoma expansion and poorer outcomes. The occurrence of “spot sign” in the Indian population is poorly studied. This study was done to explore the occurrence of “spot sign” in Indian patients with ICH and their outcomes. Methods: Patients with ICH presenting within 48 h from onset to the stroke unit were recruited. They underwent noncontrast computerized tomography (NCCT) head followed by 3D-CTA and a repeat NCCT head before discharge, surgery, or with clinical worsening within 7 days of presentation. Hematoma volume was calculated using the ABC/2 method. The primary outcome was modified Rankin Scale at 3 months. Results were analyzed using descriptive statistics, Fisher's exact test, independent t- test, and Mann–Whitney U-test. The analysis was performed using SPSS version 21. P < 0.05 was taken as statistically significant. Results: Fifty-four patients were recruited during the study period, and only three patients (5.6%) had “spot sign.” All patients with “spot sign” had poor outcome without hematoma expansion. Conclusion: This study shows a low occurrence of “spot sign” in patients with ICH than previously reported. All patients with “spot sign” showed poor outcome.
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Basal cell carcinoma: A 6-year clinicopathological study from the Sub-Himalayan Region of North India p. 254
Rashmi Kaul Raina, Vikram K Mahajan, Tashi Dolma Bodh, Bal Chander, Suman S Chandel, Karaninder S Mehta
DOI:10.4103/cjhr.cjhr_144_18  
Background: Basal cell carcinoma (BCC) has not been studied in the population of the Sub-Himalayan region in the North India, as it has been done in the rest of India. This study was performed to analyze the clinicopathological spectrum of BCC in this population. Materials and Methods: The present study is a hospital-based open-cohort observational study which was carried out in the Departments of Pathology and Dermatology at a tertiary care center of Himachal Pradesh, India, from January 2012 to December 2017. All the patients with the histopathological diagnosis of BCC were included in this study. Results: Of the 46 cases of BCC analyzed during the 6-year study period, 30 (65.3%) cases were female and 16 (34.7%) cases were male. The mean age was 65.7 ± 12.9 years and 31.4% (14/46) were in the 61–70 years age group. Majority of the lesions were located in the head-and-neck area and the nose was the most common site. The most common histological type was the solid variant. Conclusion: This study highlights that BCC is not rare in Indians and is more common in females in this region. This study also reveals the frequency of clinicopathological patterns of BCC in this region.
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CASE REPORTS Top

Bilateral variant origin of the inferior phrenic artery p. 259
Angel, Anjali Jain
DOI:10.4103/cjhr.cjhr_46_19  
The inferior phrenic arteries (IPA) arise from aorta, just above the level of celiac artery. Although descriptions of the right and left phrenic arteries are typically brief, the inferior phrenic arteries have received attention in recent years because of its involvement in treating unresectable hepatocellular carcinoma (HCC) by using transcatheter embolization. Since IPA contributes to the arterial supply of adrenal glands, they are important in angiographic examination of adrenal lesions. During routine dissection for MBBS students, bilateral variant origin of inferior phrenic arteries was observed. In this case, coeliac artery was tortuous and it measured 2 cm in length and 0.6 cm in diameter. The right IPA originated from the coeliac artery as a common trunk. This common trunk divided into two. One branch formed the right IPA and the other branch formed the superior suprarenal artery. On the left side, a common trunk originated from coeliac artery which divided into two branches. One branch joined the splenic artery and the other branch again formed a common trunk which further divided into two i.e superior suprarenal artery and left IPA. In patients with left suprarenal mass or oesophgo- gastric junction hemorrhage, certain interventional procedures such as selective IPA angiography is necessary. Due to variable anatomy of its origin, cannulation of IPA can be challenging. Therefore, the knowledge of this type of variations should be kept in mind by the surgeons and care should be taken to avoid unintentional sectioning of small caliber arteries.
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Situs inversus totalis with symptomatic cholelithiasis: A diagnostic dilemma p. 262
Vishal Bodh, Rajesh Sharma, RS Jhobta, Brij Sharma, Neeti Aggarwal
DOI:10.4103/cjhr.cjhr_96_18  
Situs inversus is a rare autosomal recessive condition, with incidence that varies from 1 in 5000 to 1 in 20,000 live births. Because of the atypical “mirror-image” anatomy associated with situs inversus, diagnosis of gallstone disease in these patients is difficult, especially in those with an unknown history of this condition. We report a case of a young female suspected to have situs inversus on esophagogastroduodenoscopy. Subsequently, she was confirmed to have situs inversus totalis with symptomatic cholelithiasis. She was managed successfully with single-incision laparoscopic cholecystectomy by a right-handed surgeon.
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Accurate diagnosis and sub categorization of benign adenomyoepithelioma of the breast-tubular type: A challenge on core needle biopsy p. 265
Prita Pradhan, Saranya Mohan, Arun K Kumar, Debasis Gochhait, Pampa Chi Toi, Jagdish Sadasivan
DOI:10.4103/cjhr.cjhr_86_18  
Adenomyoepithelioma (AME) is a biphasic myoepithelial tumor with poorly understood histogenesis. Most of these cases have a benign course. They can cause major diagnostic dilemmas, particularly on core needle biopsy. Here we report of a case of a benign adenomyoepithelioma in a fourty-four year old female who presented with hard breast lump, which highlights the diagnostic difficulties encountered on conventional histopathology and the importance of immunohistochemistry in differentiating them from their mimics.
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LETTERS TO EDITOR Top

1894 – The year of discovery of the first “hormone” and the establishment of a medical college in North India p. 268
Sanjay Kalra, Emmy Grewal, Jubbin Jagan Jacob
DOI:10.4103/cjhr.cjhr_2_19  
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Subcutaneous emphysema after emergency endotracheal intubation p. 270
Niraj Kumar Keyal, Niru Nepal, Manish Nakarmi, Sanam Karki
DOI:10.4103/cjhr.cjhr_51_19  
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Blonanserin overdose: A case report p. 272
Sandeep Kumar Goyal, Parambir Singh
DOI:10.4103/cjhr.cjhr_163_18  
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Research in medical education: The road ahead p. 274
Juhi Kalra
DOI:10.4103/cjhr.cjhr_21_19  
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