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   Table of Contents - Current issue
October-December 2019
Volume 9 | Issue 4
Page Nos. 191-258

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Radiocontrast media: Applications and concerns p. 191
Rajiv Mahajan, Pushpinder Singh
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Emergency focused assessment with sonography in blunt trauma abdomen p. 193
Shradha Engles, Navdeep Singh Saini, Shubra Rathore
Background: Focused assessment with sonography in trauma (FAST) being a rapid noninvasive examination is used primarily to evaluate for the evidence of traumatic free fluid suggestive of injury in the peritoneal, pericardial, and pleural cavities. It is widely recognized as a mainstream emergency skill in the management of trauma. Aim: The aim of the study is to evaluate the accuracy of FAST in patients presenting with blunt abdominal trauma. Methods: Data were collected prospectively from FAST scans conducted in blunt trauma abdomen (BTA) patients. Positive and negative FAST scans were confirmed either with contrast-enhanced computed tomography (CECT) abdomen or with exploratory laparotomy, thus dividing it further into four groups, i.e., true-positive, false-positive, true-negative, and false-negative scans. After collecting the data, accuracy of FAST was calculated. Results: In this study, a total of 104 patients were included. The mean age was 38.17 years. Most common cause of BTA was road traffic accident. The overall sensitivity, specificity, and accuracy of FAST were 69.8%, 92.1%, and 80.8%, respectively. Conclusion: This study showed that FAST is of paramount importance in patients who are hemodynamically unstable as it has a high positive predictive value. However, a FAST-negative result should always be confirmed by other modalities.
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Cutaneous manifestations of human immunodeficiency virus/Aids patients in Albania p. 197
Erjona Shehu, Arjan Harxhi, Artan Simaku
Context: Dermatologic diseases are common in the human immunodeficiency virus (HIV)-infected population. Cutaneous manifestations of HIV disease may result from HIV infection itself or from opportunistic disorders secondary to the declined immunocompetence due to the disease. Aims: The aim of this study is to determine the pattern of c0utaneous manifestations in HIV in an adult HIV Clinic in Tirana. Subjects and Methods: This is a retrospective study including 355 HIV-positive patients with cutaneous manifestations who referred to the Ambulatory Clinic for HIV/AIDS, at the Infective Service and Dermatology Service of University Hospital Centre “Mother Theresa,” Tirana, Albania over the period 2008–2015. Results: The mean age of patients was 43.08 (±11.8) years, with a range 15–79 years. Two hundred and forty-seven (69.6%) of patients were male and 108 (30.4%) female. Male-to-female ratio is 2.3:1. The study found a significant trend of increasing incidence of dermatological pathologies with increasing stage of the disease. Fifty-five (15.5%) of patients with cutaneous lesions were in Stage 1, 132 (37.2%) in Stage 2, and 168 (47.4%) in Stage 3 (P < 0.001). As for the HIV transmission method, the majority of patients (71%) were infected through heterosexual contact, followed by homosexual contact (16.3%), blood transfusion (3.4%), injecting drug user (2.3%), while for 7% of patients the mode of transmission was unknown. Conclusions: Early recognition of the cutaneous manifestation can help in better management of HIV infection in resource-poor setting, as it can indicate the progression of the disease and underlying immune status.
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Evaluation of peripartum depression in females p. 201
Gurkirat S Sidhu, Tanvir Kaur Sidhu, Prabhjot Kaur, Dhruvendra Lal, Navpreet K Sangha
Background: Depression is the most common mental health condition affecting perinatal women and mothers worldwide. Worldwide, about 10% of pregnant women and 13% of women who have given birth experience a mental disorder, primarily depression. In developing countries like India, this is even higher, i.e., 15.6% during pregnancy and 19.8% after childbirth. The present study was initiated with the objective of studying the prevalence of depression among women in the peripartum period and to find the association of peripartum depression and its risk factors. Materials and Methods: This was a hospital-based cross-sectional study, including mothers in antenatal and postnatal period. A sample size of 200 was calculated using Daniels' formula. A questionnaire was administered by the investigator in vernacular language by an interview technique for assessing awareness and behavior of all participants. The Edinburgh Postnatal Depression Scale was used to identify the patients at the risk of depression. Written informed consent was taken from every participant. Results: The prevalence of peripartum depression was 14%. Younger age group (not <18 years), working female, joint family, first pregnancy, social support from in-laws, and not having desire/pressure for a male child were found to be associated with a lower prevalence of peripartum depression. Other variables which were not significantly associated with peripartum depression were education of the participants and their husbands and urban/rural locality. Conclusion: The prevalence of peripartum depression is quite high and is negatively associated with first pregnancy, joint family, and working status.
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A study on hepatitis B viral seromarkers and associated risk factors among the patients suffering from acute and chronic hepatitis B infection p. 206
P Prabina, S Jayanthi, C Krishna Murthy, S Babu Kumar, AS Shameem Banu, SR Sakunthala, J Perumal
Background: Hepatitis B viral infection is the most common cause of hepatitis, and it leads to serious liver diseases such as cirrhosis and hepatocellular carcinoma. Aim: The aim of the study is to differentiate acute hepatitis B and chronic hepatitis B (CHB) among patients seropositive for hepatitis B surface antigen (HBsAg). Materials and Methods: This study was carried out in the Department of Microbiology, Chettinad Hospital and Research Institute, Kelambakkam, Tamil Nadu, India, for a period of 6 months (January 2018–June 2018). Blood samples were collected from 87 patients for the detection of hepatitis B virus (HBV) serological markers. HBsAg, hepatitis B e antigen (HBeAg), anti-HBc total, anti-HBc IgM, and antibody to hepatitis B surface antigen were screened using the ELISA method. Detailed demographic profile including history of previous hepatitis infection, previous blood transfusion, and other related details were collected and documented using a structured questionnaire. Results: A total of 87 patients were HBsAg seropositive; among them, 55 (63.2%) were male and 32 (36.9%) were female. Based on the serological markers tested, 24 and 63 were suffering from acute and chronic HBV infections, respectively. Among the acute hepatitis B patients, all samples were seropositive for HBsAg, anti-HBc total, and anti-HBc IgM. HBeAg seromarker was found in 15 patients (62.5%). Among the CHB patients, all samples were seropositive for HBsAg and anti-HBc total. HBeAg seromarker was found in 28 patients with 44.4%. Alcohol consumption was the major risk factor for the transmission of HBV infection. Conclusion: An increased sample size and detailed study of high-risk behavior will provide an alarming awareness of their association.
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Human papillomavirus detection in oropharyngeal squamous cell carcinoma using p16 immunohistochemistry p. 212
Annetmary Sabu, NV Ratna Mouli, N Tejaswini, V Rohit, G Nishitha, Divya Uppala
Introduction: Oral cancer ranks third among all cancers in the Indian population with approximately 45% of call cancer cases in India being diagnosed as oral cancer, among which 20%–50% of the cases are observed to be associated with human papillomavirus (HPV) infection. Aim: This study aims to detect and evaluate the presence of p16 in oropharyngeal squamous cell carcinoma (OPSCC) patients using immunohistochemistry (IHC). Materials and Methods: This study was based on samples collected from 21 patients with primary OPSCC who were diagnosed and treated during the period of December 2017–March 2018. Inclusion criteria were complete clinicopathologic data, adequate clinical follow-up, and availability of sufficient paraffin-embedded tumor material. HPV immunoreactivity was further investigated by means of IHC using p16 as a marker. Results: IHC results revealed p16 positivity in six OPSCC cases. There was no statistically significant association of the p16 positivity of HPV with the age, gender, or site. Conclusion: Our results suggest that IHC-based detection of p16 provides a suboptimal prognostic information if not combined with detection of HPV DNA. Although p16 expression and HPV DNA infection are correlated with HPV-associated OPSCCs, neither of the tests alone is the optimal method for HPV status detection.
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Effect of iodinated contrast media on serum electrolyte concentrations in patients undergoing routine contrast computed tomography scan procedure p. 217
Sindhu Sankaran, Gautom Kumar Saharia, Suprava Naik, Manaswini Mangaraj
Background and Objectives: Being hypertonic solutions, iodinated contrast media such as iohexol can cause a shift of fluids and electrolytes between different compartments of the body, but there is an ongoing discrepancy in data and current studies as to the effect of iodinated contrast media on serum electrolytes. Hence, this hospital-based prospective clinical observational study was carried out with objectives of evaluating the changes in serum electrolyte concentrations with intravenous iodinated contrast media administration in adult population and to correlate the changes in electrolyte concentrations, if any, with the demographic profile of the patients. Materials and Methods: We analyzed 103 numbers of adult patient samples over a period of 2 months by collecting blood both before administration of contrast and after 24 h of the contrast-enhanced computed tomography scan procedure. Serum concentrations of sodium, potassium, chloride, and ionized calcium were measured using Eschweiler Combiline analyzer based on ion-selective electrode principle. Results: The mean age of the study population in our study was 40.11 ± 20.51 years. We found that changes in serum sodium and chloride concentration after administration of contrast media are significant (sodium: 136.29 ± 3.53 vs. 132.49 ± 6.36 mmol/L and chloride: 100.03 ± 0.70 vs. 97.53 ± 0.70 mmol/L). Sodium concentration shows more decrease in females compared to males after administration of iodine contrast. The most probable reason for this decrease in serum electrolytes was secondary changes to hemodilution due to high osmolality of the contrast. Conclusions: Attending physicians must be alert for such possibilities of changes in electrolytes after contrast administration and be prepared to treat any adversity if one occurs.
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Evaluation of single-nucleotide polymorphisms of transcription factor 7-like 2 and ATP2B1 genes as cardiovascular risk predictors in chronic kidney disease p. 221
Sweta Kulkarni, M Lenin, R Ramesh, Silvia CR Wilma Delphine, Kuzhandai Velu
Introduction: Cardiovascular disease (CVD) is the primary cause of morbidity and premature mortality in chronic kidney disease (CKD). The transcription factor 7-like 2 (TCF7L2) gene product TCF4 is a transcription factor that acts as a downstream effector in the canonical Wnt signaling pathway and may be important in the development of both type 2 diabetes and renal development and disease. It is, therefore, plausible that mutations in this gene could manifest themselves in reduced kidney function or kidney disease through their effects on hyperglycemia as well as independent of this mechanism. The ATP2B1 gene encodes the plasma membrane calcium ATPase isoform 1, which removes bivalent calcium ions from eukaryotic cells against very large concentration gradients and is responsible for controlling the contraction and dilation of vascular smooth muscles. Aim and Objectives: The aims of this study are (1) to evaluate single-nucleotide polymorphisms (SNPs) of TCF7L2 gene as cardiovascular risk predictors in CKD and (2) to evaluate SNPs of ATP2B1 gene as cardiovascular risk predictors in CKD. Subjects and Methods: Fifty clinically diagnosed CKD patients in the age group between 20 and 60 years of both genders were selected as cases and fifty healthy participants from the master health checkup department were selected as controls. Genomic DNA was extracted based on the spin column kit method. The DNA samples were stored at −20°C until analysis. Genotyping for TCF7L2 gene rs7903146 (C/T) and ATP2B1 gene rs11105354 (A/G) was carried out through polymerase chain reaction. Results: T allele frequency was observed in 12 controls and 23 cases (odds ratio [OR] = 2.2, 95% confidence interval [CI]: 1.0–4.7). CC genotype was observed in 38 controls and 27 cases and CT genotype in 22 cases and 12 controls. A allele was found in 38 cases and 23 controls (OR = 2, 95% CI: 1.1–3.8). The mean values of cholesterol, low-density lipoprotein, triglycerides, glucose, insulin, urea, and creatinine were high in cases when compared to controls. Conclusion: T allele of TCF7L2 gene rs7903146 (C/T) and A allele of ATP2B1 (A/G) gene rs11105354 (A/G) are associated with CVD in CKD patients.
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Use of machine learning algorithms for prediction of fetal risk using cardiotocographic data Highly accessed article p. 226
Zahra Hoodbhoy, Mohammad Noman, Ayesha Shafique, Ali Nasim, Devyani Chowdhury, Babar Hasan
Background: A major contributor to under-five mortality is the death of children in the 1st month of life. Intrapartum complications are one of the major causes of perinatal mortality. Fetal cardiotocograph (CTGs) can be used as a monitoring tool to identify high-risk women during labor. Aim: The objective of this study was to study the precision of machine learning algorithm techniques on CTG data in identifying high-risk fetuses. Methods: CTG data of 2126 pregnant women were obtained from the University of California Irvine Machine Learning Repository. Ten different machine learning classification models were trained using CTG data. Sensitivity, precision, and F1 score for each class and overall accuracy of each model were obtained to predict normal, suspect, and pathological fetal states. Model with best performance on specified metrics was then identified. Results: Determined by obstetricians' interpretation of CTGs as gold standard, 70% of them were normal, 20% were suspect, and 10% had a pathological fetal state. On training data, the classification models generated by XGBoost, decision tree, and random forest had high precision (>96%) to predict the suspect and pathological state of the fetus based on the CTG tracings. However, on testing data, XGBoost model had the highest precision to predict a pathological fetal state (>92%). Conclusion: The classification model developed using XGBoost technique had the highest prediction accuracy for an adverse fetal outcome. Lay health-care workers in low- and middle-income countries can use this model to triage pregnant women in remote areas for early referral and further management.
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Avanafil inhibits the contractility of the isolated caprine detrusor muscle p. 231
Aakash Dhruva, Venkata kuppuswamy Hamsavardhini, Shiny Kamatham, Anushka Kataria, Aniket Kumar, Margaret Shanthi, Jacob Peedicayil
Context: Avanafil is a smooth muscle relaxant that is clinically used to treat erectile dysfunction. It is an inhibitor of phosphodiesterase-5 (PDE5), the enzyme that catalyzes the metabolism of cyclic guanosine monophosphate (cGMP). The inhibitory effect of avanafil on isolated detrusor muscle contractility has not been studied. Aims: This study investigated the inhibitory effect of avanafil on isolated caprine (goat) detrusor muscle contractility and the possible mechanisms involved. Settings and Design: 80 mM potassium chloride (KCl)-induced contractility of the isolated goat detrusor was studied using a physiograph. Materials and Methods: Ten caprine detrusor strips were made to contract using 80 mM KCl before and after addition of three concentrations (10, 30, and 60 μM) of avanafil. Three reversal agents, ODQ, a guanylyl cyclase inhibitor; glibenclamide, an adenosine triphosphate (ATP)-sensitive potassium channel blocker; and iberiotoxin, a calcium-sensitive potassium (BKCa) channel blocker, were investigated for their ability to reverse the inhibitory effect of 30 μM avanafil on KCl-induced detrusor contractility. Statistical Analysis Used: The nonparametric statistical test, Kruskal–Wallis test, was used for the analysis of the data. Results: Avanafil caused a statistically significant inhibition of detrusor contractility at 30 and 60 μM concentrations. The inhibitory effect of 30 μM avanafil on detrusor contractility was significantly reversed by the addition of ODQ, glibenclamide, and iberiotoxin. Conclusions: Avanafil inhibits the contractility of the isolated detrusor by inhibiting PDE5, leading to raised cellular levels of cGMP. The raised levels of cGMP could have inhibited detrusor contractility by activating cGMP-dependent protein kinase, by opening ATP-sensitive potassium channels, and by opening BKCa. Avanafil could be evaluated for treating clinical conditions requiring relaxation of the detrusor like overactive bladder.
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Study of association of C-reactive protein with maternal chorioamnionitis and early-onset neonatal sepsis in premature rupture of membranes deliveries: A diagnostic dilemma p. 236
Aabha Suryavanshi, Ruchi Kalra
Introduction: Term prelabor rupture of membranes and preterm premature rupture of membranes (PROM), both pose significant risk to the mother and the fetus. Early identification of sepsis is essential as the mother has risk of chorioamnionitis and neonate is at the risk of early-onset sepsis. Aim: To evaluate the diagnostic value of positive maternal C-reactive protein (CRP) in association with maternal clinical chorioamnionitis and early-onset neonatal sepsis (EONS) in PROM deliveries after 28 weeks of gestation. Methodology: The study was conducted at People's College of Medical Science and Research Centre, Bhopal, from June 1, 2017, to May 31, 2018. Maternal serum CRP test was correlated to the signs of maternal chorioamnionitis and signs of EONS within 72 h of life. Results: The maternal CRP test was compared to clinical signs of chorioamnionitis. Sensitivity of CRP for diagnosing maternal chorioamnionitis was 48% (95% confidence interval [CI] −35.99–61.12), specificity was 81 (95% CI 71.55%–88.98%), and odds ratio of maternal chorioamnionitis was 4.1176 (95% CI 1.99–8.51) with P < 0.0001. Sensitivity of positive maternal CRP in diagnosing EONS was 56.67% (95% CI 43.24%–69.41%), specificity was 84.78% (95% CI 75.79%–91.42%), and odds ratio of neonatal sepsis in maternal CRP positive was 7.28 (95%CI 3.39–15.64) with P < 0.0001. Conclusion: Our study suggests that in PROM deliveries, if maternal CRP test is positive, then it indicates early delivery and neonate screening for EONS.
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Validation and clinical application of interferon-gamma release assay for diagnosis of latent tuberculosis infection in children p. 241
Kirtilaxmi K Benachinmardi, S Sangeetha, Mohan Rao, R Prema
Background: India has the highest tuberculosis (TB) burden, accounting for one-fifth of the global incidence and two-third of the cases in Southeast Asia with an estimated 1.9 million new cases every year. Identifying and treating latent TB infection (LTBI) can reduce the risk of development of active disease by up to 90%, thereby decreasing a major burden to the prevalence of the disease, and thus reducing potential sources in future. Aim: Early diagnosis of LTBI by tuberculin skin test (TST) and a newer interferon-gamma release assay (IGRA). Materials and Methods: Seventy-seven clinically asymptomatic household contacts (≤18 years) of confirmed pulmonary TB patients were enrolled to compare the performance of TST and IGRA to diagnose LTBI. At baseline, all participants underwent testing for IGRA and TST. Results: TST showed positivity of 22%, while IGRA demonstrated positivity of 40% in the diagnosis of latent TB. Kappa value at 95% confidence interval was 0.4753, indicates a moderate agreement between the two tests. This indicates that IGRA is a better predictor of latent TB. Maximum positive percentage was in the age group of 16–18 years in both the tests followed by 1–5 years. Conclusion: IGRA is a better predictor or diagnostic marker of LTBI. Although TST remains the preferred method of testing LTBI, IGRAs like ETB-Feron; a more efficient diagnostic test can be preferred based on patient affordability, logistics, and individual preferences.
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Vaginal carcinoma with third-degree uterine prolapse p. 246
Neha K Sheikh, Shilpa S Date, Yogita S Darekar
Carcinoma of vagina in a case of uterovaginal (UV) prolapse is very rare. We hereby present a case of 72-year-old woman with uterine prolapse with ulcerative growth of 4 cm × 2 cm on vagina commonly considered as decubitus ulcer. However, for confirmation, punch biopsy was performed, which confirmed it as vaginal carcinoma. The patient underwent vaginal hysterectomy with colpoperineorrhaphy with wide excision of tumor margin and received radiotherapy postoperatively. This case illustrates the importance of biopsy of an ulcer in cases of UV prolapse to rule out malignancy to avoid incomplete treatment.
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Holt–Oram syndrome: Hands are the clue to the diagnosis p. 248
Basant Kumar, Sourabh Agstam
Holt–Oram syndrome or heart–hand syndrome consists of phenotypic and genotypic abnormalities. It is characterized by abnormalities of upper limbs and congenital cardiac defects. It is an autosomal dominant disorder due to a mutation in TBX5 gene located on chromosome 12, but sporadic cases have also been reported. We describe a 26-year-old female with a history of shortness of breath for 5 years. She had bilateral hand deformities, and on evaluation, found to have ostium secundum atrial septal defect which is common cardiac defect in Holt–Oram syndrome.
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Left atrial myxoma from anterior mitral valve p. 251
Basant Kumar, Bhupendra Kumar Sihag, Vivek Singh Guleria
Primary cardiac tumors are relatively rare, and myxoma, the most common variety, is found predominantly in the left atrium. Clinical presentation varies from asymptomatic incidental masses to serious life-threatening cardiovascular complications. Some cases are difficult to diagnose, as symptoms can be nonspecific. We present a case of a young female with 4 months of history of dyspnea, weight loss, and night sweats, eventually diagnosed as a case of large left atrial myxoma arising from the anterior mitral valve through transthoracic echocardiography.
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Oral multifocal epithelial hyperplasia: An unusual entity p. 253
Karthikeya Patil, Mahima V Guledgud, CJ Sanjay, Bharathi Penumatsa
Multifocal epithelial hyperplasia (Heck's disease) is a rare, contagious, asymptomatic, and benign disease affecting the oral mucosa. It is usually seen in childhood and adolescence and is noted only in specific groups in certain geographical regions. The lesion is clinically characterized by the presence of multiple small papules or nodules in the oral cavity, especially on the labial mucosa, buccal mucosa, and tongue. Histopathology is necessary to confirm the diagnosis. Treatment remains unspecific, although surgical excision, CO2laser therapy, and topical antivirals are in use. We present a clinical case of a 65-year-old Indian male with multiple oral lesions that clinically and histologically resemble Heck's disease.
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Giant cervical angiomyomatous polyp masquerading third-degree uterine prolapse: A rare case with review of literature p. 256
Meenakshi Gothwal, Pratibha Singh, Jyotsana Naresh Bharti, Garima Yadav, Vrushti Solanki
Giant cervical polyps are rarely seen nowadays in routine day-to-day practice and are defined as a polyp with a size >4 cm. Giant cervical polyps protruding outside the vaginal canal causing diagnostic dilemma are rarely encountered in gynecologic practice. They masquerade as uterine inversion, prolapse, or cervical malignancy. Only a few cases have been reported in the literature. We hereby report a case of giant polyp of anterior lip of the cervix occurring in a multiparous woman and presented with something coming out per vagina. Histopathology of it came out to be angiomyomatous polyp (vascular leiomyoma) of the cervix that itself is a rare entity.
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