Journal of clinical and diagnostic research https://www.jcdr.net/back_issues.asp JCDR Evaluation Of Effects Of Laparoscopic Surgery On Hepatic Function TAURO LF*, SHEETHAL CM**, AITHALA PSM***, SHETTY SR***, D’SOUZA CS*, RAO BSS*, SHENOY DH ****, RAO K** <b>Aim:</b>The purpose of this study was to investigate the effect of laparoscopic surgery on liver function and the possible mechanisms behind such effect. <b>Methods:</b>Blood samples were collected from 60 patients undergoing various types of laparoscopic procedures, preoperatively once and post operatively on day 1 and day 7. They were tested for liver function by comparing the levels of serum bilirubin, serum alanine amino transferase (ALT), serum aspartate aminotransferase (AST) and serum alkaline phosphatase. The time of CO2 insufflation was also measured. <b>Results:</b>The levels of serum AST, ALT, bilirubin and alkaline phosphatase increased significantly during the first 48 hrs post operatively. Doubling of pre-op values of AST was seen in 33.3% and of ALT was seen in 31.7%. By 7th post operative day, the levels of AST, ALT, bilirubin and alkaline phosphatase returned to near pre-operative values. CO2 pneumoperitonium was found to be a major cause of increased liver enzymes and serum bilirubin in the study. <b>Conclusion:</b>Transient elevation of hepatic enzymes occurs after laparoscopic surgery and CO2 pneumoperitoneum seemed to be the major reason. https://jcdr.net/article_fulltext.asp?issn=0973-709x&year=2008&month=December&volume=2&issue=6&page=1155-1162&id=365 https://doi.org/10.7860/JCDR/2008/.365 Clinical Case Studies: Novel Tools For Training Medical Students In Rational Prescribing Skills. SHARMA R*, CHOPRA V.S. **, Verma U*, SAWHNEY V*** Inclusion of clinical case studies in pharmacology curriculum of Medical students is a novel way to inculcate rational prescribing skills in ‘the future prescribing physicians’. The present prospective randomized cross-sectional study was conducted in the Postgraduate Department of Pharmacology and Therapeutics of a medical college as practical training of 98 fifth semester medical students to study prescribing practices in the teaching hospital and to make them aware of existing irrational practices. At the end of study 100% of students advocated conducting such exercises more frequently and 69.38% students said that rational prescribing is being practiced in our institution; however, 81.63% of students still advocated to improve rational prescribing in institute. 100% students suggested to give exposures of clinical case studies to undergraduate students, 61.22% proposed to conduct periodic seminars and CME (continue medical education) programs on rational prescribing, 40.81% suggested to conduct classes regarding rational prescribing of postgraduate students from different departments of the institute and 93.81% recommended to encourage frequent interactions between pharmacologists and practitioners to improve rational prescribing program. The present study could serve as a model for training students in various aspects of pharmacology with an aim to produce rational prescribers instead of confused practitioners. https://jcdr.net/article_fulltext.asp?issn=0973-709x&year=2008&month=December&volume=2&issue=6&page=1175-1179&id=366 https://doi.org/10.7860/JCDR/2008/.366 Value Of AST/ALT Ratio In Pediatric Liver Trauma KEPERTIS C*, FILIPPOPOULOS A** ,KALLERGIS K ***, ZAVITSANAKIS A**** This study was aimed to determine the utility of aspartate aminotransferase and alanine aminotransferase ratio (AST/ALT ratio) in first 48 hours of injury, in children with liver trauma. The study was conducted in a prospective observational series of children younger than 15 years who had sustained blunt abdominal trauma. Children who were at risk of intra-abdominal trauma, were examined by physicians at Emergency Department of the Hospital and underwent standardized laboratory testing. From January 2004 to January 2008, 104 children presenting to the Emergency Department of General Hospital “Georgios Gennimatas” of Thessaloniki, for suspected physical abuse were prospectively entered in the study. All the children underwent complete history taking, physical examination and various laboratory investigations like white blood cell/hematocrit/platelets, aspartate aminotransferase, alanine aminotransferase, amylase and urinalysis. 104 children suffered intra-abdominal injuries and 20 had liver trauma. Transaminasemia correlated with liver injury when AST>200, ALT>150 and AST/ALT ratio >1. AST/ALT ratio can be used as a predictor for diagnosis of liver trauma and as a marker for response in nonoperative treatment-resuscitation. https://jcdr.net/article_fulltext.asp?issn=0973-709x&year=2008&month=December&volume=2&issue=6&page=1145-1148&id=367 https://doi.org/10.7860/JCDR/2008/.367 Neostigmine In Unavoidable Post Operative Ileus: A Randomized Clinical Trial FANAEI SA *,KHATAMI SM **,ZIAEE SA*** <b>Background:</b> This study was aimed to show the effective way to decrease the rate of postoperative ileus. <b>Design:</b> Prospective clinical randomized trial of neostigmine in 42 patients with ileus after abdominal surgery. <b>Intervention:</b> Intravenous administration of 2.5 mg of neostigmine in 500 N/S over 30 min, or placebo. Patients who had no response to the initial injection were eligible to receive open-label neostigmine three hours later. <b>Settings:</b> Abdominal circumference, time to first flatus and defecation, HR and BP after 3 hours of administration, and radiographic colonic measurements were recorded. Patients were followed for recurrence of ileus. All organic causes of ileus excluded from the study. <b>Results:</b> 20 out of 21 neostigmine patients (95.23%) passed flatus and stools with first administration of Neostigmine administration, whereas none of the placebo-treated patients passed stools (P < 0.001). In pre study abdominal circumference, there was no significant difference, whereas after 3 hours of intervention, it was decreased significantly (100.85 ±14.61 case group, 124.71 ± 16.15, P<0.0001). No acute serious adverse effects occurred in both groups. <b>Conclusion:</b> In patients with acute colonic pseudo-obstruction who have not had a response to conservative therapy, treatment with neostigmine rapidly decompresses the colon. https://jcdr.net/article_fulltext.asp?issn=0973-709x&year=2008&month=December&volume=2&issue=6&page=1163-1168&id=372 https://doi.org/10.7860/JCDR/2008/.372 Erythrocyte Lipid Peroxidation, Glutathione, Ascorbic Acid, Vitamin E, Antioxidant Enzymes And Serum Homocysteine Levels In Patients With Coronary Artery Disease VISHNU PRIYA V * , SURAPANENI K M** <b>Background:</b> Coronary Artery Disease is the major cause of mortality and morbidity worldwide. It is associated with various risk factors such as age group (41 – 60 years), male gender, smoking habit and hypertension. The exact pro-oxidant and antioxidant status in patients with Coronary Artery Disease is still not clear. To add a new insight to the question, changes in erythrocyte lipid peroxidation products (MDA), glutathione (GSH), ascorbic acid and plasma vitamin E, and activities of antioxidant enzymes like super oxide dismutase (SOD), glutathione peroxidase (GPX), catalase in erythrocytes, plasma glutathione – S – transferase (GST) and serum homocysteine levels were measured in patients with Coronary Artery Disease. <b>Aim:</b> This work was undertaken to assess oxidative stress and antioxidant status in patients with Coronary Artery Disease and its contribution to the risk of cardiovascular disease. <b>Settings and Design</b>: The study was conducted in sixty - five patients and the values were compared to control values. Erythrocyte MDA, GSH, ascorbic acid, plasma vitamin E and activities of antioxidant enzymes SOD, GPX, catalase in erythrocytes, plasma GST and serum homocysteine were estimated in Coronary Artery Disease patients. These parameters were measured in sixty - five patients and the values were compared to control values. <b>Statistical Analysis:</b> Statistical analysis between group 1 (controls) and group 2 (patients) was performed by the Mann Whitney U test. The data was expressed as mean + SD. P < 0.05 was considered to be significant. <b>Results:</b> It was observed that there was a significant increase in erythrocyte MDA levels, SOD, GPX and plasma GST activities, and a significant decrease in erythrocyte GSH, ascorbic acid, plasma vitamin E levels and catalase activity in patients with Coronary Artery Disease when compared to controls. Serum homocysteine levels were significantly higher in Coronary Artery Disease patients than in the controls. <b>Conclusions:</b> The results of our study suggest higher oxygen free radical production which is evidenced by increased MDA and decreased GSH, ascorbic acid, vitamin E and Catalase activity and support to the oxidative stress in coronary artery disease. Increased homocysteine levels and decreased antioxidant capacity may contribute to the increased risk of cardiovascular disease in patients with coronary artery disease, in addition to known risk factors such as insulin resistance, hypertension, central obesity, and dyslipidaemia. The increased activities of antioxidant enzymes may be a compensatory regulation in response to increased oxidative stress. https://jcdr.net/article_fulltext.asp?issn=0973-709x&year=2008&month=December&volume=2&issue=6&page=1180-1185&id=377 https://doi.org/10.7860/JCDR/2008/.377 Baseline Ophthalmic Data Of School Children Aged 15 Years Or Younger In Leh, Jammu And Kashmir, India JHA K N <b>Background:</b>Due to extreme cold climate and its remoteness, Ladakh remains one of the least accessible parts of the India. Consequently, epidemiological data about this region is scarce. <b>Purpose:</b> This study was carried out to present baseline ophthalmic data of school children aged 15 years or younger from two schools at Leh, Jammu and Kashmir, India, which is climatically situated in a high altitude cold desert. <b>Design:</b> School-based cross sectional study. <b>Methods:</b> Trained ophthalmic assistants performed visual acuity measurements using Snellen chart and examination of external eye with torchlight, for children aged 15 years or younger, from two selected schools with the largest student strength. Any student with visual acuity of 20/40 or below in either eyes or any other obvious abnormality, were referred to the local eye centre at the Military Hospital. At the hospital, an ophthalmologist further examined subjects. Examination by an ophthalmologist involved repeated visual acuity measurements with Snellen chart, refraction under cycloplegia with 1 % cyclopentolate eye drops, slit-lamp anterior segment examinations, and dilated fundus examinations. <b>Results:</b> An ophthalmic assistant screened 843 (90.06%) of 936 children enumerated, and identified 91 (10.79%) children as requiring further clinical examination. Refractive errors (5.69 %) were found to be the major cause for ocular morbidity in children in this region. Conjunctival inflammatory diseases are the other important cause of ocular morbidity in this population. <b>Conclusions:</b> Refractive errors and conjunctival inflammatory conditions are the major ocular cause of ocular morbidity among the school children in Leh. https://jcdr.net/article_fulltext.asp?issn=0973-709x&year=2008&month=December&volume=2&issue=6&page=1186-1190&id=378 https://doi.org/10.7860/JCDR/2008/.378 Quality of Nursing Work Life KHANI A *, JAAFARPOUR M **, DYREKVANDMOGADAM A ** <b>Background And Aim:</b> Nurses suffer from the high demands of their profession, and often complain of overwork and underpay. Problems persist with the nurses’ job satisfaction, burnout, organizational commitment and intent to leave. The aim of this study was to explore how nurses in an Iranian state rate the quality of their work life. <b>Material and Methods:</b> This descriptive survey study was performed at the ISFAHAN Hospitals, IR, during the year 2007. The research instrument used was the Brooks and Anderson scale. A sample of 120 registered nurses (RNs) was enrolled into the study, using a simple random sample method. Data were analyzed using SPSS Version 11.5. Descriptive statistics, item summary statistics, and total scale and subscale scores were computed. <b>Result:</b> Eighty two percent nurses who were included in this study believed that their workload was heavy, salaries were inadequate (95%), nurses were dissatisfied (63%), skill mix was found to be inadequate (72%) and a majority of nurses were unable to complete their work in the time available (54%). 79% nurses indicated that they did not have the autonomy to make patient care decisions. Respondents had little energy left after work (80%), were unable to balance their work and family lives (76%) and stated that rotating schedules negatively affected their lives (69%). Few nurses felt respected by the upper management (35%) and were able to participate in decisions (29%). Many of the nurses felt that society does not have an accurate image of nurses (62%) and indicated that their work settings did not provide career advancement (62%). <b>Discussion and Conclusion:</b> Nurses' job satisfaction, salary, workload, staffing issues, skill mix, communication, autonomy, recognition and empowerment remain problematic.These findings provide information for policy makers and nursing managers on areas that need to be addressed, to retain nurses within community nursing and for important implications for nurse education administrators. Also needed is outcome-driven research examining the effectiveness, efficacy, and cost-benefit of specific strategies aimed at improving the QNWL and organizational productivity https://jcdr.net/article_fulltext.asp?issn=0973-709x&year=2008&month=December&volume=2&issue=6&page=1169-1174&id=380 https://doi.org/10.7860/JCDR/2008/.380 Utility of Clinical Improvement and Platelet Count Recovery Time in Counseling Children Hospitalized With Suspected Dengue in A Resource-Poor Setting GARG P <b> Objective:</b>We aimed to evaluate the utility of platelet count recovery time in children with suspected dengue, altered by interventions such as platelet transfusions, diagnostic groups and lowest platelet counts, in counseling and discharge planning. We also evaluated the usefulness of improvement in clinical signs and symptoms for discharge planning. <b>Methodology:</b> Baseline data was collected from 41 consecutive hospitalized children who were suspected to be suffering from dengue, during the recent confirmed dengue epidemic in North India (Sep-Nov 2006). All children were managed with standardized guidelines suggested by the World Health Organization (WHO), and time taken for the recovery of platelet counts (>100,000/cumm) was recorded. <b>Results:</b> The median recovery time(that is the time at which 50% of children had recovered) was noted to be 3 and 4 days respectively, for groups Dengue and Dengue haemorrhagic fever (all grades), using Kaplan-Meier survival analysis (p=0.003). One way analysis of variance showed the two groups to be different, with regards to platelet count recovery time (p=0.004). Duration of hospitalization correlated strongly with the platelet count recovery time (r=0.82, p<0.0001). The lowest levels of platelet count during the course of hospitalization predicted platelet count recovery time (p=0.003). There was fair to moderate agreement (kappa = 0.31-0.5) for improvement in clinical symptoms and signs at the time of discharge, except for a convalescent rash (kappa=0.7). <b>Conclusion:</b> The information derived from this study is useful for counseling and discharge planning of hospitalized children suspected to be suffering from dengue, during epidemics in the countries of South Asia where people have to make significant out-of-pocket payments. https://jcdr.net/article_fulltext.asp?issn=0973-709x&year=2008&month=December&volume=2&issue=6&page=1149-1154&id=400 https://doi.org/10.7860/JCDR/2008/.400 Awareness of Oral And Maxillofacial Surgery Among –Health Care Professionals – A Cross Sectional Study RASTOGI S *, DHAWAN V **, MODI M *** Oral and Maxillofacial Surgery (OMFS), a dentistry specialty recognized by the Federal Dentistry Board in the mid-1960s, is responsible for the diagnosis, and clinical and surgical treatment of traumatic, congenital, developmental and iatrogenic lesions in the maxillofacial complex. Even today, difficulties are experienced owing to the lack of knowledge of the general public and health professionals concerning the scope of OMFS A questionnaire survey of the perception of OMFS amongst 400 members of the general practitioners, general dentists, nursing students, and medical students is presented. Closed-ended format questions were designed to assess understanding of the range of conditions managed by Oral surgeons. The main objective was to ascertain how knowledgeable the medical/dental students, and health care professionals were about the diverse scope of surgical procedures that the oral and maxillofacial surgeon performs, and to improve the prognosis of different diseases. https://jcdr.net/article_fulltext.asp?issn=0973-709x&year=2008&month=December&volume=2&issue=6&page=1191-1195&id=401 https://doi.org/10.7860/JCDR/2008/.401 Umbilical Endometriosis RAI R *,SATHYAMOORTHY A** ,D’SOUZA C*** Endometriosis is a disorder in which abnormal growth of tissues, histologically resembling that of the endometrium, are present in locations other than the uterus. The lesions are usually found in the peritoneal surface of reproductive organs, but also can be found anywhere in the body. Primary cutaneous endometriosis is uncommon. The frequency which arises in the skin of all endometriosis is 1.1%, and those which arise in the umbilical region are about 30%. Umbilical endometriosis is a very rare surgical condition, but should be considered in the differential diagnosis of any umbilical nodule. We report a case of a 28yr old lady who presented with a bluish nodule at the umbilicus for 3 months, with no associated discharge. It was histopathologically confirmed as umbilical endometriosis. https://jcdr.net/article_fulltext.asp?issn=0973-709x&year=2008&month=December&volume=2&issue=6&page=1203-1206&id=381 https://doi.org/10.7860/JCDR/2008/.381 Traumatic Pontomesencephalic Junction Contusion Masquerading As Sixth And Seventh Nerve Palsy DHAWAN V*, SHRESTHA D **, CHERIAN I *** We report a rare case of pontomesencephalic contusion following a motorbike accident in a 4 yr old boy. Depending on the location of the injury in the brainstem, the clinical presentation varies across a spectrum, ranging from the patient being comatose, to almost undetectable or subtle neurological deficits. In the case that we report, the patient had a contusion in the junction between pons and midbrain, and we were able to identify it on a CT scan in a retrospective manner after a radiological correlation was sought with the mode of clinical presentation. https://jcdr.net/article_fulltext.asp?issn=0973-709x&year=2008&month=December&volume=2&issue=6&page=1200-1202&id=383 https://doi.org/10.7860/JCDR/2008/.383 Giant Schwannoma In The Pelvic Retroperitoneum TAURO L.F**, GEORGE C*, KAMATH A*, LOBO G***, SHETTY P***, HEGDE BR**** Schwannoma (neurilemmoma) is a peripheral nerve sheath tumour and commonly occurs on the head, neck and trunk. Giant schwannoma is rarely located on the retro peritoneum and the pelvic cavity. The majority of symptoms caused by the tumour are due to its mass effect. Surgical resection is enough to treat the tumour. Schwannoma is usually a benign tumour. Its malignant transformation is usually very rare. We report a 60 year male patient with giant pelvic schwannoma which presented with urinary symptoms. https://jcdr.net/article_fulltext.asp?issn=0973-709x&year=2008&month=December&volume=2&issue=6&page=1210-1214&id=386 https://doi.org/10.7860/JCDR/2008/.386 Primary Choriocarcinoma of the Ovary- A Case Report MISHRA S K*, CRASTA J A** Primary choriocarcinoma of ovary is rare. It could be gestational or nongestational in origin. The distinction between the two is difficult, but necessary, as the nongestational type has a bad prognosis. We present a case of pure ovarian choriocarcinoma occurring in the reproductive age group, with no history of pregnancy. <b>Key Words:</b> Choriocarcinoma, ovary https://jcdr.net/article_fulltext.asp?issn=0973-709x&year=2008&month=December&volume=2&issue=6&page=1207-1209&id=379 https://doi.org/10.7860/JCDR/2008/.379 Cellulitis With Multiple Abscesses In Leg Due To Burkholderia Pseudomallei Infection-A Case Report SHETTY A K*, HEGDE A**, SHETTY I N***, GOMES L**** Burkholderia pseudomallei is the causative agent of melioidosis. It is endemic in Southeast Asian countries and northern Australia. It was rarely encountered in India earlier. Recently, a few cases of melioidosis have been reported from several parts of southern coastal India. Burkholderia pseudomallei is a rare aetiology for cellulitis. We report a case of melioidosis presenting as cellulitis, with multiple abscesses on the leg in a diabetic patient. The causative agent was identified in time and the patient was treated for it’s infection. The patient recovered completely after completion of the antibiotic regimen. Melioidosis is an emerging infectious disease in India. https://jcdr.net/article_fulltext.asp?issn=0973-709x&year=2008&month=December&volume=2&issue=6&page=1196-1199&id=375 https://doi.org/10.7860/JCDR/2008/.375 Multidisciplinary Approach and Pivotal Role of Pathologist in Diagnosis of Breast Cancer: Technological Advances: An Updated Review for Breast Health Care experts PATRA S.B Clinical and pathological diagnosis of breast carcinoma is advancing at the same pace as the global increase in its incidence, morbidity and mortality. Research scientists (bio molecular, pathologists, clinicians and geneticists) are working on war footing for prevention, cure and treatment of breast cancer. In near future, breast cancer diagnosis may advance inexplicably. The pathology report serves not only as a hard copy for clinicians on which various treatment modalities are based , but also as a teaching module for educated cancer patients. The pathologist, who plays a very critical and pivotal role, hardly meets the patient in most institutional set ups. In unlimited resource centers, his/her role is very critical, because patients themselves can challenge clinicians and sue the pathologist. The scientific document based on observation can be finite, but the pathologist has to go beyond the finite observation, because many technical and clinical variations and limitations have to be taken into consideration. A guarded analytical opinion along with suggestions has to be given for the patient. Diagnosis of breast carcinoma has leaped rapidly from FNAC to DNA with many intermediaries in between. In some institutes, the best possible cost effective diagnosis is given, whereas in others, molecular studies are done to provide the diagnosis which influences the therapeutic and prognostic outlook. https://jcdr.net/article_fulltext.asp?issn=0973-709x&year=2008&month=December&volume=2&issue=6&page=1226-1233&id=410 https://doi.org/10.7860/JCDR/2008/.410 Biological Actions And Medicinal Applications Of Tea (Camellia Sinensis) DAS S*, THAKURIA N**, KANODIA L*** https://jcdr.net/article_fulltext.asp?issn=0973-709x&year=2008&month=December&volume=2&issue=6&page=1215-1225&id=391 https://doi.org/10.7860/JCDR/2008/.391 In Vitro Maturation And Fertilization Capacity Of Mouse GV-Stage Oocyte Following Stepwise Vitrification Mahmoudi R * ,Ragardi Kashani I ** ,Abbasi M ** ,Amidi F** ,Sobhani A** ,Abolhasani F** Saadipour Kh***,Amiri I **** <b>Background:</b> The storage of oocytes is important for advances in reproductive biology and infertility treatment. Although successful procedures for cryopreservation of human metaphase II oocytes have been reported, their results have proven unsatisfactory, and appear to require further progress. The microtubular spindle of MII oocytes is sensitive to temperature changes. Germinal vesicle (GV) stage oocytes do not have microtubular spindle, so its cryopreservation may be an alternative approach to the storage of gametes. <b>Aims:</b> examining the viability and subsequent developmental ability of murine GV oocytes after vitrification. <b>Setting:</b> Embryology research center at an academic institution. <b>Design:</b> Original Article <b>Methods and Materials:</b> Germinal vesicle oocytes with cumulus cells were transferred to vitrification solution, which was composed of 30% (v/v) ethylene glycol, 18% (w/v) Ficoll-70, and 0.3 M sucrose either by single step or in a step-wise way. After vitrification and storage in liquid nitrogen, the oocytes were thawed and washed two times in medium TCM199 and then subjected to in vitro maturation, fertilization and culture. <b>Results:</b> The oocyte survival, maturation to MII, fertilization and development rates in step-wise exposure were found to be significantly higher (P<0.05) when compared with corresponding rates in the single step procedure. Collected data was analyzed by one way ANOVA test. <b>Conclusion:</b> The results of present study indicate that GV stage oocytes have better morphology and viability after vitrification in stepwise method; and their rates of maturation and development to 2-cell stage are also higher as compared to oocytes cryopreserved via single step procedure. https://jcdr.net/article_fulltext.asp?issn=0973-709x&year=2008&month=December&volume=2&issue=6&page=1234-1239&id=368 https://doi.org/10.7860/JCDR/2008/.368 Microbial Causes Of Apparently Non Infectious Diseases RAJESH P K* , SENGODAN B ** https://jcdr.net/article_fulltext.asp?issn=0973-709x&year=2008&month=December&volume=2&issue=6&page=1240-1241&id=374 https://doi.org/10.7860/JCDR/2008/.374 Antibacterial Effects Of Adiantum Capillus-Veneris Ethanolic Extract On Three Pathogenic Bacteria In Vitro" BESHARAT M *, RAHIMIAN M **, BESHARAT S ***, GHAEMI E **** https://jcdr.net/article_fulltext.asp?issn=0973-709x&year=2008&month=December&volume=2&issue=6&page=1242-1243&id=395 https://doi.org/10.7860/JCDR/2008/.395 Prescribing By Generic Names – Possible Problems In South Asia SHANKAR PR*, THAPA HS** https://jcdr.net/article_fulltext.asp?issn=0973-709x&year=2008&month=December&volume=2&issue=6&page=1244-1245&id=403 https://doi.org/10.7860/JCDR/2008/.403 The Importance Of Pharmacovigilance SHANKAR P R https://jcdr.net/article_fulltext.asp?issn=0973-709x&year=2008&month=December&volume=2&issue=6&page=1246-1247&id=369 https://doi.org/10.7860/JCDR/2008/.369 Article Awards From Dec 08 JCDR editorial has decided to temporarily withdraw <b>Article Awards</b>. Earlier cash rewards were offered to all original articles and case reports. Now this fund will be used to sponsor original research. For any queries write to editors@jcdr.net Regards Dr Hemant Jain Chief Editor JCDR 1.11.08 https://jcdr.net/article_fulltext.asp?issn=0973-709x&year=2008&month=December&volume=2&issue=6&page=-&id=407 https://doi.org/10.7860/JCDR/2008/.407