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   Table of Contents - Current issue
January-June 2021
Volume 5 | Issue 1
Page Nos. 1-99

Online since Friday, June 18, 2021

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COVID-19 and Psychopharmacology: Critical Issues p. 1
Avinash De Sousa, E Mohandas, Afzal Javed
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Role of serotonin transporter-linked polymorphic region in suicide: Beyond association, meta-analysis, and future prospects p. 4
Bisu Singh
Serotonin transporter-linked polymorphic regions (5-HTTLPR) have been investigated intensively in suicide with inconsistent findings. However, a recent meta-analysis has observed an association of S allele with violent attempted suicide. The S allele causes a lower expression of 5-HTTLPR and is correlated with higher amygdala response to unpleasant stimuli. However, studies show that effect 5-HTTLPR genotype on mRNA expression is additive and linear. It suggests that apart from genotype, the expression of 5-HTTLPR is also controlled by epigenetic factors. Therefore, the purpose of this narrative review is to re-evaluate the findings of retrospective studies 5-HTTLPR in suicide with their limitations and highlight a new approach to understand the role of 5-HTTLPR in suicide. Reviews, meta-analysis, research articles, brief reports, and scientific correspondence were searched through PubMed, library web portal of Sikkim University, Bio-Med, and Science Direct using the terms such as “serotonin or serotonin system and suicide,” “5-HTTLPR and suicide,” “5-HTTLPR and attempted suicide,” “5-HTTLPR and completed suicide,” “5-HTTLPR meta-analysis and suicide,” and “5-HTTLPR and epigenetics.” The articles written in English were initially screened by title and later selected by abstract for possible inclusion. After the literature review, it was observed that previous studies were limited by variability of sample size, heterogeneous populations, varied social stressors, and variations in the assay and statistical methods. Hence, the cumulative study of environmental factors, 5-HTTLPR gene polymorphism, and epigenetic factors is hereby proposed in the well-defined ethnic population to understand the role of 5-HTTLPR in suicide.
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Eating disorders in India: An overview p. 12
Shorouq Motwani, Sagar Karia, Bilvesh Mandalia, Avinash Desousa
Eating disorders (EDs) are disabling, deadly, and costly mental disorders that considerably impair physical health and disrupt psychosocial functioning. Disturbed attitudes toward weight, body shape, and eating play a key role in the origin and maintenance of EDs. As EDs are under-researched, there is a great deal of uncertainty as to their pathophysiology, treatment, and management. Future challenges, emerging treatments, and outstanding research questions are addressed in this review.
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Pattern of social media use and social anxiety among the undergraduate health professionals with social media addiction Highly accessed article p. 18
Bhavin Naranbhai Kadavala, Deepak Sachidanand Tiwari, Vishal Kanaiyalal Patel, Nirav Bhupendrabhai Chanpa, Niranjan L Patel, Viral Shah
Background: There has been a significant surge in the usage of smartphones, Internet, social media platforms, and also the growing concern about the impact of Internet, gaming, and social media addiction (SMA) on mental health in the community since the last decade. Aim: This study is aimed to know the pattern of social media use and social anxiety (SA) among medical undergraduates with SMA. Materials and Methods: This was a 12-month cross-sectional, observational study of 640 medical undergraduates. Social media disorder scale was used to detect SMA and Liebowitz social anxiety scale was used to detect SA. Descriptive statistics, independent t-test, and Chi-square test were used for the analysis of data. Results: According to our findings, 11.04% of the participants had SMA. More than 60% of the participants with SMA spent 2 h or more time on social media in a day. About 29.41% of students with SMA spent more money compared to 11.86% of nonaddicted ones. About 47.05% of students with SMA reported fear of missing out (FoMO) as compared to 34.12% of nonaddicted students. Participants with SMA reported a significantly higher level (P < 0.05) of SA (SA score 67.63) compared to social media nonaddicts (SA score 49.43). Conclusion: Medical undergraduates with SMA spent more time and money on Internet, reported FoMO, frequently checked notifications, and reported regular substance use. They also had high SA; vice versa is also true.
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Prevalence and correlates of metabolic syndrome in severe mental illness: A cross-sectional survey of inpatients at a tertiary care institute p. 24
Akshada Suresh Sabnis, Anil Rane, Abhijit Nadkarni
Background: People with severe mental illness (SMI) die prematurely. They also have disproportionately high burden of diabetes, dyslipidemia, and obesity, which is further compounded by unhealthy lifestyle such as sedentary behavior and substance use. Consequently, there is a high prevalence of metabolic syndrome (MetS) in this population. MetS has been reported in 10%–50% of SMI patients, but its risk factors have been poorly studied. Aims: The aim of the study is to assess the prevalence and correlates of MetS in SMI. Methodology: A cross-sectional study at a tertiary care psychiatry hospital was conducted. A total of 304 consecutive inpatients with SMI were administered the WHO-STEPS-2 questionnaire, Brief Psychiatric Rating Scale, and World Health Organization Disability Assessment Schedule (WHODAS); and biochemical measures such as lipid and blood sugar levels were measured. Summary statistics (means and proportions) were described, followed by univariate and multivariate analyses to examine the associations between variables. Results: 25.7% of SMI patients had diabetes mellitus and 43.09% had elevated cholesterol; 23.4% (95% confidence interval 18.6–28.1) had MetS and it was associated with age (P < 0.01), female gender (P < 0.001), being married (P < 0.01), weight (P < 0.001), body mass index (P < 0.001), waist and hip circumference (P < 0.001), and duration of psychiatric illness (P < 0.001). On multivariate analyses, only age (P = 0.002), female gender (P < 0.001), body weight (P < 0.001), abnormal waist to hip ratio (W: H ratio) (P = 0.02), and lower use of alcohol (P = 0.01) were significantly associated with MetS. Conclusion: Patients with SMI have a high burden of cardiometabolic risk factors. Monitoring of traditional risk factors such as W: H ratio is an important and cheap option to screen for risk of MetS.
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Antidepressant-induced sexual dysfunction: A naturalistic study comparing sexual dysfunction among patients taking escitalopram, desvenlafaxine, and mirtazapine Highly accessed article p. 30
Raj Kiran Donthu, J Shivanand Manohar, Ravish Thunga
Background: Antidepressant drugs are frequently associated with sexual dysfunction. Sexual side effects affect the patients' quality of life and in the long term and can lead to noncompliance and relapse. However, studies covering many antidepressants with different mechanisms of action are scarce. Aims: The aim of this study is to compare the rates of sexual dysfunction among patients taking escitalopram, desvenlafaxine, and mirtazapine. Settings and Design: Cross-sectional study. Materials and Methods: Arizona Sexual Experience Scale (ASEX), Hamilton Rating Scale for Depression (21 items), and State and Trait Anxiety Inventory. Statistical Analysis Used: Fisher's exact t-test, Chi-square test, and analysis of variance depending on the type of variable. Results: Eighty-four participants (42 males and 42 females) completed all instruments. Of these, 28 were taking escitalopram (13.93 ± 5.15), 28 were taking desvenlafaxine (76.79 ± 25.39), and 28 were taking mirtazapine (16.88 ± 3.88). A substantial number of patients (40.5%, n = 34) had sexual dysfunction. The prevalence of sexual dysfunction varied across the drugs; escitalopram (60.7%), desvenlafaxine (35.7%), and mirtazapine (25%). Regression analysis revealed that the significant factor for sexual dysfunction was the type of antidepressant used. The mirtazapine group's total ASEX score was significantly lower than the scores for escitalopram and desvenlafaxine (χ2 = 7.807, P = 0.020). Conclusion: The incidence of sexual dysfunction is substantially high during antidepressant treatment. The rates of sexual dysfunction differed among antidepressants having different mechanisms of action. Mirtazapine-induced lesser sexual dysfunction compared to desvenlafaxine and escitalopram.
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Postpartum depression and its risk factors: A cross-sectional exploratory study p. 36
Vinit Rahaney, Abhijeet Faye, Rahul Tadke, Sushil Gawande, Sudhir H Bhave, Vivek Chintaman Kirpekar
Background: Postpartum depression (PPD) is a serious mental health condition affecting the psychological/physical health of a mother and the infant significantly. Aims: This study aims at assessing the prevalence, the pattern of symptoms, and the risk factors associated with PPD. The study also aims at finding the correlation between PPD and stressful life events. Subjects and Methods: A cross-sectional study was conducted in a tertiary care hospital on sixty participants after ethics committee approval. Consecutively selected patients in a postpartum state fulfilling the study criteria were selected from obstetric ward and interviewed using semi-structured pro forma, Diagnostic and Statistical Manual of Mental Disorders version 5 (DSM 5), Edinburgh Postnatal Depression Scale, Hamilton Depression Rating Scale (HAM-D), and Presumptive Stressful Life Events Scale (PSLES). Data collected were statistically analyzed with SPSS software using mean, standard deviation, and Chi-square test. Results: Mean age of the participants was 25.53 (standard deviation - 3.2). Prevalence of PPD was 6.7% which was a major depressive disorder as per the DSM 5 criteria. Sadness of mood (Depressed mood), impaired concentration, change in weight, and insomnia were the commonly reported symptoms. Seventy five percent of the participants had PSLES score of >100, indicating higher stress. Furthermore, 75% of the participants with a history of abortion showed a PSLES score above 100. Significant positive correlation was found between PSLES score and HAM-D score, with 63% of the participants with PSLES score >200 had a HAM-D score of >8 (suggestive of depression). Younger (<20 years) or older (>30 years) age at pregnancy, history of abortion, and higher level of stress were found to be the risk factors for developing PPD. Conclusion: Although the prevalence is less, PPD is an important mental health issue. It is worth screening all the patients in postpartum state so as to intervene early if needed. This may help in better care of physical and psychological health of a mother and the newborn.
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Caregiver burden and psychiatric morbidity among caregivers of children with thalassemia major: A cross-sectional study p. 43
Nisha Kanaiyalal Prajapati, Mukesh Jyantilal Samani, Arpit Madhusudanbhai Jani
Background: Caregivers of children with thalassemia major experience higher caregiver burden and psychiatric morbidity. Aims: The aims of this study were as follows: (1) to assess the caregiver burden and psychiatric morbidity among caregivers of children with thalassemia major and (2) correlation between caregiver burden and psychiatric morbidity. Settings and Design: This was an observational, cross-sectional study carried out at the tertiary care hospital setup among 245 caregivers of children with thalassemia major. Subjects and Methods: Sociodemographic details of children and their caregivers and clinical variables of children were obtained. The Caregiver Burden Scale and General Health Questionnaire (GHQ)-12 were applied. Psychiatric diagnosis was made after clinical interview as per the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Statistical Analysis Used: Chi-square test, t-test, analysis of variance, and Pearson coefficient correlation were used for statistical analysis. Results: 33.06% were having severe burden, 30.61% moderate-to-severe burden, 27.34% mild-to-moderate burden, and 8.97% were having little or no burden. 13.46% of caregivers had psychiatric illness, out of which 8.57% had major depressive disorder, 4.08% generalized anxiety disorder, and 0.8% alcohol use disorder. “Weakly positive correlation” (P = 0.0284) was found between GHQ score and burden score. Conclusions: Higher caregiver burden and presence of psychiatric morbidity among caregivers of thalassemia children suggest that caregivers should be screened at regular intervals for early detection and management of psychiatric morbidity. Social and professional networks for psychosocial support and self-help groups should be planned for caregiver burden.
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A comparative study to assess burnout and its correlates among doctors and nurses working at dedicated COVID-19 facility of civil hospital, Ahmedabad, Gujarat p. 50
Minakshi N Parikh, Dhruvkumar Shaileshbhai Patel, Vrunda Ashok Patel, Parth R Kansagra
Background: The high contagiousness of the COVID 19 disease, the uncertain course, and the high morbidity and mortality has led to unprecedented burden on the health care system, especially when the crisis has gone on for more than 5 months with no end in sight. The chronic high degree stress has made burnout in health care workers (HCWs) a reality that needs urgent attention which can otherwise lead to compromised patient care apart from their own suffering. Aims and Objectives: This study was planned to assess and compare the burnout in doctors and nurses of our dedicated COVID 19 hospital, to understand its correlates, and look for any implications on future policy decisions. Materials and Methods: Our study assessed and compared the burnout in 150 doctors and 150 nurses of our dedicated COVID 19 hospital using the Copenhagen Burnout Inventory (CBI). The CBI Scale is a 19 item scale including three domains of burnout in the form of personal (1–6), work related (7–13), and patient related burnout (14–19). More than 25% average score on these items is taken as the presence of burnout. Results: We found burnout in 58% of all HCWs with 78% in doctors (n = 150) and 38% in nurses (n = 150), the difference being statistically significant. Multiple linear regression analysis was performed to find common factors affecting burnout among both the groups, which were female gender, facing stigma due to COVID 19 duty, regular exercise/yoga, and dissatisfaction with administrative services. Our findings propose to emphasize the need to address the impact of working under pressure for sustained periods among HCWs.
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An exploratory study on the psychological and epigenetic correlates of internet addiction p. 57
Luca Cerniglia, Silvia Cimino, Pragya Lodha, Sagar Karia, Avinash Desousa
Background: The dopamine active transporter (DAT) gene has been implicated in various psychiatric disorders such as attention-deficit hyperactivity disorder and externalizing behaviors. Studies on the methylation loci of DAT and Internet addiction (IA) are sparse. The study aimed to look at the association between various methylation loci of the DAT gene and IA, impulsivity, and other related variables. Methodology: Thirty-two youths with 10/10 genotype of DAT gene were administered the IA Test, Barratt's Impulsivity Scale (BIS), and Adult Self-Report Scale and using buccal swab methylation loci 1–7 of DAT gene were assessed. The data were analyzed by a correlation between various variables and a multiple regression analysis. Results: It was noted that the met5 allele (r = 0.844, P < 0.01) and met7 allele (r = 0.517, P = 0.01) correlated with DAT MEDIA scores. The total scores on the BIS and Internet Addiction Scale (IAS) also showed a positive correlation (r = 0.641, P = 0.01). Positive correlations were also noted between the scores on IAS and rule-breaking behavior as well as withdrawn behavior. Similar positive correlations were found between total scores on the BIS and rule-breaking behavior, withdrawn behavior, and intrusive behavior. Conclusions: Further studies in larger samples are needed to draw conclusions on the relationship between DAT gene methylation loci and IA or impulsivity.
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A comparative study of facial emotion recognition pattern and its determinants in patients of alcohol dependence syndrome versus matching controls p. 61
Ch Lakshmi Rajesh, Ananda Reddy Endreddy, Subahani Shaik, SV Venu Gopala Raju
Background: Facial emotional recognition plays a pivotal role in human interactions and behavior. Long-term alcohol use leads to brain dysfunction that causes impairment in social cognitive abilities including facial emotional recognition. Objectives: Our study was aimed to assess the facial emotional recognition pattern in patients with alcohol dependence syndrome (ADS) and compared with that of matching controls and to study the sociodemographic and clinical correlates of facial emotional recognition in ADS. Setting and Design: This cross-sectional study was conducted at a tertiary care teaching hospital for a period of 1½ years. Fifty participants having ADS and fifty controls were included in the study. Materials and Methods: Fifty participants having ADS and fifty controls were included in the study. In the group with ADS, a semi-structured pro forma was used to collect the sociodemographic and clinical profile. Rating scales such as Severity of Alcohol Dependence Questionnaire, the Clinical Institute Withdrawal Assessment for Alcohol scale-revised, and facial emotion recognition test (FERT) were administered. For the control group, FERT was administered after collecting the data regarding sociodemographic profile and clinical variables. Results: It was observed a significant impairment in FERT scores in individuals having ADS (mean score = 19.93 ± 7.67) when compared to the control population (mean score = 32.73 ± 4.96T-test = −10.86; P < 0.001). Lower scores on FERT were observed in persons with severe alcohol dependence (one-way ANOVA = 41.79, P < 0.001). Post hoc Tukey testing showed the difference between groups having moderate-to-severe dependence (P < 0.001) and mild-to-severe dependence (P < 0.001). Conclusions: Significant impairment in facial emotional recognition skills were observed in patients having ADS. The subjects in ADS group were able to identify happy and angry emotions better while facing difficulties in identifying sad and fear full stimulus.
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Prescription Pattern, follow-up pattern, and medication adherence in psychiatric outpatients p. 67
Parthasarathy Ramamurthy, Aneesh Alexander, Susan Solomon, Pradeep Thilakan, Vishnu Vardhan Rudravaram
Background: Drug utilization research on psychotropic drug use facilitates rational prescriptions in psychiatric patients. Low follow-up rates and nonadherence to psychotropic medications are key challenges in psychiatry. The objective of this study was to determine the prescription pattern of psychotropic medications, the follow-up pattern, and medication adherence in psychiatric outpatients. Materials and Methods: In this retrospective observational study, the prescription pattern and number of follow-ups were abstracted for each new psychiatric outpatient for a period of 6 months from the time of the first assessment. In addition, medication adherence was assessed using a secondary database analysis. A continuous measure of medication acquisition (CMA) was calculated and those patients with CMA of 0.8 or more were considered adherent. Results: A total of 317 patients were included in the study. At the first visit, 198 patients (62.46%) were prescribed two psychotropic medications. Out of the total sample, 157 (49.53%) were prescribed once-daily medication and 151 (47.63%) received twice-daily medication. During the follow-up visits, the primary medication was changed in 40 (12.62%) patients and polypharmacy was used in 23 (7.26%) patients. After the initial visit, 138 (43.53%) patients did not come for even a single follow-up visit. Only 50 (15.77%) patients had a medication prescription for at least 80% of the study period. Conclusion: Olanzapine, escitalopram, sertraline, and clonazepam were the most commonly prescribed psychotropic medications. Most patients were prescribed two psychotropic medications which included one benzodiazepine. However, polypharmacy was an uncommon practice. Follow-up rate and medication adherence were poor across different diagnostic categories.
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Study of sociodemographic profile and psychopathology of mentally and physically handicapped children and their parents p. 74
Anup Rathi, Pankaj Sanghavi, Sagar Karia
If all chronic conditions causing disability of any degree in childhood are included, the prevalence of disability is remarkably high. Studies on families with handicapped children have indicated that both parents often experience psychological disorders such as anxiety and depression. Handicapped children too suffer from psychological illnesses. Hence, the present study was undertaken. The study aims to look at the sociodemographic profile and psychopathology of mentally and physically handicapped children and their parents and to compare it with that of nonhandicapped children. Materials and Methods: The sample consisted of 90 children of both sexes. Sixty of these were handicapped-30 physically and 30 mentally. Thirty children were nonhandicapped. A semi-structured proforma, IQ tests, and Childhood Psychopathology Measurement schedule (CPMS) were used for assessment. Chi-square test and Paired “t”-test were used in the analysis. Results: It was observed that a greater number of handicapped children belonged to the higher score groups as compared to the nonhandicapped group. Significantly higher incidence of morbidity was observed in the handicapped children as compared to nonhandicapped children. Fathers and mothers of handicapped children had higher degree of psychopathology as compared to those of nonhandicapped children. Mothers' psychopathology had a significant effect on the severity of CPMS scoring in physically handicapped children. Conclusion: Handicapped children showed more severe psychopathology as compared to nonhandicapped. Mothers of handicapped children had higher psychiatric morbidity as compared to those of nonhandicapped children. Psychopathology of mother significantly affected the psychopathology of children.
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Leukopenia Related to Haloperidol in a Case of Chronic Untreated Schizophrenia p. 79
Hrishikesh B Nachane, Gaurav E Pawar
Haloperidol is a commonly prescribed first-generation antipsychotic drug in psychiatric practice. It is usually well tolerated and presents with few side effects such as sedation, antiparkinsonian features, and hypotension. Few cases have been reported on leukopenia with haloperidol, none from India. We present a case where a patient with untreated schizophrenia for 9 years developed leukopenia (total leukocyte count [TLC] = 2800 cells/mm3) at 20 mg of oral haloperidol, in our inpatient setting. He chiefly presented with fever. The causality of adverse drug reaction (ADR) was attributed to haloperidol and using the Naranjo algorithm, the score recorded was 8, suggesting probable causal association. Hartwig's Severity Assessment Scale showed the severity of the ADR to be Level 4 (moderate severity). There was prompt reversal after drug discontinuation (TLC = 7000 cells/mm3 at discharge). Risk factors, possible mechanisms, and role of monitoring are discussed.
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Type-II Sturge-Weber Syndrome and Comorbidity with Bipolar Disorder p. 83
Sai Spoorthy Mamidipalli, Sangha Mitra Godi, Supriya Mahant, Puneet Kumar Soni
Sturge-Weber syndrome (SWS) is a rare neurocutaneous disorder which was known to occur in 1 in 50,000 births with a triad of features including the port-wine stain on the face, glaucoma, and leptomeningeal angiomas. It is further divided into three types based on the regions involved. Here, we present the case of an 18-year-old male, Type II SWS with facial involvement since childhood who was presented with affective symptoms. The psychiatric manifestations ranging from symptomatic to a diagnostic presentation to be kept in mind which are often missed in the patients presented with SWS.
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Treatment-resistant schizophrenia with high-risk pregnancy: Challenges in management p. 86
Prerna Balkrishen Khar, Smita Panse, Nishant Das
Managing a severe treatment-resistant psychiatric illness in the context of pregnancy has always been a challenge for psychiatrists, especially with a comorbid medical illness. We present a case of an elderly primigravida having schizophrenia of 22 years, with high-risk pregnancy, who suffered from an acute psychotic exacerbation during pregnancy. She was managed with clozapine, aripiprazole, and amisulpiride, after a failed trial of olanzapine and electroconvulsive therapy. This case highlights the challenges in managing an elderly primigravida with comorbid gestational diabetes mellitus and fibroid who required prolonged hospitalization throughout her pregnancy. A strong liaison with an obstetrician goes a long way in ensuring smooth management.
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Psychosis unmasked by gaming: A case series p. 89
Amey Yeshwant Angane, Prerna K Keshari, Amit S Mane, Ajita S Nayak
With easy accessibility and advancements in technology, there has been an upsurge in gaming. Players may neglect their real life, even using gaming as a medium to build self esteem. This has led to increased prevalence of gaming disorder. There is a dearth of literature regarding the interplay between gaming disorder and psychosis. Here, we present three cases where a prodromal history of progressively increasing time spent gaming was found to be followed by the emergence of florid psychotic symptoms. Gaming might act as a risk factor for precipitating psychosis. Individuals experiencing PLEs (Psychotic Like Experiences) have been shown to use the Internet for reality substitution. Mental Health Professionals should be aware of the threat that Internet Gaming Disorder provides to mental health. Irrespective of whether it is an etiology or consequence of the psychosis, it warrants treatment.
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Depression: Unraveling the gender differences p. 93
Heena Merchant, Prerna Balkrihsen Khar
Depression in men and women presents differently and there are various factors governing this. This article aims to elucidate these differences so that the management approach can be adopted as required and the morbidity be reduced.
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Recurrent episodes of cyclical vomiting in a 12 year old child p. 96
Jayasurya Suresh, R Nidheesh Chandran
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Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy presenting with treatment-resistant chronic mania p. 98
Praveen Pandey, Adarsh Tripathi, Sujita Kumar Kar
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