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   Table of Contents - Current issue
Coverpage
October-December 2021
Volume 15 | Issue 4
Page Nos. 375-474

Online since Thursday, September 2, 2021

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EDITORIAL  

Conversion disorder: A mysterious event following general anesthesia p. 375
Abdelazeem A Eldawlatly
DOI:10.4103/sja.sja_139_21  
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ORIGINAL ARTICLES Top

Assessment of pain in patients with primary immune deficiency Highly accessed article p. 377
Maram Al Banyan, Saad Al Shareef, Dina Mahmoud Ahmad Aljayar, Fayha Farraj Abothenain, Agha M Rehan Khaliq, Hassan Alrayes, Rand Arnaout, Farrukh Sheikh
DOI:10.4103/sja.SJA_87_20  
Background: Primary immune deficiency (PID) patients may develop acute or chronic pain. Pain has not been studied in this population until now. Objectives: This study systematically assessed the pain of various durations in PID patients using validated pain questionnaires. Subjects and Methods: A Short-Form McGill Pain Questionnaire (SF-MPQ), already validated in the Arabic language, was used to ascertain the characteristics and severity of pain. Additionally, an Arabic version of the Neuropathic Pain Questionnaire-Short Form (NPQ-SF) was employed to evaluate neuropathic pain in the same group of patients. Results: Forty-six patients participated in the study. The mean age of the patients was 25 years. The most commonly diagnosed PID was a common variable immune deficiency (32.6%), followed by severe combined immune deficiency (19.57%). Based on the SF-MPQ, the pain was experienced by 30.4 % of the subjects who participated in the study; 57% of whom were on regular pain medications. The most common site reported for pain was the abdomen (35.7%). The mean duration of pain was 36.1 days ± 34.6 days. The most common comorbidities in these patients were bronchiectasis, followed by immune thrombocytopenic purpura, and scoliosis. None of the PID patients had significant neuropathic pain based on NFQ-SF. Conclusion: To the best of our knowledge, this is the first study to assess the prevalence as well as the severity and duration of pain in PID patients. There were significantly more subjects who had continuous pain. Treatment of pain in PID patients will have a significant effect on improving their quality of life.
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The trends of obstetric anesthesia practice: In a tertiary care center in the Kingdom of Saudi Arabia p. 383
Mohammed Alshabibi, Azza M Madkhali, Amer A Alkinani, Ali A Alyami, Abdulaleem Alatassi
DOI:10.4103/sja.sja_83_21  
Introduction: Obstetric anesthesia provides several methods for the analgesia of labor pain. The neuraxial technique is considered the standard of care for parturient women. The epidural block is widely used in vaginal delivery while the spinal block is the preferred method for cesarean section (C-section). We aim to know the practice of obstetric anesthesia in our center. Methods: A retrospective cross-sectional study was conducted at a tertiary center in Riyadh, Saudi Arabia. The data of all delivery cases from 1/7/2019 to 30/9/2019 were reviewed. Results: We identified a total of 2,140 cases during the 3 months, vaginal delivery was the most common with 72.4% (1550) while the C-section cases were 27.6% (590). Regarding the type of analgesia/anesthesia for vaginal deliveries, intramuscular analgesia was the commonest group with 34.8% (540), followed by the group of ladies who did not receive any analgesia/anesthesia with 31.9% (495), thirdly was epidural cases with 31.8% (493), and the fourth type was spinal 0.6% (10). Regarding C-section, the emergency cases were 65.4% (386). The types of anesthesia for all C-sections were as follows spinal 63.5% (375), GA 23.8% (141), and epidural 12% (74). Regarding anesthesia for elective cases, spinal was 85% (174), GA 14% (28), and epidural 1% (2). Regarding anesthesia for emergency cases, spinal was 52% (201), GA 29% (113), and epidural 19% (72). Conclusions: The use of epidural was low, and the spinal use was relatively on par if we compare with leading western countries. More focused studies and multicenter studies are needed in the country.
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Is the SORT score reliable in predicting postoperative 30-day mortality after a nonemergency surgery in Saudi population? p. 387
Anwar Ul Huda, Asad Z Khan, Abdul S Memon, Nasrullah Sheikh, Abdullah A Anazi
DOI:10.4103/sja.sja_105_21  
Context: The process of stratifying patient risk preoperatively helps in the decision about the best-possible postoperative care for patients. There have been many scoring systems that are used in anesthesia practice. Aims: To find out whether there is any difference between the mortality predicted from SORT scoring and the observed mortality among Saudi patients. Settings and Design: This was a prospective, observational study in which we included patients underoing nonemergency surgical procedures at the Security Forces Hospital, Riyadh. Methods and Material: We calculated the SORT scores for all the included patients. We then collected the 30-day mortality data of all the patients having nonemergency surgical procedures. Statistical Analysis Used: We calculated the expected mortality ratio. A P value of less than 0.05 was considered significant. Results: The mean SORT mortality risk score (%) for the whole sample was 0.30. The expected number of deaths was 1.638 while the observed deaths were 2, which yields an O/E ratio of 0.819 (p-value: 0.006). The O/E mortality ratios for patients in each individual ASA class were found to be statistically insignificant which means that SORT score can reliably predict mortality for each ASA class. Conclusions: SORT scores can be used to predict 30-day mortality after nonemergency surgeries in Saudi population.
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Does propofol mode of administration influence psychomotor recovery time after sedation for colonoscopy: A prospective randomized assessor-blinded trial p. 390
Philippe J Van der Linden, Hans Verdoodt, Etienne Métallo, Chantal Plasman, Jean-François Fils, Denis Schmartz
DOI:10.4103/sja.sja_196_21  
Background: Propofol sedation has become increasingly popular for colonoscopy. Different modes of propofol administration have been described, but their influence on psychomotor recovery time remains largely unknown. This prospective randomized assessor-blinded study tested the hypothesis that target-controlled infusion system (TCI) combined with sedation depth monitoring should be associated with a more stable sedation than intermittent bolus application with clinical monitoring of sedation depth, resulting in a faster psychomotor skills recovery. Methods: One hundred sixty-four patients undergoing colonoscopy were randomized to receive propofol with the former (TCI group) or the latter (bolus group) mode of administration. Psychomotor skill recovery was assessed using the Choice Reaction Time (CRT) performed before and every ten minutes after waking up from propofol sedation. Clinical recovery was also assessed using the modified Post-anesthetic Discharge Scoring System (PADS). Results: Induction and wake up times were longer in the TCI group, where patients received more propofol than those in the bolus group. Evolution of CRT was similar in both groups. Twenty minutes after arrival in the post-anesthesia care unit, 35 (49%) of patients in the TCI group and 43 (54%) in the bolus group achieved CRT values equal or shorter than their baseline values. Interestingly, according to the PADS score, most of the patients were considered fit for discharge at that moment. Incidence of adverse event was not different between groups. Conclusion: In the conditions of our study characterized by short procedure duration, target-controlled infusion of propofol does not offer any benefit in terms of psychomotor skills recovery over intermittent bolus application.
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Comparative performance of two protective barriers during tracheal intubation of COVID-19 patients: A simulation cross-over study p. 396
Abdullah B Abolkheir, Ahmed El-Kabbani, Abdullah Al Raffa, Areej AlFattani, Andrew Norris
DOI:10.4103/sja.sja_274_21  
COVID-19 was declared a pandemic by the WHO in 2020. In light of the global shortage of PPE and concerns regarding the safety of healthcare providers, clinicians have resorted to the use of novel protective barriers, such as aerosol boxes and plastic sheets, during aerosol generating procedures, especially tracheal intubation. We compared the effect of these barriers on the tracheal intubation of simulated patients with severe COVID-19 in a crossover study. The study was approved by the Ethics Committee of King Faisal Specialist Hospital, and the procedures were compliant with the COVID-19 airway management guidelines of the Saudi Anesthesia Society. The time to intubation was our primary outcome. Secondary outcomes included number of optimization maneuvers, number of intubation attempts, time to glottic view and ventilation of the lungs, and damage to PPE. Thirteen consultant anesthetists performed 39 tracheal intubations on a manikin using each of three approaches (aerosol box, plastic sheet, and no-barrier). Data were collected via direct and video observation. The plastic sheet approach demonstrated the highest time to intubation (mean ± StE [95% CI]: 33.3s ± 3.5 [25.8– 40.9]) compared to the aerosol box (22.0s ± 2.5 [16.5 – 27.5], P < 0.01) and no-barrier approaches (16.1s ± 1.1 [13.7 – 18.4], P < 0.0001). Similarly, the plastic sheet approach had the highest time to glottic view, and ventilation intervals compared to the other two approaches, while the no-barrier approach had the shortest time intervals. There were no failed intubations or damage to the PPE sustained during the use of any of the three approaches. The aerosol box does not impose a significant delay in tracheal intubation using video laryngoscopy, unlike the plastic sheet barrier. Further research on the aerosolization risk is warranted before these protective barriers can be considered as mainstay approaches during aerosol generating procedures.
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Endotracheal tube cuff position in relation to the cricoid in children: A retrospective computed tomography-based analysis p. 403
Tariq M Wani, Jiju John, Vladimir Bahun, Faris AlGhamdi, Dmitry Tumin, Joseph D Tobias
DOI:10.4103/sja.sja_396_21  
Background: The use of cuffed endotracheal tubes (ETT) has become the standard of care in pediatric practice. The rationale for the use of a cuffed ETT is to minimize pressure around the cricoid while providing an effective airway seal. However, safe care requires that the cuff lie distal to the cricoid ring following endotracheal intubation. The current study demonstrates the capability of computed tomography (CT) imaging in identifying the position of the cuff of the ETT in intubated patients. Methods: In this retrospective study, the ETT cuff position was examined on the sagittal plane images of neck and chest CT scans of 44 children. The position of the proximal and the distal aspect of the ETT cuff inside the trachea was recorded in relation to the vertebral levels. The vertebral levels were used to estimate the location of the cricoid ring and its relationship to the cuff. Results: The vertebrae were used as the primary landmarks to define the position of the cricoid and its relationship to the cuff of the ETT. Correlating vertebral levels with the cricoid for different age groups, the proximal (cephalad) edge of the ETT cuff was below the cricoid in 41 of 44 patients (93%). The ETT cuff was deep in 6 patients, below the 1st thoracic vertebra, with 2 ETTs in the right mainstem bronchus. Conclusion: This is the first study demonstrating that the cuff of the ETT and its position in the trachea can be identified on CT imaging in children. The ETT cuff was below the level of the cricoid in the majority of patients irrespective of the patient's age as well as the size, make, and type of ETT.
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Psychometric and accuracy comparison of three commonly used questionnaires for the diagnosis of neuropathic pain p. 409
Abdullah Bakr Abolkhair, Ahmed O El-Kabbani, Abdulaziz Al-Mulhem, Areej A AlFattani, Ayman Al-Hammadi, Hani Alghamdi, Mamdouh Haddarra, Abdullah Alraffa, Adil S Kamal, Reema N Alsaigh, Mayyan M Mubarak, Abdullah Sulieman Terkawi
DOI:10.4103/sja.sja_352_21  
Objectives: Diagnosis of neuropathic pain is challenging. Recently, scientists developed multiple questionnaires to expedite this diagnosis including the Self-completed Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS), Douleur Neuropathique 4 questionnaire (DN4), and Neuropathic Pain Questionnaire–Short Form (NPQ-SF). Materials and Methods: We conducted a prospective cohort study to compare the psychometric characteristics and accuracy of the three questionnaires. We assessed reliability with the Cronbach's α reliability coefficient and inter-item correlations, and validity with receiver operating characteristic (ROC) and correlation analyses. We assessed agreement between the diagnosis of the questionnaires and the reference clinical diagnosis using Cohen's kappa coefficient. Results: 188 patients were analyzed: 141 (75%) had “definite neuropathic” and 47 (25%) had “nonneuropathic” pain. The NPQ-SF and S-LANSS questionnaires demonstrated acceptable reliability with Cronbach's α coefficient values of 0.54 (95% CI: 0.41–0.64) and 0.65, (95%CI: 0.57–0.72), respectively. The DN4 questionnaire demonstrated high reliability with Cronbach's α coefficient of 0.74 (95%CI: 0.68–0.79). The NPQ-SF, DN4, and S-LANSS questionnaires demonstrated “excellent” diagnostic ability with an area under the ROC curve of 0.82 (95% CI: 0.75–0.89), 0.89 (95% CI: 0.83–0.95), and 0.83 (95% CI: 0.75–0.90), respectively. Based on their optimal cutoff values, the DN4 had the highest sensitivity and lowest specificity in discriminating between neuropathic and nonneuropathic patients, while the S-LANSS had the lowest sensitivity and highest specificity. Conclusion: Both NPQ-SF and S-LANSS demonstrated acceptable reliability, while DN4 demonstrated high reliability. All three demonstrated excellent diagnostic validities; however, it is important to consider the sensitivity and specificity of each.
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A comparative study of the efficacy of Glidescope versus Macintosh direct laryngoscopy for intubation in pediatric patients undergoing cardiac surgery p. 419
Ibrahim Zabani, Mohammed AlHarbi, Abdulkarim AlHassoun, Shafat Iqbal, Dareen Al Amoudi, Sultan AlOtaibi, Hasan Saad
DOI:10.4103/sja.sja_472_21  
Background: The Glidescope is a novel, portable, reusable video laryngoscope that has provided superior laryngeal visualization to facilitate tracheal intubation, especially in the management of difficult airways. In this study, we aimed to compare the efficacy of the Glidescope (video-laryngoscope) against the Macintosh direct laryngoscope. Methods: Fifty patients were randomly selected via simple randomization using computer-generated random numbers, and sorted into two groups of 25 patients: the Glidescope group and the Macintosh group. We included pediatric patients undergoing cardiac surgery for the repair of congenital heart disease. Those with suspected difficult intubation, preterm babies with low body weight, and patients at risk of aspiration were all excluded. Results: Patients' baseline demographic and clinical characteristics were found to be comparable in the two groups. The mean intubation time was 24.1 ± 13.6 s in the Glidescope group, as compared to 18.1 ± 5.9 s in the Macintosh group. Blade insertion was easy in 92% and 96% of the patients in the Glidescope and Macintosh groups, respectively. Tracheal intubation was considered easy in 84% of the Glidescope group, compared to 92% of the Macintosh group. There was a statistically significant correlation between the ease of tracheal intubation and the used intubation method (rho = –0.35; P = 0.014). Conclusion: Our findings indicate that the Glidescope can be used as an efficient modality for obtaining successful intubations with no complications. Ease of tracheal intubation was the only outcome that was found to be affected by the used modality. Further investigations with proper sample sizes are needed.
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REVIEW ARTICLES Top

When to abandon single-lung anesthesia during video-assisted thoracoscopic surgery (VATS) in infants and young children: A case-based review p. 424
Chulananda Goonasekera, Malcolm Mathew, Meera Kurup, Steve James
DOI:10.4103/sja.sja_171_21  
Video-assisted thoracoscopic surgery (VATS) in infants and young children increasingly require one-lung anesthesia. However, the maintenance of norms of gas exchange is difficult during one-lung anesthesia in some infants. A combination of factors including added dead space of HME and the circle Y piece, intrathoracic inflation of CO2 and its pressure, airway resistance and bilateral lung disease contribute. Seeping blood from the operating lung soiling the endobronchial tube causes airway narrowing and obstruction adding to this difficulty especially during prolonged thoracoscopy. We report two cases: hypoxemia in one and hypercapnia in the other. Guidance on safe limits of permissive hypoxemia or hypercarbia in this scenario is vague. Therefore, irreversible hypoxemia and hypercarbia with changes in acid–base status should be considered as indications for swift conversion to open thoracotomy and abandon one-lung ventilation.
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Exemption from informed consent: When it is possible in investigational product and drug trials? p. 428
Swati Verma
DOI:10.4103/sja.sja_159_21  
One of the most important ethical step in conducting investigational product trials or drug trials is obtaining informed consent from the participants. Although consent from the participants regarding participation is of prime importance but is not always practical or feasible. There may be several instances where it is practically impossible to obtain informed consent, whereas in some cases, obtaining informed consent from the trial participants adversely affects the quality and validity of the study data. Obtaining informed consent is a highly complex and technical process if the participants are not literate or suffering from a terminal illness, Also in some instances obtaining informed consent regarding the washout of prior prescribed medicine which may affect the trial outcomes. Although many guidelines exist for obtaining proper informed consent while very scarce literature exists on the instances where it can be waived off. Therefore, this brief narrative review aims to provide insight into currently available knowledge about when to obtain informed consent during testing of investigational product trials and drug trials and other possible scenarios where it can be waived off considering the effects of the washout period.
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Statistical significance or clinical significance? A researcher's dilemma for appropriate interpretation of research results p. 431
Hunny Sharma
DOI:10.4103/sja.sja_158_21  
It is incredibly essential that the current clinicians and researchers remain updated with findings of current biomedical literature for evidence-based medicine. However, they come across many types of research that are nonreproducible and are even difficult to interpret clinically. Statistical and clinical significance is one such difficulty that clinicians and researchers face across many instances. In simpler terms, the P value tests all hypothesis about how the data were produced (model as whole), and not just the targeted hypothesis that it is intended to test (such as a null hypothesis) keeping in mind how reliable are the of the research results. Most of the times it is misinterpreted and misunderstood as a measure to judge the results as clinically significant. Hence this review aims to impart knowledge about “P” value and its importance in biostatistics, also highlights the importance of difference between statistical and clinical significance for appropriate interpretation of research results.
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Pediatric perioperative fluid management p. 435
Amit Mathew, Ekta Rai
DOI:10.4103/sja.sja_140_21  
Appropriate fluid management is vital for adequate tissue perfusion and balancing the internal milieu especially in perioperative settings and critically ill children. Pediatric population is heterogeneous so one formula may not suffice and hence both the quantitative and qualitative perspective of fluid management should be based on physiology and pathology of the child along with their perioperative needs. In perioperative setup, the fluid is administered to meet fluid deficits (fasting, and other daily based losses), blood losses and third space losses. Anesthetists have always followed pediatric maintenance fluid calculations based on Holiday and Segar formula; based on studies conducted on healthy children more than 70 years ago. Recently, there has been a lot of debate about this concept, especially as there are serious concerns regarding the development of complications like hyponatremia and hyperglycemia, both of which can result in neurological damage or even mortality in a sick child. This review is an attempt to provide a historical perspective and current evidence-based approach to peri-operative pediatric fluid management. We performed a PUBMED search for articles using keywords including 'children', 'intravenous fluid therapy', 'crystalloids', 'colloids', 'fluid homeostasis', 'blood loss', 'estimation of blood loss', 'blood loss management', 'perioperative fluid ' to get our source articles.
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CASE REPORTS Top

Conversion disorder upon emergence from general anesthesia—A case report and review of literature p. 441
Nourah A Alshathri, Saleh Binsaleh, Abdalrahman Al Saadon, Nuha M Alkhawajah, Abdelazeem Eldawlatly
DOI:10.4103/sja.sja_118_21  
Conversion disorder (CD) is a neurological symptom that is not related to any medical or neurological disease. Symptoms can range from sensory complaints to loss of consciousness. Psychological stressors such as surgery and anesthesia are considered a precipitating factors. Early diagnosis is crucial to prevent unnecessary interventions. Here, we report a case of a patient who developed CD upon emergence from general anesthesia.
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Pulmonary embolism in anticoagulated burn patient: A case report p. 444
Mohamed AlHarbi, Amr AlKouny, Ayaz Ahmed, Borhan Hazazi
DOI:10.4103/sja.sja_131_21  
Venous thromboembolism (VTE) represents a continuous threat to burn patients. While many thromboprophylaxis regimens exist, the best prevention protocol remains indefinable. We report a case of a burn patient who developed pulmonary embolism despite receiving VTE prophylaxis.
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Tracheoesophageal fistula in a COVID-19 patient p. 447
Cristiana Pereira, Rafael Silva, Glória C Campello, Fernando Moura
DOI:10.4103/sja.sja_294_21  
The number of patients requiring admission in intensive care units and prolonged invasive mechanical ventilation (MV) has increased significantly during the coronavirus disease 2019 (COVID-19) pandemic. Tracheoesophageal fistula (TEF) following prolonged invasive MV is a rare condition. Numerous COVID-19 pathophysiological mechanisms and treatment-related effects might support the increase of tracheal complications in this subgroup of patients. We report a case of TEF in a COVID-19 patient submitted to prolonged invasive MV and discuss its diagnosis and management.
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Opioid-free anesthesia with interfascial dexmedetomidine in a high-risk infant p. 450
Ramon Eizaga Rebollar, Elena Borreiros Rodríguez, Irene Delgado Olmos, Luis Miguel Torres Morera
DOI:10.4103/sja.sja_319_21  
Despite the advances in pediatric anesthesia, infants have higher mortality and critical incidents rates than children, especially ex-prematures and those with comorbidity. We present the case of a high-risk infant who underwent elective laparoscopic gastrostomy under opioid-free anesthesia (OFA) combined with transversus abdominis plane (TAP) block with Dexmedetomidine (DEX). Perioperative opioids were entirely avoided, and intraoperative anesthetics and postoperative analgesic were considerably reduced. The infant showed cardiorespiratory stability and optimal analgesia during the uneventful procedure and the postoperative period. We consider OFA and TAP block with DEX a safe and effective anesthetic combination for high-risk infants.
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LETTERS TO EDITOR Top

Nitrites positive in urine: Pre-operative implications for anesthesiologist's p. 454
Abhijit Nair, Suresh Seelam
DOI:10.4103/sja.sja_133_21  
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Pharmacogenomics of postoperative nausea and vomiting: Multifactorial all the way p. 455
Abhijit Nair, Manish Kumar Tiwary
DOI:10.4103/sja.sja_252_21  
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Postoperative bradycardia following bladder exstrophy surgery: An anesthesiologist's nightmare p. 457
Amarjeet Kumar, Chandni Sinha, Amit Kumar Sinha, Surabhi , Saras Singh, Kritika Singh
DOI:10.4103/sja.sja_257_21  
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Glutathione deficiency in COVID19 illness-does supplementation help? p. 458
Abhijit Nair, Praveen Sharma, Manish Kumar Tiwary
DOI:10.4103/sja.sja_320_21  
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A rare presentation of large polypoidal growth from pyriform fossa causing airway challenge p. 460
Bhavna Sriramka, Sumita Swain, Rajiba Lochan Samal, G Ashok, Bikash Parida
DOI:10.4103/sja.sja_349_21  
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Non-steroidal anti-inflammatory drugs in COVID-19 patients- What is the verdict? p. 462
Abhijit Nair
DOI:10.4103/sja.sja_313_21  
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Prolotherapy as an intervention for chronic, refractory musculoskeletal pain p. 463
Abhijit Nair
DOI:10.4103/sja.sja_374_21  
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The balancing act of hospital medical oxygen demand and supply: The need of the hour in the COVID-19 pandemic p. 465
Rakesh Vadakkethil Radhakrishnan, Chitta R Mohanty, Neha Singh, Sebastian Chakola
DOI:10.4103/sja.sja_404_21  
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2-deoxy-d-glucose therapy for preventing inflammatory cascade in COVID19 patients p. 467
Abhijit Nair
DOI:10.4103/sja.sja_419_21  
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Fixed dilated pupils following laparoscopic urological procedure: Steep trendelenburg position was the cause p. 469
Poonam Kumari, Deepshikha , Amarjeet Kumar, Rajnish Kumar, Abhyuday Kumar, Surabhi
DOI:10.4103/sja.sja_403_21  
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Pre-emptive diagnosis of cerebral ischemia during carotid endarterectomy with transcranial motor evoked potential monitoring under general anesthesia p. 471
Rohini M Surve, Suparna Bharadwaj, Dwarakanath Srinivas, JL Anju
DOI:10.4103/sja.sja_259_21  
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Fluoroscopy, a useful alternative for confirming accurate placement of double-lumen tube or bronchial blocker p. 473
Aparna Date, Harshal D Wagh, Milin Shah
DOI:10.4103/sja.sja_341_21  
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