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2011| October-December | Volume 5 | Issue 4
Online since
November 8, 2011
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REVIEW ARTICLES
Procedural sedation: A review of sedative agents, monitoring, and management of complications
Joseph D Tobias, Marc Leder
October-December 2011, 5(4):395-410
DOI
:10.4103/1658-354X.87270
Given the continued increase in the complexity of invasive and noninvasive procedures, healthcare practitioners are faced with a larger number of patients requiring procedural sedation. Effective sedation and analgesia during procedures not only provides relief of suffering, but also frequently facilitates the successful and timely completion of the procedure. However, any of the agents used for sedation and/or analgesia may result in adverse effects. These adverse effects most often affect upper airway patency, ventilatory function or the cardiovascular system. This manuscript reviews the pharmacology of the most commonly used agents for sedation and outlines their primary effects on respiratory and cardiovascular function. Suggested guidelines for the avoidance of adverse effects through appropriate pre-sedation evaluation, early identification of changes in respiratory and cardiovascular function, and their treatment are outlined.
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1,374
ORIGINAL ARTICLES
Comparative evaluation of dexmedetomidine and fentanyl for epidural analgesia in lower limb orthopedic surgeries
Sukhminder Jit Singh Bajwa, Vikramjit Arora, Jasbir Kaur, Amarjit Singh, SS Parmar
October-December 2011, 5(4):365-370
DOI
:10.4103/1658-354X.87264
Background and Aims:
Opioids as epidural adjunct to local anesthetics (LA) have been in use since long and α-2 agonists are being increasingly used for similar purpose. The present study aims at comparing the hemodynamic, sedative, and analgesia potentiating effects of epidurally administered fentanyl and dexmedetomidine when combined with ropivacaine.
Methods:
A total of one hundred patients of both gender aged 21-56 years, American Society of Anaesthesiologist (ASA) physical status I and II who underwent lower limb orthopedic surgery were enrolled into the present study. Patients were randomly divided into two groups: Ropivacaine + Dexmedetomidine (RD) and Ropivacaine + Fentanyl (RF), comprising 50 patie nts each. Inj. Ropivacaine, 15 ml of 0.75%, was administered epidurally in both the groups with addition of 1 μg/kg of dexmedetomidine in RD group and 1 μg/kg of fentanyl in RF group. Besides cardio-respiratory parameters and sedation scores, various block characteristics were also observed which included time to onset of analgesia at T10, maximum sensory analgesic level, time to complete motor blockade, time to two segmental dermatomal regressions, and time to first rescue analgesic. At the end of study, data was compiled systematically and analyzed using ANOVA with post-hoc significance, Chi-square test and Fisher's exact test. Value of
P
<0.05 is considered significant and
P
<0.001 as highly significant.
Results:
The demographic profile of patients was comparable in both the groups. Onset of sensory analgesia at T10 (7.12±2.44 vs 9.14±2.94) and establishment of complete motor blockade (18.16±4.52 vs 22.98±4.78) was significantly earlier in the RD group. Postoperative analgesia was prolonged significantly in the RD group (366.62±24.42) and consequently low dose consumption of local anaesthetic LA (76.82±14.28 vs 104.35±18.96) during epidural top-ups postoperatively. Sedation scores were much better in the RD group and highly significant on statistical comparison (
P
<0.001). Incidence of nausea and vomiting was significantly high in the RF group (26% and 12%), while incidence of dry mouth was significantly higher in the RD group (14%) (
P
<0.05).
Conclusions:
Dexmedetomidine seems to be a better alternative to fentanyl as an epidural adjuvant as it provides comparable stable hemodynamics, early onset, and establishment of sensory anesthesia, prolonged post-op analgesia, lower consumption of post-op LA for epidural analgesia, and much better sedation levels.
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Preanesthetic medication in children: A comparison of intranasal dexmedetomidine versus oral midazolam
Ashraf M Ghali, Abdul Kader Mahfouz, Maher Al-Bahrani
October-December 2011, 5(4):387-391
DOI
:10.4103/1658-354X.87268
Background:
Relieving preoperative anxiety is an important concern for the pediatric anesthesiologist. Midazolam has become the most frequently used premedication in children. However, new drugs such as the α
2
-agonists have emerged as alternatives for premedication in pediatric anesthesia.
Methods:
One hundred and twenty children scheduled for adenotonsillectomy were enrolled in this prospective, double-blind, randomized study. The children were divided into two equal groups to receive either intranasal dexmedetomidine 1 μg/kg (group D), or oral midazolam 0.5 mg/kg (group M) at approximately 60 and 30 mins, respectively, before induction of anesthesia. Preoperative sedative effects, anxiety level changes, and the ease of child-parent separation were assessed. Also, the recovery profile and postoperative analgesic properties were assessed.
Results:
Children premedicated with intranasal dexmedetomidine achieved significantly lower sedation levels (
P
=0.042), lower anxiety levels (
P
=0.036), and easier child-parent separation (
P
=0.029) than children who received oral midazolam at the time of transferring the patients to the operating room. Postoperatively, the time to achieve an Aldrete score of 10 was similar in both the groups (
P
=0.067). Also, the number of children who required fentanyl as rescue analgesia medication was significantly less (
P
=0.027) in the dexmedetomidine group.
Conclusion:
Intranasal dexmedetomidine appears to be a better choice for preanesthetic medication than oral midazolam in our study. Dexmedetomidine was associated with lower sedation levels, lower anxiety levels, and easier child-parent separation at the time of transferring patients to the operating room than children who received oral midazolam. Moreover, intranasal dexmedetomidine has better analgesic property than oral midazolam with discharge time from postanesthetic care unit similar to oral midazolam.
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Addition of intrathecal Dexamethasone to Bupivacaine for spinal anesthesia in orthopedic surgery
Nadia Bani-hashem, Bahman Hassan-nasab, Ebrahim Alijan Pour, Parviz Amri Maleh, Aliakbar Nabavi, Ali Jabbari
October-December 2011, 5(4):382-386
DOI
:10.4103/1658-354X.87267
Objectives:
Spinal anesthesia has the advantage that profound nerve block can be produced in a large part of the body by the relatively simple injection of a small amount of local anesthetic. Intrathecal local anesthetics have limited duration. Different additives have been used to prolong spinal anesthesia. The effect of corticosteroids in prolonging the analgesic effects of local anesthetics in peripheral nerves is well documented. The purpose of this investigation was to determine whether the addition of dexamethasone to intrathecal bupivacaine would prolong the duration of sensory analgesia or not.
Methods:
We conducted a randomized, prospective, double-blind, case-control, clinical trial. A total of 50 patients were scheduled for orthopedic surgery under spinal anesthesia. The patients were randomly allocated to receive 15 mg hyperbaric bupivacaine 0.5% with 2 cc normal saline (control group) or 15 mg hyperbaric bupivacaine 0.5% plus 8 mg dexamethasone (case group) intrathecally. The patients were evaluated for quality, quantity, and duration of block; blood pressure, heart rate, nausea, and vomiting or other complications.
Results:
There were no signification differences in demographic data, sensory level, and onset time of the sensory block between two groups. Sensory block duration in the case group was 119±10.69 minutes and in the control group was 89.44±8.37 minutes which was significantly higher in the case group (
P
<0.001). The duration of analgesia was 401.92±72.44 minutes in the case group; whereas it was 202±43.67 minutes in the control group (
P
<0.001). The frequency of complications was not different between two groups.
Conclusion:
This study has shown that the addition of intrathecal dexamethasone to bupivacaine significantly improved the duration of sensory block in spinal anesthesia without any changes in onset time and complications.
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Use of Airtraq, C-Mac, and Glidescope laryngoscope is better than Macintosh in novice medical students' hands: A manikin study
Abdullah M Kaki, Waleed A AlMarakbi, Hazem M Fawzi, Abdulaziz M Boker
October-December 2011, 5(4):376-381
DOI
:10.4103/1658-354X.87266
Background and Aim:
Obtaining patent airway is a crucial task for many physicians. When opportunities to practice intubations on patients are really limited, skill gaining methods are needed. We conducted a study among novice 6
th
year medical students to assess their ability to intubate the trachea in normal airway in manikin using four airway tools.
Setting and Design:
Prospective, cohort study conducted at simulation center of university-based, tertiary care hospital.
Methods:
Fifty medical students performed either oral or nasal tracheal intubation using the following four intubating tools: C-Mac videolaryngoscope, Glidescope, and Airtraq in comparison with regular Macintosh laryngoscope. Intubation time, visualization of glottic opening, ease of intubation, satisfaction of participants, incidence of dental trauma, and the need for optimization manoeuvres' use among different airway tools were recorded.
Results:
In oral intubation, Airtraq was better than others in regard to intubation time, glottic opening, ease of intubation, and the need for external laryngeal pressure application, followed by Glidescope, C-Mac, and finally Macintosh laryngoscope (
P
<0.001). Airtraq and Glidescope associated with less dental trauma than C-Mac and Macintosh. In nasal route, fastest intubation time was reported with Airtraq followed by Glidescope, C-Mac, and lastly Macintosh. Airtraq, Glidescope, and C-Mac were similar to each other and better than the Macintosh in regard to ease of intubation, satisfaction, and number of attempts (
P
≤0.008).
Conclusions:
New devices like Airtraq, Glidescope, and C-Mac are better than the regular Macintosh when used by novice medical students for oral and nasal intubation on manikin.
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EDITORIAL
Video laryngoscopes
Amir B Channa
October-December 2011, 5(4):357-359
DOI
:10.4103/1658-354X.87262
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ORIGINAL ARTICLES
Maternal and neonatal effects of nalbuphine given immediately before induction of general anesthesia for elective cesarean section
Sabry M Amin, Yasser M Amr, Sameh M Fathy, Ashraf E Alzeftawy
October-December 2011, 5(4):371-375
DOI
:10.4103/1658-354X.87265
Background:
Although nalbuphine was studied extensively in labour analgesia and was proved to be acceptable analgesics during delivery, its use as premedication before induction of general anesthesia for cesarean section is not studied. The aim of this study was to evaluate the effect of nalbuphine given before induction of general anesthesia for cesarean section on quality of general anesthesia, maternal stress response, and neonatal outcome.
Methods:
Sixty full term pregnant women scheduled for elective cesarean section, randomly classified into two equal groups, group N received nalbuphine 0.2 mg/kg diluted in 10 ml of normal saline (
n
=30), and group C placebo (
n
=30) received 10 ml of normal saline 1 min before the induction of general anesthesia. Maternal heart rate and blood pressure were measured before, after induction, during surgery, and after recovery. Neonates were assisted by using APGAR0 scores, time to sustained respiration, and umbilical cord blood gas analysis.
Result:
Maternal heart rate showed significant increase in control group than nalbuphine group after intubation (88.2±4.47 versus 80.1±4.23,
P
<0.0001) and during surgery till delivery of baby (90.8±2.39 versus 82.6±2.60,
P
<0.0001) and no significant changes between both groups after delivery. MABP increased in control group than nalbuphine group after intubation (100.55±6.29 versus 88.75±6.09,
P
<0.0001) and during surgery till delivery of baby (98.50±2.01 versus 90.50±2.01,
P
<0.0001) and no significant changes between both groups after delivery. APGAR score was significantly low at one minute in nalbuphine group than control group (6.75±2.3, 8.5±0.74, respectively,
P
=0.0002) (27% of nalbuphine group APGAR score ranged between 4-6, while 7% in control group APGAR score ranged between 4-6 at one minute). All neonates at five minutes showed APGAR score ranged between 9-10. Time to sustained respiration was significantly longer in nalbuphine group than control group (81.8±51.4 versus 34.9±26.2 seconds,
P
<0.0001). The umbilical cord blood gas was comparable in both groups. None of the neonates need opioid antagonist (naloxone) or endotracheal intubation.
Conclusion:
Administration of nalbuphine before cesarean section under general anesthesia reduces maternal stress response related to intubation and surgery, but decreases the APGAR score at one minute after delivery. So, when nalbuphine was used, all measures for neonatal monitoring and resuscitation must be available including attendance of a pediatrician.
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CASE REPORTS
Difficult intubation in a parturient with syringomyelia and Arnold-Chiari malformation: Use of Airtraq
™
laryngoscope
Bensghir Mustapha, K Chkoura, M Elhassani, R Ahtil, H Azendour, N Drissi Kamili
October-December 2011, 5(4):419-422
DOI
:10.4103/1658-354X.87274
Anesthetic technique in parturient with syringomyelia and Arnold-Chiari malformation is variable depending on the teams. Difficult intubation is one of the risks when general anesthesia is opted. Different devices have been used to manage the difficult intubation in pregnant women. We report the use of Airtraq™ laryngoscope after failed standard laryngoscopy in a parturient with syringomyelia and Arnold-Chiari type I malformation.
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328
Accidental five fold overdose of propofol for induction in a 38-days-old infant undergoing emergency bilateral inguinal hernia repair
Mahin Seyedhejazi, Ghafur Abafattash, Reza Taheri
October-December 2011, 5(4):417-418
DOI
:10.4103/1658-354X.87273
The induction dose of propofol is higher in younger children (2.9 mg/kg for infants younger than 2 years) than in older children (2.2 mg/kg for children 6-12 years of age). A modest reduction in systolic blood pressure often accompanies bolus administration. The major concern with propofol is the potential for propofol infusion syndrome (lactic acidosis, rhabdomyolysis, cardiac and renal failure), which is generally associated with high-dose infusion for an extended period. We report a 38-days-old male infant underwent emergency bilateral inguinal hernia repair who accidentally received a five-fold dose of propofol for induction of general anesthesia.
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Dexmedetomidine as the primary anesthetic agent during cardiac surgery in an infant with a family history of malignant hyperthermia
Aymen Naguib, Chris McKee, Alistair Phillips, Joseph D Tobias
October-December 2011, 5(4):426-429
DOI
:10.4103/1658-354X.87276
Malignant hyperthermia (MH) is an acute hypermetabolic crisis triggered in susceptible patients by the administration of succinylcholine or a volatile anesthetic agent. When providing anesthetic care for MH-susceptible agents, a total intravenous anesthetic (TIVA) technique is frequently chosen. When choosing the components for TIVA, several options exist including the combination of propofol or dexmedetomidine with an opioid. We present our experience with the use of dexmedetomidine as a key component of the anesthetic regimen in a 5-month-old infant with a family history of MH. Previous reports of the use of dexmedetomidine in MH-susceptible patients are reviewed and its benefits in such patients discussed.
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4,348
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REVIEW ARTICLES
Ultrasound guidance of uncommon nerve blocks
Ahmed Thallaj
October-December 2011, 5(4):392-394
DOI
:10.4103/1658-354X.87269
In the past nerve stimulation was considered the standard tool for anesthesiologists to locate the peripheral nerve for nerve blocks. However, with the recent introduction of ultrasound (US) technology for regional anesthesia, the use of nerve stimulation has become a rarity nowadays. There is a growing interest by most anesthesiologists in using US for nerve blocks because of its simplicity and accuracy. US is now available in most hospitals practicing regional anesthesia and is a popular tool for performance of nerve blocks. Although nerve stimulation became a rarity, however the use of it is now limited to identify small nerve structures, such as greater auricular nerve and medial antebrachial cutaneous nerve of the forearm. However, in this review article we discuss the role of ultrasonography for greater auricular and antebrachial cutaneous nerve blocks, which could replace nerve stimulation technique. We look at the available literature on the role of US for the performance of uncommon nerve blocks and its benefits.
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3
10,428
549
CASE REPORTS
Awake intubation with Bonfil's retromolar fibroscope in a patient with hard and fixed swelling of the right side of the neck and the tonsillar tumor
Mamdouh Medhat, T Aljuhani
October-December 2011, 5(4):423-425
DOI
:10.4103/1658-354X.87275
Bonfil's rigid fibroscope is an instrument used to perform tracheal intubation, proven to be effective both in patients with normal and in those with difficult airways. We use this device in awake intubation in a patient presenting with a large right neck mass and a tonsillar tumor which limited the mouth opening. Also, we describe our technique of insertion of Bonfil's retromolar fibroscope from the right side of the mouth across the tongue.
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5,196
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Broncho-pleuropericardial fistula complicating staphylococcal sepsis
Abeer A Arab, Maan A Kattan, Walid A Alyafi, Jamal A Alhashemi
October-December 2011, 5(4):434-437
DOI
:10.4103/1658-354X.87278
This is a rare case of broncho-pleuropericardial fistula in a 12-year-old female who presented with fever, painful joint swelling, and pleural and pericardial effusion secondary to disseminated methicillin-sensitive
Staphylococcus aureus
infection. The pleural and pericardial effusion were drained, however, air leak was observed from both tubes and was synchronous with mechanical inspiration. A broncho-pleuropericardial fistula was suspected and confirmed with computed tomography. This case report demonstrated that disseminated
S.
aureus
bacteremia could result in broncho-pleuropericardial fistula. The ability of disseminated staphylococcal infection to produce pnemopericardium should be added to the list of other complications associated with disseminated staphylococcal sepsis.
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3,315
175
REVIEW ARTICLES
The SensaScope
®
- A new hybrid video intubation stylet
Peter Biro
October-December 2011, 5(4):411-413
DOI
:10.4103/1658-354X.87271
The recently developed SensaScope
®
is a hybrid intubation endoscope that has been designed and developed according to our clinical requirements for a safe, easy-to-handle, and effective video-assisted intubation. The attribute "hybrid" derives from the fact that the shaft of the instrument is combined by both, rigid and flexible parts. Its S-shaped rigid segment enables a very intuitive handling by one hand only, thus leaving the left hand free to operate a conventional laryngoscope. The tip of the device can be controlled via a steering handle in a similar fashion as fiberoptic endoscopes. Due to these attributes, the SensaScope
®
became a very versatile and effective tool to master the unanticipated difficult intubation in anesthetized and paralyzed patients. For this reason, in our institution it has been included as the first-line technique into our local failed intubation algorithm. The first clinical experience with the device and its standardized technique of use produced encouraging results; the success rate for novices was found to be at 97% (in 194 of 200 patients) of all intubation attempts in both patients categories: those who were rated as having normal (84.5%) and in those showing difficult intubation conditions (15.5%). The technical development, the way of using the device, the suitable indications, and limitations are discussed here.
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3,531
196
CASE REPORTS
Application of indigenous continuous positive airway pressure during one lung ventilation for thoracic surgery
Rahul Yadav, Arvind Chaturvedi, Girija Prasad Rath, Keshav Goyal
October-December 2011, 5(4):438-439
DOI
:10.4103/1658-354X.87279
During one lung ventilation (OLV) hypoxemia may occur due to ventilation-perfusion mismatch. It can be prevented with application of ventilation strategy that prevents atelectasis while minimally impairing perfusion of the dependant lung. Here, two cases are reported who required OLV and in whom hypoxemia could be prevented with the application of continuous positive airway pressure to the deflated or non-dependant lung, using an indigenous technique. We suggest use of this technique which is easy to be employed during the intraoperative period.
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5,009
188
Anesthetic management in a patient with Kindler's syndrome
Sohan Lal Solanki, Amit Jain, Ishwar Bhukal, Sukhen Samanta
October-December 2011, 5(4):430-433
DOI
:10.4103/1658-354X.87277
A 35-year-old male with pan-anterior urethral stricture was scheduled to undergo perineal urethrostomy. He was a known case of Kindler's syndrome since infancy. He was having a history of blister formation, extensive poikiloderma and progressive cutaneous atrophy since childhood. He had a tendency of trauma-induced blisters with clear or hemorrhagic contents that healed with scarring. The fingers were sclerodermiform with dystrophic nails and inability to completely clench the fist. Airway examination revealed thyromental distance of 7 cm with limited neck extension, limited mouth opening and mallampatti class III with a fixed large tongue. He was reported as grade IV Cormack and Lehane laryngoscopic on previous anesthesia exposure. We described the anesthetic management of such case on guidelines for epidermolysis bullosa. In the operating room, an 18-G cannula was secured in the right upper limb using Coban
TM
Wrap. The T-piece of the cannula was than inserted into the slit and the tape was wrapped around the extremity. The ECG electrodes were placed on the limbs and fixed with Coban
TM
. Noninvasive blood pressure cuff was applied over the wrap after wrapping the arm with Webril® cotton. Oral fiberoptic tracheal intubation was done after lubricating the laryngoscope generously with a water-based lubricant with 7-mm endotracheal tube. Surgery proceeded without any complication. After reversing the residual neuromuscular block, trachea was extubated once the patient became awake. He was kept in the postanesthesia care unit for 2 hours and then shifted to urology ward.
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4,665
283
LETTERS TO EDITOR
Intraoperative anuria: An unusual cause
Babita Gupta, Manpreet Kaur, Prabhjot Singh, Kamran Farooque, Sarita Ramchandani, Chandni Sinha
October-December 2011, 5(4):443-444
DOI
:10.4103/1658-354X.87283
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3,133
169
CASE REPORTS
Intubation in a pediatric difficult airway using an adult flexible fiber-optic bronchoscope and a j-tipped guidewire: An innovation in adversity
Manish Naithani, Alpna Jain, Zainab Chaudhary
October-December 2011, 5(4):414-416
DOI
:10.4103/1658-354X.87272
Management of an anticipated difficult airway relies heavily on flexible fiber-optic bronchoscope (FFB) guided awake intubations. In a pediatric patient with difficult airway, doing an awake procedure may be difficult, and hence the child is either deeply sedated or anesthesia is induced before attempting intubation with an appropriate sized FFB. We present the anesthetic management of a 6-year-old child with a lacerated tongue and fractured mandibular condyle, with subsequent inability to open his mouth, who was posted for urgent exploration and open reduction under anesthesia. Unhindered by a damaged pediatric FFB, we innovated by positioning the tip of an adult FFB just outside the larynx, passing a j-tipped guidewire through the working channel of the FFB, and successfully railroaded a naso-tracheal tube over the guidewire. The surgery, reversal and extubation, and the postoperative period were uneventful.
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ERRATA
Errata
October-December 2011, 5(4):364-364
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1,985
166
LETTERS TO EDITOR
Use of nasopharyngeal airway for interim dilatation of lower tracheal stenosis
Lakesh Kumar Anand, Surinder K Singhal, Suman Sekhawat
October-December 2011, 5(4):445-446
DOI
:10.4103/1658-354X.87284
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3,236
175
Tracheal intubation with nasal speculum
in situ
Varun Jain, Navdeep Sokhal, Girija Prasad Rath, Keshav Goyal
October-December 2011, 5(4):440-441
DOI
:10.4103/1658-354X.87280
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3,618
181
Gastric tube connector: A simple solution for everyday problem
Anju Gupta, Nishkarsh Gupta
October-December 2011, 5(4):441-442
DOI
:10.4103/1658-354X.87281
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2,949
154
An alternative to bite block in a patient with restricted mouth opening
Chhavi Sawhney, Pramendra Agrawal, Kapil Dev Soni, Sarita Ramchandani, Chandni Sinha
October-December 2011, 5(4):442-443
DOI
:10.4103/1658-354X.87282
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3,884
177
ORIGINAL ARTICLES
Effects of local low-dose rocuronium on the quality of peribulbar anesthesia for cataract surgery
Ayman A Abdellatif, Mohamed A El Shahawy, Ahmed I Ahmed, Waleed A Almarakbi, Jamal A Alhashemi
October-December 2011, 5(4):360-364
Objectives:
Peribulbar anesthesia is associated with delayed and/or incomplete orbital akinesia compared with retrobulbar anesthesia. This study examined the effects of adding rocuronium 5 mg to two different concentrations of lidocaine-bupivacaine mixture on onset time of orbital and eyelid akinesia in patients undergoing cataract surgery.
Methods:
In a double-blind study, 90 patients were equally randomized to receive a mixture of 0.5 ml normal saline, 4 ml lidocaine 2%, and 4 ml bupivacaine 0.5% (group I), a mixture of rocuronium 0.5 ml (5 mg), 4 ml lidocaine 2%, and 4 ml bupivacaine 0.5% (group II), or a mixture of rocuronium 0.5 ml (5 mg), 4 ml lidocaine 1%, and 4 ml bupivacaine 0.25% (group III). Orbital akinesia was assessed on a 0-8 score (0 = no movement, 8 = normal) at 2 min intervals for 10 min. Time to adequate anesthesia was also recorded. Results are presented as mean±SD.
Results:
Ocular movement score decreased during the assessment period in all groups. However, at 2 min after block administration, the score decreased to 4±2 (95% CI 3,5) in groups II and III compared with 5±2 (95% CI 4,6) in group I (
P
<0.01). Time to adequate condition to begin surgery was 9.8±2.9 vs. 6.9±4.1 vs. 7.9±3.9 min for groups I, II, and III, respectively (
P
=0.01).
Conclusion:
The addition of rocuronium 5 mg to a mixture of lidocaine 2% and bupivacaine 0.5% shortened the onset time of peribulbar anesthesia in patients undergoing cataract surgery without causing adverse effects.
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QUIZ
Guess what?
Ahmed Thallaj
October-December 2011, 5(4):447-447
DOI
:10.4103/1658-354X.87285
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