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   Table of Contents - Current issue
Coverpage
March-April 2015
Volume 81 | Issue 2
Page Nos. 113-232

Online since Monday, March 02, 2015

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EDITORIAL  

IJDVL International Awards Highly accessed article p. 113
M Ramam
DOI:10.4103/0378-6323.152167  
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GUEST EDITORIAL Top

Designing a research protocol in clinical dermatology: Common errors and how to avoid them Highly accessed article p. 115
Saumya Panda
DOI:10.4103/0378-6323.152168  
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THERAPEUTIC GUIDELINES - IADVL Top

Phototherapy for mycosis fungoides p. 124
Sunil Dogra, Rahul Mahajan
DOI:10.4103/0378-6323.152169  
Background: Both phototherapy and photochemotherapy have been used in all stages of mycosis fungoides since they improve the symptoms and have a favourable adverse effect profile. Materials and Methods: We performed an extensive search of published literature using keywords like "phototherapy", "photochemotherapy", "NBUVB", "PUVA", "UVA1", "mycosis fungoides", and "Sezary syndrome", and included systematic reviews, meta-analysis, national guidelines, randomized controlled trials (RCTs), prospective open label studies, and retrospective case series. These were then arranged according to their levels of evidence. Results: Five hundred and forty three studies were evaluated, of which 107 fulfilled the criteria for inclusion in the guidelines. Conclusions and Recommendations: Photochemotherapy in the form of psoralens with ultraviolet A (PUVA) is a safe, effective, and well tolerated first line therapy for the management of early stage mycosis fungoides (MF), that is, stage IA, IB, and IIA (Level of evidence 1+, Grade of recommendation B). The evidence for phototherapy in the form of narrow-band UVB (NB-UVB) is less robust (Level of evidence 2++, Grade of recommendation B) but may be considered at least as effective as PUVA in the treatment of early-stage MF as an initial therapy. In patients with patches and thin plaques, NB-UVB should be preferentially used. PUVA may be reserved for patients with thick plaques and those who relapse after initial NB-UVB therapy. For inducing remission, three treatment sessions per week of PUVA phototherapy or three sessions per week of NB-UVB phototherapy may be advised till the patient achieves complete remission. In cases of relapse, patients may be started again on PUVA monotherapy or PUVA may be combined with adjuvants like methotrexate and interferon (Level of evidence 2+, Grade of recommendation B). Patients with early-stage MF show good response to combination treatments like PUVA with methotrexate, bexarotene or interferon-α-2b. However, whether these combinations hold a significant advantage over monotherapy is inconclusive. For late stage MF, the above-mentioned combination therapy may be used as first-line treatment (Level of evidence 3, Grade of recommendation C). Currently, there is no consensus regarding maintenance therapy with phototherapy once remission is achieved. Maintenance therapy should not be employed for PUVA routinely and may be reserved for patients who experience an early relapse after an initial course of phototherapy (Level of evidence 2+, Grade of recommendation B). Bath-water PUVA may be tried as an alternative to oral PUVA in case the latter cannot be administered as the former may show similar efficacy (Level of evidence 2-, Grade of recommendation C). In pediatric MF and in hypopigmented MF, both NB-UVB and PUVA may be tried (Level of evidence 3, Grade of recommendation D).
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REVIEW ARTICLE Top

Patient-assisted teledermatology practice: What is it? When, where, and how it is applied? Highly accessed article p. 136
Garehatty Rudrappa Kanthraj
DOI:10.4103/0378-6323.152172  
Recent teledermatology practice has been focused on different models made possible by robust advances in information technology leading to consistent interaction between the patient and health care professionals. Patient-assisted teledermatology practice also called patient-enabled teledermatology or home based teledermatology is one such novel model. There is a lack of scientific literature and substantive reviews on patient-assisted teledermatology practice. The present article reviews several studies and surveys on patient-assisted teledermatology practice and outlines its advantages and barriers to clinical utility and analyses the potentiality of this concept. Incorporating patient-assisted teledermatology practice as a novel model in the revised classification of teledermatology practice is proposed. In patient-assisted teledermatology, the patient can upload his/her clinical images as a first contact with the dermatologist or an initial face-to-face examination can be followed by teledermatology consultations. The latter method is well suited to chronic diseases such as psoriasis, vitiligo, and leg ulcers, which may need frequent follow-up entailing significant costs and time, particularly in the elderly. Teledermatology may also be used by the treating dermatologist to seek expert opinion for difficult cases. Studies have demonstrated the importance and usability of the concept of patient-assisted teledermatology practice. Various teledermatology care models are available and the appropriate model should be chosen depending on whether the clinical situation is that of easily diagnosed cases ("spotters"), chronic cases or doubtful cases and difficult-to-manage cases.
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ORIGINAL ARTICLES Top

Relapse in psoriasis with two different tapering regimens of methotrexate: A randomized open-label controlled study p. 144
Satyendra Kumar Singh, Tulika Rai
DOI:10.4103/0378-6323.152175  
Background : Systemic therapy with methotrexate is a very useful modality in psoriasis, but relapses can occur soon after stopping it. Aim : To compare the relapse rates in psoriasis with two different tapering regimens of methotrexate after control is achieved. Methods : This was a randomized open-label controlled study, and patients of chronic plaque psoriasis with psoriasis area and severity index (PASI) >10 were included. Methotrexate 0.3 mg/kg weekly was given and the PASI calculated every 2 weeks. After achieving a 75% reduction in the PASI (PASI-75), patients were assigned randomly in to one of three groups. In the half-dose group, the dose of methotrexate was reduced to half and given weekly; in the 2-weekly group, the same dose was given at 2-week intervals; in the control group, methotrexate was stopped. Patients were followed up for 12 weeks. Results : Out of 141 registered patients, 81 were included: 27 in the half-dose group, 28 in the 2-weekly group, and 26 in the control group. After further exclusions due to adverse effects and loss to follow-up, the results were analysed for 16, 17 and 19 patients respectively in the 3 groups. There was statistically a highly significant difference in relapse rates between the half-dose and control groups (P < 0.001), and a significant difference between the 2-weekly and control groups (P = 0.001). Relapse rates in the half-dose and 2-weekly groups did not show a significant difference (P = 0.680). Limitation: Many (35.8%) patients were excluded and only 52 (64.2%) completed the study. Conclusion: There appears to be no significant difference in the frequency of relapse in psoriasis whether methotrexate is tapered by halving the weekly dose or by doubling the interval between two doses, and both methods led to fewer relapses than abrupt cessation of the drug.
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Screening for depressive disorders in outpatients with mild to moderate psoriasis: A study from North India p. 148
Shubh Mohan Singh, Tarun Narang, Sunil Dogra, Anant Kumar Verma, Sunil Gupta, Sanjeev Handa
DOI:10.4103/0378-6323.152178  
Background: Psoriasis and depressive disorders commonly occur together. Depressive disorders have an impact on the quality of life and the outcome of psoriasis. Aims: The aim of this study was to test the feasibility of using a modification of the Hindi translation of the Patient Health Questionnaire-9 (PHQ-9) as a verbal, clinician administered, short screening questionnaire for detecting depressive disorders. Materials and Methods: One hundred and four out-patients with psoriasis were recruited in the study. In the first stage of the study, socio-demographic data, Psoriasis Area Severity Index (PASI) score, and Dermatological Quality of Life (DLQI) score were recorded. The modified questionnaire was administered by the dermatologist. In the second stage, psychiatric diagnoses were confirmed using the Mini International Neuropsychiatric Interview. Results: The prevalence of depressive disorders was 39.4%. Receiver operating curve (ROC) analysis showed that the questionnaire had a good discriminant ability in detecting depressive disorders (area under curve: 0.81, SE = 0.04, 95% confidence interval = 0.72-0.89). Limitations: The sample size is small and more studies are needed with the screening questions in different languages to validate the findings of the study. Conclusion: The questionnaire can be a useful screening instrument for detecting depressive disorders in patients with psoriasis.
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Topical photodynamic therapy in the treatment of basal cell carcinoma in Singaporean Chinese patients p. 151
Hui-Yi Chia, Shui-Lyn Claire Koh, Thiam-Seng Colin Theng, Wei-Sheng Chong
DOI:10.4103/0378-6323.152180  
Background: Topical photodynamic therapy has been used for the treatment of superficial and nodular basal cell carcinomas, with varying cure rates. Aims: This study aims to evaluate the effectiveness of topical photodynamic therapy in the treatment of superficial and nodular basal cell carcinomas in Asian patients treated at the National Skin Centre, Singapore. Materials and Methods: A retrospective analysis of Asian patients with histologically confirmed basal cell carcinomas and treated with photodynamic therapy was performed. Results: Eight Chinese patients, with an equal gender distribution and mean age of 83.4 years were included. Five of eight basal cell carcinomas were superficial while the remaining three were nodular. The basal cell carcinomas were located in the head and neck in seven patients. The overall clearance rate at 3 months was 87.5% while the clearance rate for superficial and nodular basal cell carcinomas was 100% and 66.6% respectively at 3 months. At 12 months, the overall clearance rate was 85. 7%. Limitations: This is a retrospective analysis with small patient numbers. Conclusions: In this small series of eight Asian patients, topical photodynamic therapy has been shown to be effective and generally well-tolerated in the treatment of basal cell carcinomas, particularly of the superficial subtype. However, larger studies are needed to evaluate its overall efficacy in Asian patients.
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BRIEF REPORT Top

Report of rpoB mutation in clinically suspected cases of drug resistant leprosy: A study from Eastern India p. 155
Abu Hena Hasanoor Reja, Nibir Biswas, Supratik Biswas, Mallika Lavania, Vedithi Sundeep Chaitanya, Surajita Banerjee, Prasanta Sinha Maha Patra, Umesh Dutta Gupta, Pradip Kumar Patra, Utpal Sengupta, Basudev Bhattacharya
DOI:10.4103/0378-6323.152185  
Background: The current strategy for leprosy control depends mainly on early case detection and providing the recommended multidrug therapy (MDT) dosage. Understanding the molecular mechanisms of drug resistance to each of these drugs is essential in providing effective treatment and preventing the spread of resistant strains in the community. The progress of molecular biology research provides a very efficient opportunity for the diagnosis of drug resistance by in vitro method. Aim: We aimed to investigate the point mutations within the rpoB gene region of the Mycobacterium leprae genome, which are responsible for resistance to rifampicin, in order to determine the emergence of drug resistance in leprosy in the Kolkata region of West Bengal. Methods: A total of 50 patients with a relapse of leprosy were enrolled in the study. Skin smears were obtained for estimation of bacillary index and biopsies were obtained in 70% alcohol for extraction of DNA. The extracted DNA was amplified by M. leprae-polymerase chain reaction (PCR) targeting rpoB gene region. Every single nucleotide base in the sequence is aligned to reference sequence and identity gaps were determined by NCBI - BLAST. Later in-silico analysis was done to identify the changes in the translated protein sequences. Results: A mutation at the base pair position 2275405 where G is replaced by C in the M. leprae genome, which corresponds to the coding region of rpoB gene (279 bp - 2275228 to2275506), was observed in two patients. This missense mutation in CAC codon brings about a glutamic acid to histidine change in the amino acid sequence of RNA polymerase beta subunit at the position 442 (Glu442His), a region specific for rifampicin interaction, which might be responsible for unresponsiveness to rifampicin by manifesting a stable bacteriological index in these 2 patients even after completion of 24 months of multibacillary multi-drug therapy (MB-MDT). Limitations: The major limitations of multiple-primer PCR amplification refractory mutation system (MARS) assay is that it capable of detecting mutation at codon 425 and cannot distinguish any silent amino acid changes. Conclusion: The study indicates the existence of rifampicin drug resistance in Eastern India.
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CASE REPORTS Top

Frontal fibrosing alopecia and lichen planopilaris in HLA-identical mother and daughter p. 162
María Mercedes Otero Rivas, Sara Calleja Antolín, Pedro Sánchez Sambucety, Elia Samaniego González, José María García Ruíz de Morales, Manuel Ángel Rodríguez Prieto
DOI:10.4103/0378-6323.152284  
Frontal fibrosing alopecia (FFA) is a lymphocyte-mediated scarring alopecia thought to be a variant of lichen planopilaris (LPP). We present a 67-year-old woman with frontal fibrosing alopecia whose daughter was diagnosed to have lichen planopilaris. Both patients had identical human leukocyte antigen (HLA) D types, supporting a phenotypical relationship between the two clinical entities. Interestingly, our patient also had of autoimmune chronic atrophic gastritis, a previously unreported association.
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Psoriasis in autoimmune polyendocrine syndrome type I: A possible complication or a non-endocrine minor component? p. 166
Shital Amin Poojary, Nikita Lodha, Nikita Gupta
DOI:10.4103/0378-6323.152285  
Introduction: Autoimmune polyendocrine syndrome type I (APS I) is an autosomal recessive systemic autoimmune disorder, affecting primarily endocrine glands, in which chronic mucocutaneous candidiasis is an early and prominent manifestation. We describe the rare occurrence of unstable psoriasis (with onset of pustular lesions) in a case of APS I without mucocutaneous candidiasis. A patient presenting with unstable psoriasis (with onset of pustular lesions) was detected to have persistent hypocalcemia which led to the diagnosis of hypoparathyroidism. Subsequently he was found to have hypergonadotrophic hypogonadism, primary adrenal insufficiency (compensated), and coeliac disease, thus confirming the diagnosis of APS I. Psoriasis is very rarely reported in APS I, possibly due to the protective effect of antibodies to Th17 cytokines, which are responsible for the occurrence of candidiasis in this syndrome. However, psoriasis could occur in APS I patients without mucocutaneous candidiasis, who lack these antibodies. In our patient, possible factors aggravating psoriasis include hypocalcemia due to hypoparathyroidism as well as coeliac disease via anti-tissue transglutaminase antibodies. However, defining psoriasis as a possible minor component of APS I would require further studies of the autoimmune regulator (AIRE) gene functions.
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Spontaneous regression in an ulcerated CK7 positive Merkel cell carcinoma p. 170
Anza Khader, Sandhya George, Swapna Balakrishnan, Karumathil Puthiaveetil Aravindan
DOI:10.4103/0378-6323.152286  
Merkel cell carcinoma is an aggressive and frequently lethal tumor of the elderly, associated with sun exposure and immunosuppression which is less common in the dark-skinned. We report the case of a 40-year-old woman who presented with multiple slowly progressive, mildly itchy ulcerated plaques of size ranging from 2 × 3 cm to 5 × 7 cm on the left knee of 1 year duration. Skin biopsy showed diffuse dermal infiltration by small round cells with molding of cells and lymphocyte infiltration. The cells stained positive for cytokeratin (CK) 20, CK7, neuron-specific enolase, and chromogranin. The skin lesions underwent spontaneous regression within 1 month of skin biopsy and have not recurred during the past 2 years. The immune mechanisms triggered by biopsy possibly explain the spontaneous regression.
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IMAGES IN CLINICAL PRACTICE Top

Hemorrhagic acne in immune thrombocytopenia p. 174
Manjot Marwah, Vivek Sharma, Gurjot Marwah
DOI:10.4103/0378-6323.152287  
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RESIDENT’S PAGE Top

Skin substitutes in dermatology Highly accessed article p. 175
Sudha Anish
DOI:10.4103/0378-6323.152288  
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LETTERS TO THE EDITOR Top

Syphilis among sexually transmitted infections clinic attendees in a tertiary care institution: A retrospective data analysis p. 179
Bhushan Kumar
DOI:10.4103/0378-6323.152289  
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Author's reply: Significance of seropositivity for syphilis in asymptomatic individuals p. 179
Sarita Sasidharanpillai, Valiaveetil Bindu, Najeeba Riyaz, Pentam V Beegum Sherjeena, Saleem Rahima, Nirmal Chandrasekhar
DOI:10.4103/0378-6323.152290  
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The pH of skin cleansers for acne p. 181
Nakaraj Pluetrattanabha, Kanokvalai Kulthanan, Piyavadee Nuchkull, Supenya Varothai
DOI:10.4103/0378-6323.152291  
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A curious case of hourly attacks of disabling episodic spontaneous hypothermia with hyperhidrosis p. 185
Sharad Mehta, Tarun Ralot, Vaishali Masatkar, Nidheesh Agarwal, Atul Rana
DOI:10.4103/0378-6323.152292  
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Unilateral pruritus following stroke p. 186
Satyaki Ganguly, C Vijay Krishna, Nisha V Parmar, Sheela Kuruvila, Dilip S Phansalkar
DOI:10.4103/0378-6323.152294  
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Severe abdominal wall defect leading to dehiscence in focal dermal hypoplasia (Goltz syndrome) p. 188
Nilendu Sarma, Sayantani Chakraborty, Subhamoy Neogi, Sushila Hansda
DOI:10.4103/0378-6323.152295  
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Rothmund - Thomson syndrome with bronchiectasis: An uncommon phenotype? p. 190
Vikram K Mahajan, Vikas Sharma, Pushpinder S Chauhan, Karaninder S Mehta, Rashmi Raina
DOI:10.4103/0378-6323.152297  
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A recurrent R936X mutation of CYLD gene in a Chinese family with multiple familial trichoepithelioma p. 192
Qi-Guo Zhang, Yan-Hua Liang
DOI:10.4103/0378-6323.152298  
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Annular epidermolytic ichthyosis: A rare phenotypic variant of bullous congenital ichthyosiform erythroderma p. 194
Aditi Jha, Jitender Taneja, V Ramesh, Avninder Singh
DOI:10.4103/0378-6323.152299  
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Precocious puberty in a 3-year-old child with systematized verrucous epidermal nevus p. 197
Taru Garg, Ram Chander, Niti Gaur, Kanika Sahni
DOI:10.4103/0378-6323.152301  
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Eruptive blue nevi p. 198
Katarina Kesty, Omid Zargari
DOI:10.4103/0378-6323.152302  
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Churg-Strauss syndrome with asymptomatic pulmonary emboli p. 201
Chau Yee Ng, Rosaline Chung-Yee Hui, Tseng-tong Kuo, Chun-Yu Cheng, Jennifer Wu
DOI:10.4103/0378-6323.152303  
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Sweet's syndrome associated with chronic neutrophilic leukemia p. 203
Sukhjot Kaur, Amit Bery, Bhavna Garg, Neena Sood
DOI:10.4103/0378-6323.152304  
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Squamous cell carcinoma mimicking lupus vulgaris p. 206
Surendra Kumar, Swati Gondane, Neena Kasliwal
DOI:10.4103/0378-6323.152305  
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Systemic anaplastic large cell lymphoma with secondary cutaneous involvement p. 208
Amit S Murkute, Dhananjay K Damle, Bhavana R Doshi, Vasudha A Belgaumkar
DOI:10.4103/0378-6323.152306  
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Metastatic porocarcinoma p. 210
G Raghurama Rao, Rajiv Joshi, KA Seetharam, A Amareswar, M Sridevi
DOI:10.4103/0378-6323.152307  
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Papular mucinosis associated with monoclonal gammopathy of unknown significance p. 213
Sarvesh S Thatte, Atul M Dongre, Siddhi B Chikhalkar, Uday S Khopkar
DOI:10.4103/0378-6323.152308  
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Recalling the recall phenomenon p. 214
Sharmila Patil, Nitin Nadkarni, Snehal Shende
DOI:10.4103/0378-6323.152310  
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Nilotinib-induced psoriasis in a patient of chronic myeloid leukemia responding to methotrexate p. 216
Sukhjot Kaur, Amanjot Kaur Arora, Jagdev S Sekhon, Neena Sood
DOI:10.4103/0378-6323.152311  
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Aminolevulinic acid photodynamic therapy for bowenoid papulosis p. 219
Yin-hua Wu, Jian-jun Qiao, Juan Bai, Hong Fang
DOI:10.4103/0378-6323.152313  
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QUIZ Top

An asymptomatic swelling on the neck p. 221
Swagata Tambe, Shylaja Someshwar, Ami Dedhia, Raviraj Jadhav, Kalpana Bhatt, Hemangi Jerajani
DOI:10.4103/0378-6323.152314  
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E-IJDVL - NET LETTERS Top

Association of type 2 lepra reaction with filariasis and malaria p. 224
Satyendra Kumar Singh, Taniya Sharma, Gopal Nath, Tej Bali Singh, Manoj Kumar Shrivastava
DOI:10.4103/0378-6323.152318  
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Ulceronodular syphilis as the first manifestation of HIV infection p. 224
Romina Andino Navarrete, Cristián Vera Kellet, Juan Manriquez
DOI:10.4103/0378-6323.152320  
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Black dot tinea capitis caused by trichophyton rubrum in an adult female presenting with cicatricial alopecia p. 224
Chitralekha Keisham, Rashmi Sarkar, Nita Khurana, Nivedita Ghosh, Vijay Kumar Garg, Raj Kumar Manoj
DOI:10.4103/0378-6323.152323  
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White fibrous papulosis of the neck p. 224
Rajat Kandhari, Sanjiv Kandhari, Sudhir Jain
DOI:10.4103/0378-6323.152325  
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Evaluation of blood and urinary mercury in pemphigus vulgaris and pemphigus foliaceus patients and its comparison with control group p. 225
Shafagh Nikpour, Mohammad Javad Yazdanpanah, Reza Afshari, Masoud Maleki, Majid Ghayour-Mobarhan, Mohammad Taghi Shakeri, Zahra Maghami, Mohsen Sadrneshin, Zohre Seidi
DOI:10.4103/0378-6323.152329  
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RESIDENTS CORNER Top

Viva questions from the IJDVL Highly accessed article p. 226
Vishalakshi Viswanath, Resham Vasani
DOI:10.4103/0378-6323.152315  
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OBITUARY Top

Prof. Dr. B. Narasimha Rao p. 231
G Raghu Rama Rao
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IADVL ANNOUNCEMENT Top

IADVL Announcement p. 232
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Online since 15th March '04
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