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Email: [email protected] www.theantiseptic.in Vol. 115 • No. 1 JANUARY 2018 ISSN 0003-5998 • ` 100

Thrombolytic Therapy in Acute Myocardial Infarction Page No. - 23 THE ANTISEPTIC - A MONTHLY JOURNAL OF MEDICINE & SURGERY Vol 115 No 1 CONTENTS JANUARY 2018 (Pages : 1-52)

Editorial...... 06

GENERAL Methylcobalamin in Diabetic Neuropathy Sanjay Agrawal, Nita Sharma Das ...... 08 Imaging Modalities in Polycystic Ovarian Disease ( PCOD) Vidisha Malpani, Rudraksh Gupta, Vipul Malpani, Ridhima Gupta Jain, Hemant Kumar Mishra ...... 14

Isolation, purification and characterization of E.coli isolated from different water sources Prabhat Kumar Mishra, Vijay Thawani ...... 17 Prevalence of Stress-Related Skin Disorders among rural population in Erode District Rajesh Rajagopalan, Vethanayagam Mohankumar, Deepalakshmi E., Tamilkodi ...... 19 Thrombolytic Therapy in Acute Myocardial Infarction Abhilasha Rashmi, Kumar Rajeev ...... 23 Types of Hepatitis Sanjay Agrawal...... 28 Common Clinical Laboratory Errors and Methods of their Elimination : An Overview Nataraja Thamizh Selvam ...... 29

CASE REPORT Multicystic Dysplastic Kidney (MCDK) on left in Clinically Edward Syndrome Sangeeta Tripathy ...... 32 Systemic sclerosis and ulcerative colitis - A rare association Mayank Jain ...... 35 Liver involvement in visceral larva migrans Mayank Jain ...... 37

ALTERNATIVE MEDICINE Clinical Evaluation of “Brahma Rasayana” in the Management of Acquired Immuno-Deficiency Syndrome Kulkarni N.H., Kulwant Singh ...... 38 Comparative Clinical Study of Trayodashanga Taila and Jatyadi Taila in Management of the Sadyovrana Kulkarni N.H., Sachin N. Patil, Banakar C.S...... 40 Management of Varicose Veins and its Complications through Ayurveda Pratap K. M. Shankar, Babu G...... 43

Occasional Review ...... 45 Gleanings...... 47

Glimpse into history...... 48

Case of the month...... 49

Medi Quiz ...... 50

4 THE ANTISEPTIC Vol. 115 • January 2018 general Methylcobalamin in Diabetic Neuropathy Sanjay Agrawal, Nita Sharma Das

Introduction of type 2 diabetes, which may DNA synthesis and its regulation 7 Insulin is a hormone secreted develop in future. Type 1 diabetes and production of energy. The from pancreatic β- cells to utilize is an auto-immune disorder, in deficiency of vitamin B12 causes glucose (the smaller unit of edible which body’s own immune system different diseases like pernicious 8 carbohydrate) and provides energy destroys pancreatic β- cells and anemia, neurological damage etc. to every body cells for perform insulin synthesis is reduced. Type Different dietary nutrients contain cellular functioning. Diabetes is 1 diabetes is a inherited condition vitamin B12 analogs, but except a condition in which blood glucose and can occur at any age.1 The Methylcobalamin, none of the level is significantly higher exact etiology of type 1 diabetes is vitamin B12 analogs are readily (hyperglycemia) than the normal unknown.3 Type 2 diabetes usually absorbable in the intestine. In range. Impaired functioning of develops in middle aged people and addition, Methylcobalamin is an insulin is primarily responsible is the most common form. The active form and directly increases for this disease development.1 hyperglycemic condition in type the bioavailability of vitamin Chronic and progressive diabetic 2 diabetes can develop either due B12. Healthcare experts expect condition impairs overall to insufficient insulin synthesis, systemic or oral administration of physiological condition by or body unable to utilize insulin Methylcobalamin supplementation damaging blood vessels, heart, properly. Both insulin insufficiency can provide better treatment kidney, nerves and eyes. The and insulin resistance along with opportunity in nervous system involved pathophysiology of hyperglycemia are characteristic related conditions.7 4 diabetes mainly develops either features of type 2 diabetes. In this article we broadly discuss due to impaired pancreatic β- cells One of the most common why we should concern about functioning leads to insufficient complications of diabetes is diabetic neuropathy at very early insulin synthesis or body unable to diabetic neuropathy. Diabetic stage and role of Methylcobalamin utilize produced insulin properly. neuropathy is a peripheral nervous in the control and treatment of According to WHO estimation, system dysfunction associated the diabetic neuropathy. globally four hundred twenty two with diabetes. Broadly diabetic Prevalence and Difficulties of million adults have diabetes in neuropathy is classified into two Diabetic Neuropathy 2014. This value is almost four groups - symmetric and asymmetric Almost 60 percent of diabetic times greater than the estimated diabetic neuropathy. Beside this, diabetes incidence in 1980.2 Type1 patients suffering from diabetic diabetic polyneuropathy is one neuropathy9 and face several and type 2 and gestational diabetes of the clinical classification of are three broad categorization 5 associated disabilities, including symmetric diabetic neuropathy. foot ulceration, gait disturbance, of diabetes. Among these three Metformin is widely used types, gestational diabetes is not a leg amputation, and fall-related anti-diabetic medicine, which 6 prolonged condition, as it develops injury. Diabetic neuropathy accumulates in the body. Prolonged affected patients have five times during pregnancy and after child consumption of this medicine birth, blood glucose level become greater risk of falling. The leads to vitamin B12 deficiency normalized. However, sometimes consequences of this, leads to and considered as one of the gestational diabetes an indication difficulty to move of the injured most common cause of Diabetic 6 joint, restricted mobility, evasion neuropathy. of daily activity, hospitalization Dr. Sanjay Agrawal, Leading Pharmaceutical Consultant and Editor-in Vitamin B12 is a water soluble and mortality. These consequences Chief of IJMToday, vitamin and has significant role not only provide physical harm, 6/146, Malviya Nagar, Jaipur -302017 Rajasthan. Dr. Nita Sharma Das, in blood cells production, DNA but also negatively affect patient’s Doctor of Naturopathy and Ph.D. in Alternative Medicine, Medical Writer, Flat No. - D 1402, synthesis and normal functioning psychology, as patient may have BPTP Princess Park (Near Sai Dham Mandir of nerves. Vitamin B 12 analogs behavioral issues like patient is Tigaon Road), Sector - 86, Greater Faridabad, Faridabad. Haryana. Pin - 121 002. is participating in different too afraid to go outside or even Specially Contributed to "The Antiseptic" essential metabolic functioning, move inside the house alone, due Vol. 115 No. 1 & P : 08 - 13 including fatty acids production, to fear of falls. It is noticeable that 8 THE ANTISEPTIC Vol. 115 • January 2018 general most of the diabetic neuropathy neuropathy is classified as supply to nerve tissues due to patients face problem in balance Acute sensory type neuropathy vasoconstriction and increased impairment at the median and chronic sensorimotor thickening of the basement lateral plane during upright neuropathy. Acute diabetic membrane, damages nerves.10 or downright of the staircase neuropathy pain usually occurs in Different therapeutic and life style and one of the major risks of hyperglycemic condition and after managements are recommended fall down. Gait disturbance or normalization of glucose level for treating diabetic neuropathy, balancing problem associated with in blood the condition becomes but none of these can completely diabetic neuropathy is associated less. Neuropathic cachexia is cure this problem. 11 with sensory and motor nerve an outcome of acute diabetic Correlation of Vitamin B12 dysfunctionalities which cause neuropathy pain, which mainly Deficiency and Diabetic lack of sensation during motion occurs in male patients and affected Neuropathy and coordination difficulty during individuals have sudden weight It has been found that elderly movement. Postural hypotention is loss and depression. Whereas, patients have more risk to develop also another contributory factor chronic diabetic neuropathy diabetic neuropathy due to age for falling. Diabetic neuropathy pain is a classic painful diabetic related loss of nerve functioning.12 also has higher risk to burn during neuropathy, which may last for But the compromised metabolic cooking or other activities due to several months to year and often condition with increasing of lack of sensory nerve perception. leads to with tolerance or drug age also causes vitamin B12 Sometimes delayed wound healing addiction. Gradual reduction of deficiency. It is estimated that and infection of the injured nerve fibers density is remarkable 30 percent diabetic patient above 5, 10 area may require amputation. in diabetic neuropathy. 40 years aged diagnosed with Therefore, diabetic neuropathy Causes of Diabetic Neuropathy vitamin B12 deficiency induced hampers patient’s quality of life. 13 Hyperglycemia or uncontrolled neuropathy. But apart from Researchers also assumed that diabetic condition is a primary age factor, Metformin, the anti- cardiac autonomic neuropathy cause of diabetic neuropathy. diabetic medicine also a leading and renal failure in diabetic But obesity, hypertension, cause of vitamin B12 deficiency patients also have a correlation hyperlipidemia, alcohol in diabetic patients and risk with diabetic neuropathy and consumption and cigarette smoking increasing factor for developing albuminuria.9 are also associated with diabetic Diabetic Neuropathy in any age Besides the above mentioned neuropathy.10 group. World health organization problems, almost 10 percent Pathophysiology of Diabetic already recommended screening diabetic neuropathy patients often Neuropathy for B12 deficiency in diabetic population, as early detection faced persistent pain symptom. Hyperglycemic condition in is treatable and restored Vitamin The characteristic features of the diabetes due to poor blood glucose B12 level may prevent Vitamin painful diabetic neuropathy include management alters different B12 deficiency related diabetic severe, unmovable, impulsive or metabolic pathways. The result neuropathy.14 spontaneous pain, which mainly of this leads to intracellular worsens at night. Patients complain protein glycation enhancement, Metformin is an oral burning sensation, pin pricking the higher concentration of hypoglycemic agent and most like symptoms. The nature of the glucose in nerve and vascular frequently recommended anti- pain includes shooting, cramping, tissue, vasoconstriction and diabetic agent. Globally almost jabbing, sharp aching and tingling increased thickening of the 120 million diabetic patients sensation with feeling of cold. basement membrane of the blood regularly consume Metformin. Depending upon the affected vessels. Both intracellular protein several study report suggested nerve fibers, the symptoms may glycation enhancement and higher prolonged use of Metformin is vary, like small fibers neuropathy concentration of glucose in nerve the leading cause of vitamin B12 leads to paresthesia, along with and vascular tissue damage nerve deficiency, as dosage and duration pain symptoms, which may be tissues by increasing oxidative of Metformin therapy inversely associated with insulin therapy. stress, as reactive oxygen species affect serum vitamin B12 level. It Classification of Diabetic (ROS) triggers the synthesis of is expected that Metformin may Neuropathy advanced glycation end products. reduce calcium dependent vitamin Broadly painful diabetic In addition, impaired blood 12 absorption, especially in type Vol. 115 • January 2018 THE ANTISEPTIC 9 general 2 diabetic patients.13 Because experts expect that this benefit cause nerve regeneration and Metformin competes with calcium of Methylcobalamin can be functional recovery.19 for binding to receptors present therapeutically successful to treat in the mucosal cell membrane. or prevent nervous system related • Methylcobalamin increases Thus, unavailability of calcium conditions.7 protein synthesis by up-regulation of gene due to presence of Metformin How Methylcobalamin acts 20 in the gut wall leads to decrease Against Diabetic Neuropathy? transcription. absorption and bioavailability of • Clinical trial data The basic pathophysiology of Vitamin B12, as Vitamin B12 suggest treatment with diabetic neuropathy is associated absorption is a calcium dependent Methylcobalamin can improve with nerve damage and the result process.15 A cross-sectional the symptoms of diabetic of this leads to impaired nerve study result also concluded that neuropathy; possibly through conduction. Apart from controlling prolonged Metformin treatment regeneration of motor nerve hyperglycemia and life style with co-administration of acid fibers and gradually also management, one of the primary blocker increase the risk of improve nerve conduction.17 therapeutic approach is in diabetic vitamin B12 deficiency. Experts neuropathy management is nerve Methycobalamin acts as an also suggested that Vitamin B12 analgesic in Painful Diabetic regeneration and improved nerve supplementation with Metformin Neuropathy conduction.5,6 therapy can prevent vitamin B12 Pain management is another deficiency in diabetic patients.13 The possible mechanism therapeutic challenge in painful Methylcobalamin and Its Role in of action of Methylcobalamin diabetic neuropathy. The intensity Diabetic Neuropathy is obtained from different in of pain and other symptoms Vitamin B12 is vitro, in vivo, pre-clinical and of Diabetic neuropathy can alternatively known as clinical studies, which support vary from patient to patient. cobalamin; cyanocobalamin, Methylcobalamin can alter Analgesics, NSAIDs (non- methylcobalamin, hydroxy- pathophysiology of the diabetic steroidal anti-inflammatory cobalamin, and adenosylcobalamin neuropathy: drugs), antidepressants, and 7 anticonvulsants are different are analogs of vitamin B12. Our • Animal study data showed that body is unable to use Vitamin B12 classes of medication used for Methylcobalamin in a high dose and therefore Vitamin B12 analogs the purpose of Neuropathic pain effective to regenerate motor are taking primary role in different management . But most of the nerve fibers and also to improve metabolic functioning of the body. commonly used drugs increase the nerve conduction. Thus, high They are important contributors side effect burden. For example, dose of Methylcobalamin in fatty acid synthesis, DNA opioid analgesics, non-steroidal treatment will be able to alter production and also take part in anti-inflammatory drugs may pathophysiology of the diabetic energy production and regulation. provide addictive effect and neuropathy.17 Among the four vitamin B12 other drugs like duloxetine cause analogs, Methylcobalamin is an • Methylcobalamin also inhibits withdrawal symptoms.5 active and readily absorbable in discharge of ectopic nerve Vitamin B12 has analgesic the body. In protien methylation impulsions from injured property, as it increase the cycle, Methylcobalamin is a primary sensory neurons.7 effectiveness and availability coenzyme of methionine synthase • Methylcobalamin also able of noradrenaline and and takes part in methionine 5-hydroxytryptamine at the site 7 to repair the oxidative stress- formation. of pain, which inhibits nociceptive induced nerve cell damage 21 A clinical trial conducted with and impaired protein kinase system. Methylcobalamin as an Type 2 diabetic patients concluded C nerve signaling pathway.18 analog of vitamin B12 assists the that supplementation of vitamin regeneration of nerves and has B12 along with folic acid and • Sufficient dose of inhibitory effect against ectopic vitamin B6 can delay the onset of Methylcobalamin increases spontaneous discharges. But apart diabetes. 16 Both systemic and oral methylation and activates Akt from these, following evidences administration of Methylcobalamin ERK1/2 and AKT signals. support that Methylcobalamin can increase the bioavailability Increased activation of Akt can assist to reduce Diabetic of the Vitamin B12.8 Healthcare ERK1/2 and AKT signals neuropathy related pain symptom. 10 THE ANTISEPTIC Vol. 115 • January 2018 general • Methycobalamin is effective in functioning load of the kidneys. available in the blood in comparison improving Diabetic neuropathy 26 Chronic diabetes reduces with cyanocobalamine.30, 31 27 related pain, burning sensation, kidney functioning. These Cyanocobalamin cannot paraesthesia and heaviness factors increase the incidence of produce any health benefits of of the limb. Different diabetes associated kidney failure. vitamin B12 until it converts to clinical trial reports showed Therefore, renal failure is quite a Methylcobalamin. In human body, Methycobalamin alone or in common complication in diabetes the Cyanocobalamin is initially and most of the drugs are restricted combination with others has inactive; but in mitochondria, for them. Because drug cannot potent analgesic effect and methylmalonyl Co-A mutase be completely eliminated from effectively reduces Diabetic converts Cyanocobalamin to the body and the accumulated neuropathy pain symptom and Methylcobalamin by replacing other associated symptoms.7 drug increases the side effect- risk. Methycobalamin is a good its cyanide group with a methyl • Oral dose of Methycobalamin treatment option for diabetic group. Therefore, it is clear and pregabalin combination neuropathy patients with kidney that cyanide is released in this therapy for two weeks treatment metabolic reaction, which can get problem. A small scale clinical trial 7 can reduce a significant pain showed intravenous administration accumulated in the body. Liver score. This combination is also and kidney are two major organs 22 of methycobalamin treatment well tolerated by patient. It potentially provides benefits in involve in cyanide elimination has been also noticed that nerve diabetic neuropathy with chronic from the body. Rhodanese enzyme conduction also improved hemodialysis patients. This study present in liver and kidney takes in Diabetic neuropathy also conclude that Methycobalamin part in cyanide metabolism and patients during different treatment is safe for patients with converts it to thiocyanate, which 21 32 Methycobalamin trial period. impaired renal functioning.28 is excreted in the urine. • Epalrestat is an aldose Critical evaluation of Both liver disease and reductase inhibitor and used Methylcobalamin efficacy in kidney problems are associated comparing with other cobalamin 33 in treatment of Diabetic supplements in Diabetic with diabetes. Therefore, total neuropathy. Clinical study Neuropathy excretion of cyanide from the showed combination therapy of Cyanocobalamin, Methyl- system is doubtful in diabetic Epalrestat and Methycobalamin patients. In addition, subchronic cobalamin and Hydroxocobalamin is better than Epalrestat alone cyanide poisoning can cause are the three therapeutic analogues in the treatment of Diabetic neurologic lesions and provides of vitamin B12. It is quite a neuropathy.23 sensory spinal ataxia, nerve common finding that lack of deafness, bilateral optic atrophy, • Electrophysiologic techniques detailed knowledge about the applied to measure the weakness of legs, and numbness different cobalamin substrates, 32 symptomatic relief of the of feet, which can also aggravate general people often thought 5 patients who underevent diabetic neuropathy symptoms. that the all the cobalamins are Therefore, Cyanocobalamin is not different therapeutic synonymous. But different studies approaches to control the at all suitable for diabetic patients showed that the efficacy of as a supplement of vitamin B12. diabetic neuropathy. A clinical Methylcobalamin is better than trial finding support that pure other cobalamin analogs. Cyanocobalamin containing Methylcobalamin intervention products usually have 0.14 mg in diabetic neuropathy patient Hydroxocobalamin is bioactive average daily dose. But in some improves the electrophysiologic form; but cannot be given orally products the amount of daily dose results, which indicates and Hydroxocobalamin injections of Cyanocobalamin can increase symptoms get better.24 are painful.29 A clinical review up to 1 mg. It has been also Methylcobalamin is safe for report showed that among analyzed that in the gastrointestinal treating diabetic neuropathy other vitamin B 12 analogs, tract, almost 2 percent of total patients with renal impairment methylcobalamin is best to Cyanocobalamin dose converts to Diabetes is a chronic condition treat vitamin B12 deficiency. cyanide.34 Therefore, the increased and gradually small blood vessels After oral administration of dose of Cyanocobalamin has a present in kidney become damaged. methylcobalamin, significant great risk of increased cyanide 25 Moreover, diabetes increases the amount of this active component is concentration in the body. Usually Vol. 115 • January 2018 THE ANTISEPTIC 11 general this risk is increased in case of the market for treating diabetic 10. Sharonjeet Kaur, Promila Pandhi, Pinaki Dutta. Painful diabetic neuropathy: an kidney failure patient or smokers, neuropathy. But more detail update. Ann Neurosci. 2011 Oct; 18(4): though healthy people eliminate and long-term clinical trial 168–175. doi: 10.5214/ans.0972- this little amount of cyanide from will be required to establish 7531.1118409 their system. But most of the time, Methylcobalamin as a prospective 11. Anne K Schreiber, Carina FM Nones, people prefer to Cyanocobalamin nutraceutical in diabetic Renata C Reis, Juliana G Chichorro, Joice M Cunha. Diabetic neuropathic formulation because of its lower neuropathy treatment for future pain: Physiopathology and treatment. cost.35 generation. World J Diabetes. 2015 Apr 15; 6(3): 432–444. Published online 2015 Apr Dose of Methylcobalamin References 15. doi: 10.4239/wjd.v6.i3.432 According to Food and 1. The National Institute of Diabetes and 12. Aaron I. Vinik, Elsa S. Strotmeyer, Nutrition Board (FNB) the Digestive and Kidney Diseases. Online Abhijeet A Nakave, Chhaya V Patel. available at https://www.niddk.nih.gov/ “Diabetic Neuropathy in Older Adults”. 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Gaiță, Cristian Oancea, Codrina Levai, Diana Lungeanu. The Impact 18. Mizukami H, Ogasawara S, Yamagishi This mechanism of action of Diabetic Neuropathy on Balance and S, Takahashi K, Yagihashi S. may showcase the potency of on the Risk of Falls in Patients with Methylcobalamin effects on diabetic Methylcobalamin to challenge Type 2 Diabetes Mellitus: A Cross- neuropathy and nerve protein kinase Sectional Study. Published: April 27, C in rats. Eur J Clin Invest. 2011 different analgesics and other 2016. https://doi.org/10.1371/journal. Apr;41(4):442-50. doi: 10.1111/j.1365- synthetic drugs available in pone.0154654 2362.2010.02430.x. Epub 2010 Dec 3. 12 THE ANTISEPTIC Vol. 115 • January 2018 general

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Vol. 115 • January 2018 THE ANTISEPTIC 13 general Types of Hepatitis Sanjay Agrawal Hepatitis B virus (HBV) is Hepatitis B spreads when At least five viruses can cause a small, circular and partially blood, semen, or certain other hepatitis disease from these the double-stranded deoxyribonucleic body fluids from a person infected three common are hepatitis viruses acid (DNA) virus in the with the Hepatitis B virus even A, B and C. Each is caused by a Hepadnaviridae family. Hepatitis in microscopic amounts enters different virus. All three types can refers inflammation of liver cells the body of someone who is not be acute, lasting for 6 months or and finally getting damage to infected. The Hepatitis B virus can less, and types B and C can be the liver. The functions of liver also be transmitted from birth to chronic, lasting for longer. Each include detoxifying the blood, an infected mother; sex with an type has different characteristics storing vitamins and producing infected person; sharing equipment and is transmitted in different hormones. Hepatitis can disrupt that has been contaminated with ways, but symptoms tend to be these processes and create severe blood from an infected person, more or less similar. health problems throughout the like tools of needles, syringes, India has intermediate human body. There are many medical equipment such as glucose endemicity of Hepatitis B, with causes. Heavy alcohol use, monitors; sharing personal items Hepatitis B surface antigen toxins, some medications, and such as toothbrushes or razors. (HBsAg) prevalence between certain medical conditions can 2 per cent and 7 per cent also be caused hepatitis. However, Hepatitis C is spread when blood from a person infected among populations studied. hepatitis is most often caused by The prevalence does not vary a virus. The liver is a vital organ with the Hepatitis C virus even in microscopic amounts enters significantly by region in the that processes nutrients, filters country. The number of HBsAg the blood, and fights infections. the body of someone who is not infected. This can happen through carriers in India has been estimated When the liver is damaged, its to be over 40 million (4 crore). It function can be affected. The most multiple ways of sharing equipment that has been contaminated with has been estimated that, in India common types of viral hepatitis of the 25 million infants born are Hepatitis A, Hepatitis B and blood from an infected person, such as needles and syringes. every year, over one million run Hepatitis C. Hepatitis A can last the lifetime risk of developing There is no vaccine available for from a few weeks to several chronic HBV infection. Every year Hepatitis C. About 75 per cent months. Hepatitis B can range over 100,000 Indians die due to to 85 per cent of people who get from a mild illness, lasting few illnesses related to HBV infection, infected with the Hepatitis C virus weeks to a serious life long or according to report. chronic condition. Hepatitis C develop a chronic infection; 5 also can range from a mild illness, per cent to 20 per cent of people  lasting few weeks, to a serious with chronic Hepatitis C develop life long infection. Most people cirrhosis; and 1per cent to 5 per The rare finding of colonic who get infected develop chronic cent will die from cirrhosis or interposition between Hepatitis C. liver cancer, according to report. the liver and the right Hepatitis A is spread when a Many people with hepatitis hemidiaphragm (chilaiditi person ingests fecal matter even do not have symptoms and do in microscopic amounts from not know they are infected. If sign) may present as a contact with objects, food or symptoms occur with an acute syndrome with mild to severe drinks contaminated by feces or infection, they can appear anytime gastrointestinal symptoms stool from an infected person. from 2 weeks to 6 months after including abdominal exposure. Symptoms of hepatitis pain, constipation, bowel Dr. Sanjay Agrawal, can include: fever, fatigue, loss Leading Pharmaceutical Consultant and Editor-in of appetite, nausea, vomiting, obstruction, volvulus or Chief of IJMToday, 6/146, Malviya Nagar, Jaipur -302017. Rajasthan. abdominal pain, dark urine, grey even ischemic bowel. coloured stools, joint pain and Specially Contributed to "The Antiseptic" Clinical Vignettes - Colon Vol. 115 No. 1 & P : 28 - 28 jaundice. 28 THE ANTISEPTIC Vol. 115 • January 2018 The Antiseptic - registered with the RNI under No.1351/57 Postal Regn.No.TN/MA/87/2018-2020 Licensed to post at Madurai BPC Published and Posted on 1st of Every Month

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