Mirror therapy (MT) is a valuable method for enhancing motor recovery in poststroke hemiparesis. The technique utilizes the mirror-illusion created by the movement of sound limb that is perceived as the paretic limb. MT is a simple and economical technique than can stimulate the brain noninvasively. The intervention unquestionably has neural foundation. But the underlying neural mechanisms inducing motor recovery are still unclear. In this review, the neural-modulation due to MT has been explored. Multiple areas of the brain such as the occipital lobe, dorsal frontal area and corpus callosum are involved during the simple MT regime. Bilateral premotor cortex, primary motor cortex, primary somatosensory cortex, and cerebellum also get reorganized to enhance the function of the damaged brain. The motor areas of the lesioned hemisphere receive visuo-motor processing information through the parieto-occipital lobe. The damaged motor cortex responds variably to the MT and may augment true motor recovery. Mirror neurons may also play a possible role in the cortico-stimulatory mechanisms occurring due to the MT.

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A single clear binocular vision is made possible by the nature through the oculomotor system along with inputs from the cortical areas as well their descending pathways to the brainstem. Six systems of supranuclear control mechanisms play a crucial role in this regard. These are the saccadic system, the smooth pursuit system, the vestibular system, the optokinetic system, the fixation system, and the vergence system. In gaze disorders, lesions at different levels of the brain spare some of the eye movement systems while affecting others. The resulting pattern of eye movements helps clinicians to localize lesions accurately in the central nervous system. Common lesions causing gaze palsies include cerebral infarcts, demyelinating lesions, multiple sclerosis, tumors, Wernicke's encephalopathy, metabolic disorders, and neurodegenerative disorders such as progressive supranuclear palsy. Evaluation of the different gaze disorders is a bane of most budding neurologists and neurosurgeons. However, a simple and systematic clinical approach to this problem can make their early diagnosis rather easy.

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Objective: To describe the clinical presentation, radiological findings, management details, and outcome in nine cases of tuberculous brain abscess (TBA). Materials and Methods: Nine patients (5 females, 4 males) harboring a TBA, as defined by the Whitener's criteria, were managed over a span of one and a half decade by the authors. All, except one patient, underwent contrast-enhanced magnetic resonance imaging scans, followed by surgical excision of the abscesses due to the failure of complete resolution of the lesion after its drainage using a burr-hole. Results: The infra-tentorial location (n = 4) in TBAs was as common as the supra-tentorial location (n = 4). All large TBAs (more than 3 cm in diameter) failed to resolve after tapping of the purulent material and required surgical excision for a favorable long-term outcome. Two patients expired, while seven patients survived with Karnofsky Performance scale of 90 for 3, 80 for 3, and 70 for 1 patient. The follow-up ranged from 2 to 12 years (mean = 5.7 years). Conclusion: TBAs should be considered in the list of differential diagnoses for pyogenic abscesses, especially in developing countries, as it is difficult to differentiate between them on the basis of clinical or radiological findings. Hence, all pus samples should be sent for Ziehl–Neelsen staining and culture for Mycobacterium tuberculosis. Surgically excised and pathologically evaluated specimens remain the gold-standard for diagnosing TBAs. Larger abscesses warrant surgical excision, while concomitantly associated smaller lesions tend to resolve with prolonged antituberculous therapy.

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Background: The association between chronic inflammation and dementia has been identified in several epidemiologic studies. However, the data on rheumatoid arthritis (RA), one of the most common chronic inflammatory disorders, remains unclear. Materials and Methods: We conducted a systematic review and meta-analysis of cohort, case–control, and cross-sectional studies that compared the risk of dementia in patients with RA versus non-RA controls. Data from each study were combined using random-effect, generic inverse variance method of DerSimonian and Laird to calculate the pooled risk ratio (RR) and 95% confidence interval (CI). Results: Three cohort studies and two cross-sectional studies were identified and included in the meta-analysis. We found a significantly increased risk of dementia among patients with RA, with the pooled risk ratio of 1.61 (95% CI, 1.10–2.37). The statistical heterogeneity was high, with an I² of 91%. Conclusions: Our study demonstrated a statistically significant increase in the risk of dementia among patients with RA.

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Background: In this study, we assessed 75 patients with myasthenia gravis (MG) for coexistent autoimmune diseases (ADs) and for the characteristic autoantibodies that are associated with the most relevant forms of ADs. Methods: The demographic and clinical characteristics of the patients were recorded. In all patients, thyroid function tests, thyroid autoantibodies, and other autoantibodies were studied. The diagnosis of autoimmune thyroid disease (AITD) was made based on the clinical features, physical examination, and laboratory findings. The diagnoses of rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) were made in accordance with the revised criteria of American College of Rheumatology. The presence of other ADs were also recorded which was based on whether or not the patient already had a diagnosis of ADs; or, whether it was detected during the period of the study based on clinical findings and/or laboratory abnormalities. Results: Thirty-nine patients (52%) had autoantibody positivity in their sera. Thyroid autoantibodies and antinuclear antibodies were the main autoantibodies detected. In twenty one of these patients, a diagnosis of AD could not be confirmed. Eighteen patients (24%) had a confirmed diagnosis of a coexisting AD. These ADs included AITD (16%), RA (4%), SLE (2.6%), and Lambert–Eaton myasthenic syndrome (1.3%). In ten patients, the diagnosis of ADs had been established before the development of MG; 8 of the patients included those who were newly diagnosed with ADs in the course of the management of MG. Conclusions: MG has an increased frequency of coexisting ADs. Autoantibodies that are characteristic for ADs can be found in the patients without the presence of any of the clinical findings of ADs. Clinical attention towards the management of ADs is especially needed during the follow-up of patients with MG.

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Adequate nutritional therapy is essential for recovery from critical illness. Nutritional requirement varies in different patients and varies daily in a single patient. Both under and over feeding are associated with complications. Besides this, not all patients behave in a similar way to nutritional therapy. Appropriate nutritional therapy requires identification of patients “at nutritional risk” and providing aggressive nutritional support to them. The current article deals with nutritional support in critical illness with special emphasis on neurocritical care patients.

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Context: Endoscopic third ventriculostomy (ETV), wherein a stoma is created in the floor of the third ventricle, has now become the standard procedure for noncommunicating hydrocephalus across the world. However, in certain situations, this procedure may pose technical difficulties. These include a narrow prepontine space, vascularized third ventricular floor, the presence of prominent blood vessels traversing within the prepontine space, significant basal exudates, thickened and ill-defined third ventricular floor, and distorted floor anatomy. In such situations, an endoscopic lamina terminalis opening may provide a safer and more effective alternative to the standard technique. Aims: The paper aims to discuss the different indications, technical nuances, and outcome of endoscopic third ventriculostomy through the lamina terminalis (ETV LT) utilizing the standard transventricular transforaminal route. Settings and Design: A total of 240 patients underwent ETV between January 2007 and January 2014. Of these patients, 8 patients required an EVT LT and these patients formed the subset of patients for the present study. In all the 8 patients, the decision to perform fenestration of the LT during the endoscopic procedure was taken intraoperatively. We qualified a procedure to be a success when a second procedure was not required subsequently. Results: Of the eight patients in whom ETV LT was done, four had aqueductal stenosis (including one case of post-primary ETV), three patients were diagnosed with post-meningitic hydrocephalus, and the remaining patient had a posterior fossa tumor. The procedure was successful in 6 of our patients who did not require a second procedure till the last follow-up. Conclusions: Endoscopic transventricular transforaminal LT fenestration with a flexible neuroendoscope is a feasible alternative to the standard ETV when technical difficulties precludes safe performance of the latter procedure.

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Stroke, a heterogeneous multifactorial disorder, is known to be a major cause of death and adult disability within both the developed and developing countries. Approximately 85% of stroke cases are ischemic, whereas the remaining 15% are hemorrhagic. It is caused by multiple genetic factors, environmental factors, and interactions among these factors. Several candidate genes have been found to be associated with ischemic stroke. The most extensively studied genes include those involved in hemostasis, inflammation, nitric oxide production, homocysteine and lipid metabolism, and rennin–angiotensin–aldosterone system. Combined linkage/association studies have demonstrated that genes encoding phosphodiesterase 4D (PDE4D) and arachidonate 5-lipoxygenase-activating protein (ALOX5AP) confer risk for stroke. Even though there is substantial evidence for the genetic basis of stroke as provided by the epidemiological data from twin- and family-based studies, the contribution of genetic factors identified till now is either not enough or very less to explain the entire spectrum of encountered phenomena associated with ischemic stroke. Till date, no genome-wide association studies (GWAS) have been carried out in India. We aim to extensively review the studies on candidate genes that may have potential applications in the early diagnosis, prevention, and treatment of ischemic stroke in the Indian population. This article further emphasizes the role of GWAS in ischemic stroke and the need for an extensive GWAS in the Indian population.

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Background: The examination of the cerebrospinal fluid (CSF) for proteins, glucose, and leukocytes still remains the basic gold standard investigation for the initial diagnosis of meningitis. Early diagnosis and initiation of antibiotics within 3 h can reduce the mortality and morbidity associated with meningitis. Hence, we conducted this study to document the usefulness of urinary reagent strip for the semi-quantitative analysis of CSF chemistry and cellularity. Materials and Methods: All clear CSF samples were subjected for two types of tests, the definitive test and the index test. CSF microscopy and biochemical values are considered as definitive. Combur-10 urinary reagent strip was used as the index test for proteins, glucose, and leukocytes. The diagnostic accuracy of each index test was calculated using different cut-off levels (leukocyte esterase positivity 1+ vs. CSF granulocytes ≥10/cumm, proteins 1+ and 2+ vs. CSF protein ≥30 mg/dl and ≥100 mg/dl, respectively, and glucose 0 vs. ≤40 mg/dl and ≤50 mg/dl). Statistical analysis was performed to derive the specificity, sensitivity, positive predictive value, negative predictive value, likelihood ratio (LR)⁺, LR⁻, and area under curve (AUC). Results: The study subjects comprised 103 cases. The strip showed a high sensitivity and specificity for leukocytes ≥10 cells/cumm. The strip showed a sensitivity of 96% and a specificity of 87.1% for proteins at a cut-off ≥100 mg/dl while the strip was less specific at a cut-off of ≥30 mg/dl. With respect to glucose, the strip was highly specific (100%) and less sensitive at both the cut-off levels. The AUC for leukocytes ≥10 cells/cumm was 99.05%; for proteins ≥30 mg/dl and ≥100 mg/dl, it was 84.86% and 95.69%, respectively; and, for glucose ≤40 mg/dl and ≤50 mg/dl, it was 86.51% and 76.99%, respectively. Conclusion: The routinely used urinary reagent strip can be utilized for the rapid analysis of CSF. If implemented, this technique will be useful in rural areas. It would also decrease the turnaround time in centers where the facility is available.

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Granulomatous amoebic encephalitis (GAE) caused by certain species belonging to the genus Acanthamoeba, Balamuthia, or Naegleria presents as a subacute or chronic illness. Amoebic encephalitis caused by Acanthamoeba is seen more often in immunosuppressed individuals. Thus, it may often be associated with human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS), organ transplantation, administration of steroids and systemic lupus erythematosus (SLE). The clinical progression is rapid, most often leading on to mortality of the patients. The diagnosis in most of these patients is established on postmortem examination. We describe a case of fatal granulomatous amoebic encephalitis in a patient recently diagnosed to be having SLE, who was receiving corticosteroids, cyclophosphamide, methotrexate, and hydroxychloroquine. The patient presented in an altered sensorium and expired after being hospitalized for 6 days. Postmortem examination of the brain showed extensive areas of necrosis and neutrophilic infiltrate with trophozoites and cysts of Acanthamoeba.

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Background: To review our experience with patients undergoing 3 level cervical central corpectomy (CC) with un-instrumented fibular autograft fusion. Materials and Methods: This is a retrospective study, involving 33 patients with cervical spondylotic myelopathy (CSM) or ossified posterior longitudinal ligament (OPLL) who underwent a 3 level CC between 2002 and 2010. The patients were followed up clinically and radiologically. Their functional status was assessed using Nurick's grading system. Parameters such as intraoperative complications, segmental curvature of the cervical spine, graft subsidence, graft fusion and functional outcome of these patients were assessed. Results: There was transient morbidity in 28.6% of patients, with no permanent morbidity or mortality. We obtained follow up in 29 patients (87.9%) with a mean duration of follow up of 65.1 months (range, 12 to 138 months). The mean difference of segmental cervical curvature on follow up was 3.60⁰ and the average graft subsidence was 5.70 mm. We achieved a fusion rate of 90%. There was no instance of graft extrusion in our series. There was a significant improvement in the functional status of our patients (from Nurick grade 3.55 to 2.42; P = 0.0001), with no clinical deterioration in any patient. Conclusions: Three level cervical corpectomy with un-instrumented fusion is a relatively safe surgery in experienced hands, and can achieve excellent clinical and radiological outcomes.

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Introduction: Patients with traumatic brain injury (TBI) need frequent computed tomography (CT) of the head for assessment and management. In view of the associated polytrauma, hemodynamic instability, and various in-dwelling catheters and tubes, shifting of patients for CT scans may be difficult. Aims and Objectives: To assess the role of mobile CT (Ceretom^®; NeuroLogica Corporation, Boston, MA, USA) in a trauma center with respect to patient management. Materials and Methods: In this retrospective study over 67 months (June 2009 to January 2015), the number of CT scans done, the time taken for CT and downtime were evaluated. Also, for the first 1000 mobile CT scans, the clinical and radiological records of all patients with TBI who underwent imaging using the mobile CT scanner in the intensive care units (ICUs) were analyzed. Observations and Results: A total of 10,000 mobile CT scans were done on the mobile CT scanner till January 5, 2015. Of the first 1000 patients evaluated, 75.3% had severe TBI, 15.1% had moderate TBI, and 9.6% had mild TBI. 78.1% patients were on ventilator, with 80.2% requiring sedation and 8.4%, an inotropic support. An in situ intracranial pressure monitoring was present in 21.1% of patients. In all, 12.4% of patients had long-bone fractures requiring skeletal traction; and, the tube thoracostomy was in-situ in 7.4%. No adverse events related to line malfunction/pullout occurred. The mean time for the performance of imaging using the mobile CT scan was 11.6 minutes compared with 47.8 minutes when patients were shifted to a conventional CT scan suite. The machine was nonfunctional 94 times, with an average downtime of 4.2 hours (range 2–72 hours). The life-cycle cost per mobile CT scan was Rs. 1340. Conclusions: A mobile CT has considerably changed the management response time in the neurosurgical intensive care unit (ICU) setup and decreased patient transfer times and the associated complications. Inclusion of a mobile CT scanner in the armamentarium of a neurosurgeon as a “bedside tool” can dramatically change decision making and the response time. It should be considered as the standard of care in any large-volume emergency department or neurosurgical facility.

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Objective: To evaluate the disparity in authorship based on gender and nationality of institutional affiliation among journals from developed and developing countries. Materials and Methods: Original articles from two neuroscience journals, with a 5 year impact factor >15 (Neuron and Nature Neuroscience) and from two neurology journals from a developing country (Neurology India and Annals of Indian Academy of Neurology) were categorized by gender and institutional affiliation of first and senior authors. Articles were further divided by the type of research (basic/translational/clinical), study/target population (adult/pediatrics/both) and field of neurology. Data was collected for the years 2002 and 2012. Results: There are large disparities in authorship by women and from developing countries in high impact factor neuroscience journals. However, there was a non-statistical rise in female first and senior authorship over a 10 year period. Additionally there was a significant increase in first authorship from institutions based in developing countries in the two neuroscience journals examined (P < 0.05). In the two neurology journals based in India there was a significant increase in the number of articles published by international investigators between 2002 and 2012 (P < 0.05). Conclusions: Over the last decade, there has been a non-statistical increase in proportion of female first and senior authors, and a significant increase in authors from developing countries in high impact factor neuroscience journals. However they continue to constitute a minority. The disparity in authorship based on gender also exists in neurology journals based in a developing country (India).

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Background: EGFR gene amplification is the hallmark of primary glioblastomas; however, its frequency in patients of Indian origin remains sparsely investigated. Aims: The aim of this study was to explore the frequency of EGFR amplification in high grade gliomas (HGGs) in Indian patients and to study its correlation with p53 protein overexpression. Methods and Materials: 324 cases of HGGs, where EGFR gene amplification was evaluated by fluorescence in-situ hybridization formed the study group. Ratio of >2 was considered as EGFR gene amplification. Immunohistochemically, p53 overexpression was evaluated and graded as positive for strong intensity staining in more than 50% of tumour cells. Results: 249 patients were male and 75 female (M: F-3.3:1); their age range was 8-91 years [paediatric glioblastoma (pGBM; 8-18yrs; n = 24)], adult HGGs [>18yrs; n = 300]}. 258 patients were having a GBM [including 31 with a GBM with oligodendroglioma component (GBM-O)], 31 with a gliosarcoma, 13 with an anaplastic astrocytoma (AA), 12 with an anaplastic oligodendroglioma (AO), and 10 with an anaplastic oligoastrocytoma (AOA). 79/233 cases (34%) with an adult GBM, (including 10/31 with a GBM-O [32.2%]), 1/31 (3.2%) with a GS and 1/10 (10%) with an AOA showed EGFR gene amplification. None of the pGBMs (n = 24) showed amplification. Amplification was seen in 19/81 (23.4%) of diffuse p53 protein positive cases and 53/143 (37%) of cases with focal or negative p53 protein expression. Conclusions: 34% of our adult GBM patients showed EGFR gene amplification. The amplification was uncommonly associated with a strong diffuse p53 protein expression.

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Aim: The duration of improvement in quality of life after subthalamic nucleus deep brain stimulation (STN DBS) for Parkinson's disease (PD) and the presurgical identification of factors predicting sustained clinical benefits have implications in patient selection and timing of surgery. These aspects were assessed in patients who underwent yearly assessment for at least 7 years after surgery. Materials and Methods: The quality of life, motor and cognitive outcomes of 25 patients who completed the 7-year assessment, and 12 patients who completed the 10-year assessment, were analyzed. Results: The improvement in quality of life was sustained only for 5 years, while the severity of motor signs and motor fluctuations remained reduced at 7 and 10 years. Tremor and rigidity showed more enduring reduction than bradykinesia and axial signs. The dose reduction in medications could be maintained until 7 years, by which time, the axial scores were worse than that seen at the pre-DBS levels. At 10 years, a higher levodopa requirement and recurrence of dyskinesias were noted. Patients with greater pre-DBS levodopa-responsive motor signs had greater long-term motor improvement. Conclusions: STN DBS performed in patients with advanced motor fluctuations and severe dyskinesias provide only an average of 5 years of quality of life improvement. STN DBS in patients with motor signs that are less responsive to levodopa results in shorter duration of clinical benefits. The improvements in the severity of motor fluctuations, rigidity, and tremor are the most enduring benefits of STN DBS that last a decade . However, these are offset by worsening axial and cognitive functions, bradykinesia, a higher levodopa requirement, and recurrence of dyskinesias by the end of the decade.

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