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   Table of Contents - Current issue
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July-December 2020
Volume 26 | Issue 2
Page Nos. 95-182

Online since Monday, July 27, 2020

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ORIGINAL ARTICLES  

Urine cytology as seen in Uyo, Nigeria: How relevant is it to medical practice? Highly accessed article p. 95
Chukwuemeka Charles Nwafor, Emmanuel Benjamin Etuk, Kanu Obioha, Elijah A Udoh
DOI:10.4103/njs.NJS_48_19  
Aim: The aim of this study is to know the pattern of urine cytology (UC) requests seen in Uyo and how relevant they were to the management of the patients. Materials and Methods: This retrospective study was carried out in the Department of Pathology, University of Uyo Teaching Hospital. The extracted data from the cytology registers were analyzed using the Statistical Package for the Social Sciences version 17. Results: A total of 46 patients did UC during the period. The patients were aged between 21 years and 90 years, with a mean age of 56.89 ± 14.65. Thirty (67.4%) were male. The age group of 60–69 years accounted for most cases (37.8%). Suspicion of bladder cancer was the most common indication as it was seen in 28.9% (n = 13) of cases. Thirty-eight cases (84.4%) were referred from urology clinic, 2 each (4.4%) from general outpatient clinic, general surgery clinic, and from gynecology clinic. In 44.4% (n = 20) of cases, the cytological diagnosis was inflammatory smear, while the UC was normal in 24.4% (n = 11) cases. Malignant cells were seen in 11.1% of (n = 5) cases. Of the 13 cases that the indication was suspected bladder cancer, only four were positive for malignant cells and one was suspicious on UC. No malignant cell or suspicious cell was seen in any of the UC specimens from patients that had prostate cancer, lower urinary tract outlet obstruction with hematuria due to prostatic enlargement. Conclusion: UC should not be requested for in prostatic diseases since the reports are always negative or at most inflammatory. The department should start using The Paris System of UC reporting to assist the managing physician/surgeon to take the best decision.
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Impact of nighttime emergency surgeries on patients' outcome: A prospective study p. 99
Ashok Kshirsagar, Shirish Kannur
DOI:10.4103/njs.NJS_32_19  
Background and Aim: The aim of this study was to evaluate the relationship between the time of the day the surgery is conducted and its outcome to provide better protection for patients against fatigue-related errors and reduce the incidence of postoperative morbidity/mortality. Methods: All general surgical emergency operations recorded prospectively on the operation theater database of Krishna Hospital and Medical Research Centre, Karad, between April 01, 2018, and March 31, 2019, were included in this study. The operations were categorized according to whether they commenced during the daytime (08:01–20:00 h), or nighttime (20:01–08:00 h). The type of procedure and grade of the participating surgical personnel were also recorded. Results: In total, 1128 emergency operations were performed over the study period. The number of emergency procedures performed during the daytime and nighttime was 652 (57.8%) and 476 (42.2%), respectively. Laparotomies and complex vascular procedures collectively accounted for half of all the cases performed after midnight, whereas they represented only 30% of the combined daytime emergency workload. Thirty-two percent (n = 152) of all nighttime operations were supervised or performed by a consultant surgeon. Conclusion: When considering a surgical procedure, surgeons must bear in mind that cases that start after the routine hours may face an elevated risk of complications that warrants further evaluation and surgical start times are associated with risk-adjusted patient outcomes.
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Assessment of antimicrobial efficacy of bioceramic sealer, epiphany self-etch sealer, and AH-plus sealer against Staphylococcus aureus and Candida albicans: An In vitro study p. 104
Ruchita Kishor Rathod, Pradeep Dilip Taide, Rohan Dattatraya Dudhale
DOI:10.4103/njs.NJS_60_19  
Aim: The aim and objective of this in vitro study was to evaluate the antimicrobial efficacy of root canal sealers (bioceramic [BC] sealer, Epiphany self-etch sealer, and AH-Plus sealer) on Staphylococcus aureus and Candida albicans. Materials and Methods: An agar well diffusion assay method was used to determine the efficacy of the root canal sealer against S. aureus (ATCC 6538) and C. albicans (ATCC 10231). Root canal sealers were divided into three groups: BC sealer, Epiphany self-etch sealer, and AH-Plus sealer, and the standard antibiotic disc of amoxiclav and fluconazole was kept as a control against S. aureus and C. albicans. The diameters of the growth inhibition zones against S. aureus and C. albicans for each group were recorded and compared at 24 h. The differences between groups were analyzed by one-way ANOVA and Tukey's post hoc tests for intergroup analysis. Results: AH-Plus sealer exhibited a larger zone of inhibition than the other two sealers against S. aureus and C. albicans at 24 h. The standard antibiotic disc of fluconazole, which was used as a control against C. albicans, exhibited a higher antimicrobial activity than the AH-Plus sealer at 24 h, whereas Epiphany self-etch sealer showed the least antimicrobial activity against S. aureus and C. albicans. Conclusion: The AH-plus root canal sealer exhibits a better antibacterial action against S. aureus and C. albican s at 24 h.
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Delay of surgery start time: Experience in a Nigerian teaching hospital Highly accessed article p. 110
Chike John Okeke, Chukwudi Ogonnaya Okorie, Rufus Wale Ojewola, Njoku Isaac Omoke, Anselm Okwudili Obi, Agama Nnachi Egwu, Okechukwu Valentine Onyebum
DOI:10.4103/njs.NJS_61_19  
Background: Operating room delay has multiple negative effects on the patients, surgical team, and the hospital system. Maximum utilization of the operating room requires on-time knife on the skin and efficient turnover. Knowledge of the reasons for the delay will form a basis toward proffering solutions. Patients and Methods: This was a prospective study of all consecutive elective cases done over a 15-month period from January 2016 to March 2017. Using our departmental protocol that “knife on skin” for the first elective case should be 8.00am, the delay was defined as a surgery starting later than 8.00am for the first cases while the interval between the cases of >30 min for the knife on the skin was used for subsequent cases. Reasons for delay in all cases of delay were documented. The prevalence and causes of the delays were analyzed. P < 0.05 was considered statistically significant. Results: Of 1178 surgeries performed during the period of study, 1170 (99.3%) of cases were delayed. The mean delay time was 151 min for all cases. First on the list had a longer delay time than others; 198.9 min versus 108.5 min (P = 0.000). Delay in the first cases accounted for 47.5% of all delayed cases. Overall, patient-related factor was the most common cause of delay (31.3%) followed in descending order by surgeon-related factor (28.5%) and hospital-related factor (26.2%). Patient-related factors accounted for 43.2% of first-case delays. Conclusion: Delays encountered in this study were multifactorial and are preventable. Efforts should be directed at these different causes of delay in the theater to mitigate these delays and improve productivity.
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Comparing objective structured clinical examinations and traditional clinical examinations in the summative evaluation of final-year medical students p. 117
Balantine Ugochukwu N Eze, Anthony Jude Edeh, Anthony Ikemefuna Ugochukwu
DOI:10.4103/njs.NJS_19_20  
Background: Medical schools have traditionally assessed medical students using long and short cases. Objective structured clinical examination (OSCE) has been found to be more reliable. Aim: To compare OSCE and traditional method of assessment in the summative assessment of final-year medical students. Methodology: This was a retrospective cross-sectional study conducted at Enugu State University of Science and Technology College of Medicine. The Department of Internal Medicine organized clinical examinations consisting of long and short cases. The Department of Surgery organized an OSCE consisting of two parts (picture OSCE and clinical OSCE). Students' scores in both internal medicine and surgery were collated and subjected to analysis with SPSS version 23 (IBM; SPSS, Chicago, IL, USA). Pearson's correlation was used to assess the correlations, paired t-test was used to compare the mean scores, and Cronbach's alpha was used to assess the reliability. P < 0.05 was considered statistically significant. Results: Out of the 73 candidates, 41 were female and 32 were male giving a female: male ratio of 1.3:1. Using paired sample t test, there were significant differences between the mean score in long case (mean = 52.86, standard deviation [SD] = 4.315) and mean score in clinical OSCE (mean = 58.356, SD = 7.906), t (72) = −7.181, P = 0.000; mean score in short case (mean = 52.86, SD = 4.097) and mean score in picture OSCE (mean = 48.580, SD = 8.992, t (72) =4.558, P = 0.000; no significant difference between the mean total score in internal medicine clinicals (mean = 105.712, SD = 6.680) and mean total score in surgery clinicals (mean = 106.915, SD = 15.846), t (72) = −0.788, P = 0.433. The Cronbach's alpha for traditional examination and OSCE was 0.437 and 0.863, respectively. Conclusion: OSCE gives a similar mean score to traditional method, but OSCE is more reliable.
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Comparison of effect of pH modulation on wound healing with topical application of citric acid versus superoxide ions p. 122
Sunit Tandon, Baldev Singh, Sudarshan Kapoor, Suruchi Mangal
DOI:10.4103/njs.NJS_14_19  
Background: Wound healing is a dynamic process involving tissue repair and regeneration. Nonhealing and chronic wounds are a significant health problem that many patients all over the world are suffering from. Proper wound care is hence very important. Wound dressings have undergone continuous and significant changes over the time period. Optimal dressing should ensure a moist wound bed, help drainage, remove debris, and be anti-allergic and without immunogenicity. Objectives: The objective of the study is compare the effect of pH modulation on wound healing with topical application of citric acid versus superoxide ions. The aim is to study the efficacy and safety of citric acid versus superoxide ions in the prevention and control of infection and their effect on wound healing in similar wound types. Materials and Methods: We conducted randomized, prospective comparative study in a total of 100 patients admitted at Guru Nanak Dev Hospital, attached to Government Medical College, Amritsar. The patients were divided into two groups: Group A where wound management was done using superoxide ions and Group B where citric acid was used. A standard grading was done in terms of a decrease in wound size, an increase in granulation tissue, and a reduction in wound discharge. Results: The wounds treated with citric acid showed an average reduction in wound size of 73.43% by the 14th day as compared to 66.52% in the control group. The difference seen in the average reduction of wound size was statistically significant (P = 0.032). The wounds treated by citric acid application showed an average increase in granulation tissue of 56.66% as compared to 50.87% in the wounds treated by superoxide ions. The average hospital stay in patients of Group B was comparatively less than that of patients in Group A. Conclusion: Citric acid is safe and effective in all types of wound management and gives better efficacy and faster response as compared to superoxide ions. Citric acid promotes wound healing by the formation of granulation tissue and fibroblast proliferation.
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Intraoperative dye test in total laryngectomy: A technique to reduce the incidence of pharyngocutaneous fistula p. 127
Adekunle Daniel, Segun Ayodeji Ogunkeyede, Ayotunde James Fasunla, Onyekwere George Benjamin Nwaorgu
DOI:10.4103/njs.NJS_69_19  
Background: Pharyngocutaneous fistula (PCF) could complicate laryngectomy in advanced disease. The cause is multifactorial, and this may include poor technique in pharyngeal repair. Intraoperative assessment of the repaired mucosa integrity for adequate closure may reduce PCF, but this is not routinely done. Objective: The objective of this study is to describe a novel technique that has been successfully used to ascertain intraoperative pharyngeal repair integrity. Methods: Thirty-one patients who had total laryngectomy and pharyngeal reconstruction for locally advanced laryngeal squamous cell carcinoma were studied. Connell extramucosal suturing technique was used for the mucosal repair. Thereafter, a small feeding tube was introduced through the oral cavity to the site of the pharyngeal repair, and diluted methylene-blue dye was injected through it while digitally occluding the cervical esophagus. Whenever leakage of the dye was seen, the leakage site (s) was repaired. Thereafter, the dye test would be repeated to confirm the integrity of the repair. Results: Their mean age was 53.4 ± 10.9 years. Seven (22.6%) patients had Stage 3 disease and 24 (77.4%) had Stage 4 disease. All the patients had neck dissection, whereas 3 (9.7%) patients had salvage laryngectomy postradiotherapy. Dye test was performed intraoperatively for all the patients and leakages were seen in 4 (12.9%) patients which were successfully repaired. Oral feeding was commenced on the fifth postoperative day, and none of the patients had PCF. Conclusion: Performing a dye test intraoperatively helps detect the point of leakage and immediate repair will prevent PCF.
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Analysis of the determinants, characteristics and management of recurrent urethral strictures p. 130
Nasir Oyelowo, Muhammed Ahmed, Musliu Adetola Tolani, Ahmad Tijani Lawal, Mudi Awaisu, Abdullahi Sudi, Olagunju Jemila, Ahmad Bello, Husseini Yusuf Maitama
DOI:10.4103/njs.NJS_54_19  
Background: The presentation and management of the recurrent urethral stricture varies and depends largely on the initial treatment and the characteristics of the recurrent stricture. What are the likely determinants of recurrence? Patients and Methods: This is a retrospective review of all patients who had urethroplasties from January 2013 to December 2017 for anterior urethral strictures in our institution. Patients with a recurrence of the strictures were identified and reviewed, while patients with hypospadias and posterior urethral stenosis or contractures were excluded from the study. The etiology, length, site, and type of urethroplasties were evaluated as variables that may contribute to the recurrence of strictures using inferential statistics and logistic regression analysis. Time to recurrence was analyzed using the Kaplan–Meier method. Results: A total of 206 urethroplasties for anterior urethral strictures were evaluated with recurrence of strictures noted in 29 patients and a recurrence rate of 14.1%. Recurrence was higher in long-segment strictures, penobulbar strictures, and postinflammatory strictures. Pedicle flaps were used in 45% of the strictures that reoccurred. Using Chi-square, the length, site, of urethroplasties were statistically significant determinants of recurrence; however, only the site of stricture was found to be statistically significant following logistic regression analysis. The site of recurrence was in the bulbar urethra in 79% and the penile urethra in 21%. The choice of treatment of the recurrent strictures was anastomotic urethroplasty in 76.5%. The mean time to failure in this study was 13 months with a range of 6-120 months. Conclusion: In this study, the site of stricture was found to be the most determinant of stricture recurrence, with penobulbar strictures mostly implicated. Long-segment strictures were also noted to contribute to some extent in recurrence. These recurrent strictures were mostly short-segment strictures in the bulbar urethra which were amenable to excision and anastomosis to achieve cure.
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The effect of single-dose bupivacaine on postoperative iliac crest graft donor site pain p. 135
Olalere Omoyosola Gbolahan, Babatunde Babasola Osinaike, Adeola Olanike Olusanya, Michael Oluyinka Okunola
DOI:10.4103/njs.NJS_68_19  
Background: Postoperative donor site pain remains a major source of morbidity following iliac crest bone graft harvesting (ICBGH). Aim: The aim of this study was to investigate the effect of single-dose infiltration of bupivacaine on donor site pain following ICBGH. Subjects and Methods: This study was a double-blind randomized controlled trial of 30 adult individuals that required an ICBG as part of the treatment for mandibular reconstruction. Individuals were divided into two groups, to receive a single-dose subcutaneous infiltration of either 0.25% bupivacaine or 0.9% normal saline at the iliac crest graft incision site following ICBGH. Length of incision at the ICBGH site, dimensions of harvested graft, time taken for the iliac crest harvest surgery, total daily dose of postoperative analgesics, pain from the ICBGH site as well as gait disturbance were recorded. Data were analyzed using SPSS version 17.0, and P < 0.05 was considered statistically significant. Results: There was a progressive decrease in pain score from the 1st to the 4th postoperative day, with no significant difference between the two groups. There was no statistical difference between the two groups in terms of dynamic median pain score at the early postoperative period as well as at the 4th and 12th week postoperative period. The analgesic consumption between the two groups also did not show any significant difference. Conclusion: Local injection of single dose of 0.25% bupivacaine did not offer additional benefit in the management of postoperative iliac crest donor site pain following ICBGH.
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Assessment of complications of transurethral resection of the prostate using Clavien-Dindo classification in South Eastern Nigeria p. 142
Timothy Uzoma Mbaeri, Joseph Amauzo Abiahu, Emmanuel Ahuizechukwu Obiesie, Chinonso Odo, Kingsley Chidi Oranusi, Alexander Maduaburochukwu Ekwunife Nwofor, Jideofor Chukwuma Orakwe
DOI:10.4103/njs.NJS_20_20  
Background: Benign prostatic hyperplasia is one of the most common diseases in aging males. For men that need surgical treatment, transurethral resection of the prostate (TURP) is the gold standard. The aim of this article is to retrospectively review the complications of TURP over a 3-year period in Nnamdi Azikiwe University Teaching Hospital Nnewi and a Specialist Urology Center in Awka all in Anambra South-East Nigeria using Clavien-Dindo classification. Patients and Methods: The study was a retrospective review of consecutive TURPs done over a 3-year period. Patients' information and complications arising from the procedure were collected and graded using the Clavien-Dindo classification with a pro forma designed for the study and analyzed with the Statistical Package for the Social Sciences software version 20.0. Results: Ninety-seven patients had TURP during the period of this study. Twenty-nine complications were noted in 24 patients. The postoperative morbidity rate was 24.74%, and no mortality was recorded. Most of the complications were grade 2 (55%), followed by grade 1 and 3 (20.69%) each. Grade 4a complication accounted for only 3.45%. No grade 5 complication was recorded. Conclusion: TURP is safe, with minimal life-threatening morbidity even in a resource-poor economy where TURP is gradually gaining grounds.
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A comparative study of fine-needle aspiration and nonaspiration cytology diagnosis in thyroid lesions p. 147
Elangovan Archana, Chellappa Vijayakumar, Nagarajan Raj Kumar, Gopal Balasubramanian, Krishnamachari Srinivasan, GS Sreenath, N Siddaraju
DOI:10.4103/njs.NJS_29_20  
Background: Aspiration cytology is one of the first-line diagnostic tests in thyroid malignancies. Fine-needle aspiration cytology (FNAC) in thyroid lesions causes hemorrhagic smear and cell trauma, often leading to the repetition of smear and delay in diagnosis. This study was conducted to identify the diagnostically superior technique with regard to thyroid swelling and to assess the quality of smears obtained from FNAC and fine-needle nonaspiration cytology (FNNAC). Methodology: This was a prospective diagnostic study carried out for 2 years in a tertiary care center from South India. All patients with complaints of thyroid swellings, after examination, underwent FNNAC, followed by FNAC of the lesion. They underwent thyroidectomy when indicated. The final postoperative biopsy reports were compared with the preoperative reports of these two techniques (FNNAC and FNAC). The quality of smears was compared using Mair's score. Results: The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy in diagnosing malignancy were 93.4%, 100%, 100%, 98.78%, and 98.96% for FNNAC and 94.12%, 100%, 100%, 98.82%, and 99% for FNAC, respectively, which were comparable. Regarding the quality of smears, FNNAC had more smears with less blood in the background. FNAC had more smears with adequate cellularity. The difference in overall Mair's score between the two techniques was not significant (P = 0.28). Conclusion: No difference was found in the accuracy of FNAC and FNNAC in diagnosing thyroid lesions. Furthermore, the smear quality of both techniques was comparable. Hence, either can be used based on the operator's preference and experience.
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Fibrolipomatous hamartoma of the median nerve: An outcome of surgical management in six consecutive cases p. 153
Avinash Prabhu, R Anil, Niranjan Kumar
DOI:10.4103/njs.NJS_16_20  
Background: Lipoma is a nonneurogenic benign tumor. Neurolipoma and fibrolipomatous hamartoma are variants of this universal tumor. All these variants are grouped under lipomatosis of the nerve. Majority of these tumors are asymptomatic, which can be observed. Symptomatic patients require surgery, which is not standardized. As there are insufficient number of cases, no randomized controlled studies have been performed in the treatment of fibrolipomatous hamartoma. The aim of our study was to determine the pattern of presentation of fibrolipomatous hamartoma, surgical management offered, and the outcome in the form of recovery and complications. Materials and Methods: This retrospective descriptive study includes six patients diagnosed with fibrolipomatous hamartoma over a period of 12 years. Patient details were collected from the medical records. Patients diagnosed of fibrolipomatous hamartoma in the hand were included. Patients with other soft-tissue tumors were excluded from the study. Out of six patients, four required excision of nerve followed by reconstruction using sural nerve graft and two underwent microsurgical dissection of neural element. Patients were instructed to take care of the operated hand during the recovery phase. Institutional physiotherapy protocol was started during the 3rd postoperative week. Follow-up period was between 1 and 3 years. Results: All the six patients were free from symptoms postoperatively. Minimal complications were noted in two patients, which were managed conservatively. Conclusion: Surgical excision of fibrolipomatous hamartoma of median nerve below elbow, with nerve dissection or with nerve reconstruction using sural nerve graft, followed by proper postoperative care and physiotherapy has proven beneficial for the patients in our study.
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Cavernous hemangioma of the adrenal gland: A rare adrenal incidentaloma p. 159
Amit Gupta, Ashish Gupta, Sweety Gupta, Prashant Durgapal, Rohik Anjum T Sideek, Shashank Verma
DOI:10.4103/njs.NJS_12_19  
Cavernous hemangiomas of the adrenal gland are rare, benign, endocrinologically inactive tumors. They present as adrenal incidentalomas, mostly asymptomatic, but patients may have abdominal pain. Surgery is the mainstay of treatment.
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Gastric glomus tumor p. 162
Sumitoj Singh, Ashok Kumar, Vikas Singh
DOI:10.4103/njs.NJS_8_19  
This case report describes glomus tumor of the stomach, a rare entity, which is a mesenchymal origin tumor. They are generally benign and account for nearly 1% of all gastrointestinal (GI) soft-tissue tumors. They are almost impossible to diagnose preoperatively because of the lack of specific characteristics and are often mistaken for GI stromal tumors (GISTs). In our hospital setup, a female aged 24 years, presented with right lumbar abdominal pain which after a thorough workup leads to the preoperative diagnosis of GIST, and distal gastrectomy with Roux-en-y anastomosis was done. However, pathological and immunohistochemical findings done after the surgery were found consistent with the diagnosis of gastric glomus tumor. Discovered on GIST-1 (DOG-1) nonreactivity is considered for the diagnosis of glomus tumor which helps in excluding the diagnosis of GIST, which is positive for DOG-1. Hence, it was concluded that differential diagnosis on the basis of immunohistochemical findings can lead to an accurate preoperative diagnosis and further targeted surgical intervention.
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Desmoid-type fibromatosis of the splenic hilum: A rare tumor at an unusual location p. 166
Ana Sanchez-Gollarte, Fernando Mendoza-Moreno, Marina Perez-Gonzalez, Manuel Diez-Alonso, José María Muguerza-Huguet, María Del Rocío Diez-Gago, Fernando Noguerales-Fraguas, Alberto José Gutierrez-Calvo
DOI:10.4103/njs.NJS_35_19  
Desmoid-type fibromatoses (DTFs), also known as desmoid tumors, are benign but infiltrative neoplasms that often appear next to previous surgical site. Intra-abdominal tumors usually involve the mesentery, but splenic hilum is an unusual localization. We present a case of a desmoid tumor of the splenic hilum laparoscopically resected in a 70-year-old male with a previous history of chromophobe renal cell carcinoma and ocular spindle melanoma. Although benign, desmoid tumors might be infiltrative and produce serious complications. Treatment remains controversial, ranging from surgery and medical therapies to observation. Management of DTF must be individualized, considering the risk of complications and recurrence.
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ABSTRACTS Top

Nigerian Surgical Research Society 76th Scientific Conference Asaba, 2019 p. 170

DOI:10.4103/1117-6806.290662  
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