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   Table of Contents - Current issue
June 2022
Volume 11 |  Supplement 1
Supplement 1
Page Nos. 1-67

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18F fluorodeoxyglucose positron-emission tomography–computed tomography in the diagnosis of brachial plexopathy in carcinoma breast Highly accessed article p. 1
Suma Tammineni Medara, KB Sricharan, V Sai Krishna Mohan, Ranadheer Gupta Manthri, AY Lakshmi, Tek Chand Kalawat
We report the case of a 42-year-old female who had received treatment for carcinoma left breast, now presenting with pain in the left upper limb for 2 months and paraesthesia for 1 month. Magnetic resonance imaging of the brachial plexus revealed altered signal intensity involving divisions and cords of the brachial plexus on the left side. 18F fluorodeoxyglucose (FDG) positron emission tomography-computed tomography revealed moderately increased FDG concentration in multiple ill-defined nodules, along the left brachial plexus suggestive of metastatic brachial plexopathy.
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Prostate abscess with acute urinary retention as the initial presentation of granulomatosis with polyangitis Highly accessed article p. 5
KM Bhargav, CV S Manasa, G Sindhu, Alladi Mohan, AK Chowhan, K Sirisha
A 50-year-old male presented with acute urinary retention. He also had a history of cough, haemoptysis, exertional dyspnoea, loss of appetite, generalised weakness and left-ear discharge of 1-month duration. Prior episode of acute urinary retention had occurred 2 months ago; diagnostic evaluation revealed prostate abscess, and he had received treatment elsewhere for the same. He also had a history of hypertension. Physical examination revealed fever, pallor, bilateral parotid enlargement and left-ear serous discharge. Clinical examination, imaging of chest revealed consolidation with cavitation on the left side, bilateral pleural effusion. Laboratory testing revealed normocytic normochromic anaemia (haemoglobin 6.6 g/dL); neutrophilic leucocytosis (total leucocyte count 13,100 cells/mm3; polymorphs 87%); raised erythrocyte sedimentation rate (110 mm at the end of the first hour); elevated serum creatinine (2.69 mg/dL) and an active urine sediment. Flexible fibreoptic bronchoscopy showed alveolar haemorrhages. Bronchoalveolar lavage fluid Xpert MTB/RIF testing, cytopathology were negative. Computed tomography-guided biopsy from the lesion was suggestive of granulomatous vasculitis. Cytoplasmic antineutrophil cytoplasmic antibodies (C-ANCA) tested positive. The patient was diagnosed to have granulomatosis with polyangitis (GPA). As arterial hypoxaemia was evident, tracheal intubation and mechanical ventilatory support were initiated. Renal replacement therapy, intravenous (iv) methyl prednisolone and cyclophosphamide pulse therapy and five sessions of plasmapheresis were administered. As remission could not be achieved, iv rituximab was started. On the 36th day of admission, the patient developed septic shock and died. The present case documents the uncommon association of GPA with prostate abscess, acute urinary retention.
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An interesting case of glomerulonephritis and rhabdomyolysis p. 9
Kamani Naresh Babu, D Amulya Reddy, Mallikarjuna Shetty, M Nageshwar Rao
A 19-year-old male from a rural background with no prior co-morbidities came with chief complaints of fever for 4 days, associated with chills, rigors, myalgias and high coloured urine. On general examination, pallor was present. Vitals and systemic examination were normal. Routine blood investigations were sent, and two sets of blood cultures were sent. The patient was empirically started on ceftriaxone. Complete urine examination showed >20 red blood cells (RBCs)/high-power field (HPF) with four to five RBC casts/HPF. Initial creatine phosphokinase was 3216 U/L. The patient's fever spikes continued, and antibiotic was changed to piperacillin-tazobactam after 48 h and then to meropenem. Fever spikes continued. The patient developed pancytopenia and acute respiratory distress syndrome. Final blood culture report grew Brucella melitensis. The patient was started on streptomycin and doxycycline. The patient improved clinically and discharged in clinically stable condition.
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An interesting case of Parkinsonism in the young p. 12
Akula Sushmitha, Kamani Naresh Babu, Ashwitha Chawan, Y Sathyanarayana Raju
A 16-year-old female with no prior comorbidities came with chief complaints of fever and headache for 4 days associated with altered sensorium for the past 15 days in the form of decreased responsiveness. On general physical examination, Glasgow Coma Scale score was 6 with E1V1M4. Vitals were stable. Central nervous system examination revealed that bilateral pupils were sluggishly reactive to light. All extremities were rigid. A provisional diagnosis of viral encephalitis was made and was empirically started on acyclovir, doxycycline, ceftriaxone and vancomycin. Cerebrospinal fluid (CSF) showed lymphocytic pleocytosis, elevated proteins and normal glucose. CSF pan-neurotropic virus panel was negative. Serological testing for immunoglobulin M (IgM) against Japanese encephalitis virus positive. Magnetic resonance imaging of the brain showed symmetrical T2 hyperintense areas in the bilateral basal ganglia, thalamus and splenium of corpus callosum. The patient was started on oral levodopa plus carbidopa; sensorium became better and Parkinsonian features improved gradually.
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Non-Hodgkin's lymphoma presenting with pulmonary involvement p. 15
KM Bhargav, M Shri Ramya, Alladi Mohan, N Rukmangadha, TC Kalawat, N Sairam, C Sunil Kumar
A 25-year-old woman presented with a history of episodes of fever with night sweats, multiple joint pains and breathlessness for 5 months. Eight months before the present episode, she had developed a generalised rash and transient swellings in the groin on both sides. Physical examination revealed pallor, pedal oedema and a hyperpigmented rash over the chest, back and thighs. Pulse was 126 beats per minute and respirations 38/min; while breathing ambient air, the oxygen saturation by pulse oximetry was 83%. On auscultation of the chest, breath sounds were diminished bilaterally and crepitations were heard in both the lung bases. Neurological examination revealed weakness of proximal muscles of both upper and lower limbs on both sides with a power of grade 3/5. Laboratory investigations revealed elevated total leucocyte count with neutrophilic leucocytosis; band forms and metamyelocytes were seen in the peripheral blood smear. Oxygen inhalation and broad-spectrum intravenous antibiotics were initiated. Echocardiogram showed severe tricuspid regurgitation with moderate pulmonary arterial hypertension. Computed tomography (CT) of the chest revealed patchy consolidation in both the lungs, bilateral pleural effusions and pericardial effusion. Bone marrow biopsy showed normocellular normoblastic marrow with erythroid hyperplasia. 18F-fluorodeoxyglucose positron emission tomography-CT showed metabolically active lymphadenopathy both above and below the diaphragm and bilateral patchy lung infiltrates. Biopsy of the inguinal lymph node along with immunohistochemistry staining confirmed the diagnosis as T-cell lymphoma.
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Nitrofurantoin-induced interstitial lung disease p. 18
Mohammed Salman, Adarsh Marikanty, Shiva Kumar Reddy, Mallikarjuna Shetty
We report the case of a 55-year-old woman diagnosed with interstitial lung disease due to long-term nitrofurantoin therapy that was administered for recurrent urinary tract infection. Despite distorted pulmonary parenchymal architecture and patchy fibrosis confirmed by computed tomography of the thorax, the symptoms and radiographic findings disappeared within 3 months after the administration of prednisone. This case shows that nitrofurantoin-induced lung disease may run a benign course and respond favourably to corticosteroids, even when there is radiographic evidence of established lung fibrosis. This case report highlights the need for vigilance of pulmonary toxicity in patients taking long-term nitrofurantoin therapy.
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Interstitial lung disease with congenital erythrocytosis p. 21
DT Katyarmal, M Haneesha, KM Bhargav, C Chandrasekhar, B Vijayalakshmi, N Mounika
A 45-year-old male weaver, smoker, known case of interstitial lung disease with cor pulmonale on long-term oxygen therapy diagnosed 6 months ago who is on tapering doses of oral steroids presented to our tertiary care teaching hospital with complaints of worsened shortness of breath, cough with expectoration and fever for the past 4 days. The patient had headache, dizziness for the past 6 months. On examination, he was febrile with plethoric facies, conjunctival congestion and digital clubbing were noted. Tachycardia and tachypnoea were noted. Haemoglobin saturation on pulse oximetry was 75% while breathing on room air, 94% with 0.4 fraction of inspired oxygen. On respiratory system examination, bilateral infraaxillary crepts were present, jugular venous pressure was elevated. Remaining systemic examination was unremarkable. Investigations revealed elevated haemoglobin, elevated leucocyte count with neutrophilic leucocytosis, raised packed cell volume and red cell count. Platelet count 1.67 × 105/mm3, erythrocyte sedimentation rate 4 mm at the end of the first hour. Computed tomography (CT) of the chest (plain) showed inter and intralobular septal thickening with honeycombing in the bilateral lower lobes predominantly features suggestive of interstitial lung disease. Ultrasonography of the abdomen showed no hepatosplenomegaly. Two dimensional echocardiography was suggestive of corpulmonale. As patient had hyperviscosity symptoms due to polycythaemia and no improvement in haemoglobin with supplemental oxygen for the past 6 months, patient was further evaluated for alternate cause of polycythaemia. Serum erythropoietin (Epo) levels were normal. Arterial oxygen tension at which oxygen saturation was 50% (P50) was 28 mm Hg. Epo gene receptor mutation was positive suggestive of congenital erythrocytosis. Patient was advised long-term oxygen therapy and regular therapeutic phlebotomy to maintain haemoglobin levels and was discharged in a haemodynamically stable condition.
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Thyrotoxic periodic paralysis p. 24
KM Bhargav, V Sai Krishna Mohan, N Mounika, M Haneesha, P Seelabanu, Alladi Mohan
A 39 -year-old male, with primary hyperthyroidism for the last-3 years, for which he was not receiving any treatment, presented with complaints of sudden onset weakness in all four limbs for one day. Weakness was more in the lower limbs; and was not associated with sweating or related to a carbohydrate-rich diet. Family history, drug- history was unremarkable. On physical examination, he was anxious; exophthalmos was evident. Resting pulse rate was 112/min; rest of the general physical examination was normal. Systemic examination revealed complete absence of movement in lower limbs power 0/5 [Medical research Council (MRC) grading], but he was able to move his upper limbs against gravity 3/5 (MRC grading). Deep tendon reflexes were absent. Rest of the neurological and other systems examination were unremarkable. Laboratory testing showed hypokalemia (serum potassium 2.6 mEq/L); thyroid profile revealed TSH 0.01 mIU/L, T3 2.0ng/ml, free T4 3.3 ng/mL. A possible diagnosis of thyrotoxic periodic paralysis was considered; he was treated with intravenous correction of potassium and was started on carbimazole and propranolol. On the next 48 hours, power in all the limbs became normal and deep tendon reflexes were normally elicitable. He was asymptomatic by the third day and was discharged in a stable condition with advice to follow-up in Medicine out-patient department. Thyrotoxic paralysis is a benign condition if it is diagnosed early and treated promptly. Though it is a rare condition, it requires special mention because of its life-threatening complications. The diagnosis at initial presentation is often delayed because of the subtleness of clinical features of thyrotoxicosis.
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An infective cause of obstructive jaundice p. 27
Sai Subrahmanyam Pappu, Naresh Babu Kamani, Sushmitha Akula, Y Sathyanarayana Raju, Naval Chandra
A 48-year-old mason, smoker and alcoholic came with complaints of yellowish discolouration of eyes with high coloured urine and pale stools for 15 days. The patient also had abdominal pain that increased on food intake and dyspnoea on exertion. The patient also had anorexia and significant weight loss. On examination, icterus was evident. The blood pressure was 70/50 mm Hg, features of shock were present. Leucocytosis with left shift was observed with conjugated hyperbilirubinaemia was present. Abdominal ultrasonography showed a cystic lesion with peripheral calcification. Contrast-enhanced computed tomography revealed stage 2 hydatid cyst with dilatation of common biliary duct (CBD), right hepatic duct (RHD) and left hepatic duct (LHD) and intrahepatic biliary radicles due to compression at the confluence of RHD and LHD. Endoscopic retrograde cholangio-pancreatography showed a dilated CBD with multiple filling defects and membranes on balloon sweepage. CBD Stenting was done. Patient's general condition improved and was taken up for surgery.
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Retrograde nasal intubation for an anticipated difficult intubation p. 30
Sharon Linnet, Natham Hemanth, Aloka Samantaray, M Hanumanth Rao
A 58-year-old female patient with recurrence of carcinoma in the angle of the mouth on the left side was posted for composite resection and Pectoralis major myocutaneous flap reconstruction. The patient had carcinoma left buccal mucosa 1 year back and had undergone left partial mandiblectomy and radiotherapy. On airway examination (MPG) could not be assessed; on mouth opening one-and-half finger was admitted. There was a 4 cm × 4 cm ulceroproliferative growth in the left angle of the mouth extending to lower lip, which was bleeding on touch. After shifting to the operating theatre, venous access was secured with a with a wide-bore cannula. Standard monitoring was connected and preoxygenation was done. Under strict aseptic precaution under local anaesthesia, trachea located with Touhy's needle. Epidural catheter passed through the needle into the larynx and taken out through the oral cavity and Ryle's tube, which the patient already had for feeds, was pulled and taken out of the oral cavity. Catheter tip was tied to it and pulled out through the nostril and passed through murphy's eye of 6.5 mm (ID ETT) and lower end pulled, thereby pulling ETT into the trachea, cuff was inflated and tube fixed at 25 cm. General anaesthesia was administered. Thorough airway assessment, preparat ion and counselling of patient help in reducing airway-related morbidity and mortality.
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Role of anaesthesiologist in the management of an infant with hydrocephalus for shunt surgery p. 34
B Radhika, Kuraparthi Jasmitha, Janaki Subhadra Peyyety, Aloka Samanta Ray, Mangu Hanumantha Rao
Hydrocephalus is a disorder of abnormal accumulation of cerebrospinal fluid (CSF) in the ventricular system. Accumulation of CSF occurs due to an imbalance between CSF production and absorption. In the new-born and infants, hydrocephalus almost entirely presents as an enlarged head resulting from the separation of cranial bone plates, so any new-born or infant with an enlarged head should undergo evaluation. We report the case of a gross hydrocephalus in a 9-month-old infant (head circumference 55 cm) posted for ventriculoperitoneal shunt surgery with anaesthetic consideration of difficult intubation because of such a large head size, positioning, age-related pathophysiology and temperature regulation. The case was managed successfully with an uneventful hospital stay, and a significant decrease in head size was noted.
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Hydropneumothorax in a patient with COVID-19 p. 38
P Suresh Babu, C Manoj Krishna, M Pradeep, M Uday Kiran, P Bharghav, V Kiran Kumar, M Pradeep Kumar, B Rajesh, S Himaja, P Lakshmi Aishwarya, AY Lakshmi, R Ram
Pneumothorax had been reported in a few patients COVID-19. However, the significance and frequency of this association remains unclear. We report a 42-year-old man with COVID-19 disease who presented with left-sided hydropneumothorax. We managed the patient with intercostal tube drainage underwater seal, oxygen inhalation, injections remedesivir, dexamethasone, and ceftriaxone. The repeat computerised tomography scan of chest after 10 days revealed reduction in the left hydropneumothorax; no features suggestive of COVID-19 viral pneumoniawre evident.
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COVID-19 to mucormycosis p. 41
Tejaswini Kasinede, Srilakshmi Gaddam, Joy Blessy Lois Ts, K Dinesh Kumar, J Rani, A Naga Soumya, Lakshmi Aishwarya Pavuluri, M Murali, Rapur Ram, V Siva Kumar
A 54-year-old man with hypertension, end-stage renal disease (ESRD) who was receiving thrice-weekly haemodialysis for the past 3 years, developed breathlessness after a session of haemodialysis. Oxygen saturation by pulse oximetry (SpO2) was 88% and he was admitted for evaluation. Nasopharyngeal swab real time-polymerase chain reaction (RT-PCR) had tested positive for SARS-CoV-2. He was started on intravenous azithromycin, dexamethasone 8 mg, and subcutaneous heparin. On the 8th day after admission, he had painful swelling, redness and watering of the left eye. Within hours, he also complained swelling of the left half of the face, diminished vision and reduced eye movements of the left eye. Magnetic resonance imaging (MRI) and magnetic resonance angiography of the brain revealed left orbital cellulitis. angioinvasive fungal sinusitis. Laboratory testing confirmed the diagnosis. The patient was treated with intravenous ammphotericin B and surgery.
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Left renal vein thrombosis in a COVID-19 patient p. 45
Cherukuru Namratha Vaghdevi, Dara Sindhu, Bommu Jahnavi, Dondapati Pooja Chowdary, Sri Lakshmi Gaddam, Pavuluri Lakshmi Aishwarya, Muparapu Murali, S Mathani, Prasanna Kumar, R Ram, V Siva Kumar
The multiorgan deleterious effects of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease (COVID-19) are now well known. Although COVID-19 disease is a hypercoagulable state and thrombotic complications occur in about one-third of critically ill patients with COVID-19, thrombosis is not typically a presenting symptom. We report the case of a patient presented with the complaints of abdominal pain due to renal vein thrombosis as the first feature of the COVID-19.
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Pulmonary cavity in a COVID-19 patient p. 50
M Divya Bharathi, K Niharika, L Prakhya, Sri Lakshmi Gaddam, S Mathini, N Prasanna Kumar, R Ram, V Siva Kumar
Even though a small number of published single patient reports have more recently reported pulmonary cavitation in COVID-19 disease, it is still considered a rare radiology feature. We report a 45-year-old man with COVID 19 disease and a pulmonary cavity.
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Acute pancreatitis due to scrub typhus p. 53
G Sri Lakshmi, S Yeshaswini, B Alekhya, Maria Bethasaida Manuel, A Sunnesh, R Ram, V Siva Kumar
Scrub typhus caused by organism Orientia tsutsugamushi and transmitted to humans by the bite of a leptotrombidium mite (chigger). Although eschar formation is one of the important signs that aid in diagnosis, multiple eschar formation is a rare presentation. Although scrub typhus causes multiple organ dysfunction, the pancreas involvement is rare. Here, we describe a patient with scrub typhus with multiple eschars complicated with acute pancreatitis and acute kidney injury.
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Amlodipine-induced gingival hyperplasia: A report of two cases p. 55
G Sri Lakshmi, G Tejaswini, B Alekhya, Maria Bethasaida Manuel, R Ram, V Siva Kumar
Drugs associated with gingival overgrowth fall into three broad categories – anticonvulsants, immune suppressants and calcium channel blockers. Amlodipine is a third-generation dihydropyridine. The prevalence of amlodipine-induced gingival hyperplasia is 4.2%. We report two patients with the amlodipine-induced gingival hyperplasia.
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Tuberculosis presenting as immune thrombocytopenia p. 58
Deepak Moka, Sai Subrahmanyam Pappu, Rajender Badavath, M Nageshwar Rao
A 19-year-old male presented with chief complaints of generalised weakness and unintentional weight loss from 50 Kg to 45 Kg within a span of 1 month. He complained of fever for 15 days and had developed petechiae over bilateral upper limbs and bilateral subconjunctival haemorrhage. Laboratory investigations done elsewhere showed platelet count of 10,000/mm3. On further investigation, Widal test, dengue serology, and smear examination for malarial parasite, antinuclear antibodies, and viral markers were negative. Abdominal ultrasonography showed multiple conglomerative enlarged lymph nodes in peripancreatic, peripatetic and paracaval, with few of them showing necrosis and loss of hilum and minimal ascites. Bone marrow examination showed megakaryocytic hyperplasia features, suggestive of immune thrombocytopenic purpura (ITP). No improvement in the platelet count was noted with intravenous methylprednisolone. On examination, the patient had ecchymotic patches over bilateral upper limbs and bilateral subconjunctival haemorrhages. Bilateral supraclavicular lymph nodes were palpable, non-tender, mobile, measuring 3 cm × 3 cm in the right side and 2 cm × 2 cm in the left side and firm in consistency. Cervical lymph node biopsy showed caseous necrotising granulomatous inflammation. Contrast-enhanced computed tomography neck, chest and abdomen showed multiple enlarged conglomerated heterogeneous enhancing lymph nodes with central non-enhancing areas s/o necrosis noted in the neck, mediastinum and abdomen. Tuberculin skin test (Mantoux test) revealed induration of 20 mm. The patient was started on eltrombopag, and four doses of intravenous immunoglobulin were given without improvement. The patient was started on liver-friendly anti-tuberculosis treatment in view of deranged liver function tests with isoniazid, rifampicin, ethambutol and levofloxacin and later pyrazinamide was added. The platelet count increased after 1 month of ATT to 40,000, and after 2 months, the count was 100,000/mm3.
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Aortic aneurysm associated with rheumatoid aortitis p. 62
Deepak Moka, Sai Subrahmanyam Pappu, Azigiri Sri Nanditha, Naval Chandra
A 59-year-old female, presented with dry cough, burning micturition with urgency and frequency for 2 months. She was known to have hypertension, hypothyroidism and rheumatoid arthritis for the past 30 years; and was receiving oral methotrexate 20 mg per-week. She also had complianed of low backache for 2 months. No phenotypic features of Marfans/Ehler Danlos were evident. Cardiovascular system examination was unremarkable. Chest radiograph showed mediastinal widening with a large fusiform descending thoracic aortic aneurysm. Computed tomography (CT) of the chest showed subpleural fibrosis and fusiform dilatation of the aorta from the origin till the supracoeliac aorta. CT aortogram revealed an irregular non-enhancing wall thickening and calcification of the aorta with fusiform dilatation (4.5 cm × 4.6 cm in the ascending aorta and 4.4 cm × 4.3 cm in the distal descending aorta). The patient did not have any features of giant cell arteritis (GCA)/Takayasu's arteritis; Venereal Disease Research Laboratory (VDRL) test was negative. The patient was diagnosed to have aortic regurgitation due to long standing rheumatoid arthritis and was referred to the department of cardiothoracic and vascular surgery for further management.
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Modified radical mastectomy under paravertebral block in a patient diagnosed with active pulmonary tuberculosis with moderate restriction of pulmonary function p. 65
Mohammad Abuzahid Uns, Dyva Manogna Reddypogu, M Sneha Valli
Mastectomy is mostly performed as definitive management for resectable breast cancer (BC). Implementing paravertebral nerve block for patients with metastasis features of cancer to lungs and other organs, patients with co-morbidity, geriatrics and malnourished individuals will eliminate the risks and complications of general anaesthesia (GA). Although thoracic paravertebral block is an established technique as post-operative pain management for breast surgery, there is no conclusive evidence on its use as a sole anaesthetic for modified radical mastectomy (MRM). In this case report, we present a 45-year-old woman who underwent a successful MRM for Stage IIIb BC associated with pulmonary tuberculosis with moderately restricted pulmonary function test under paravertebral nerve block. We believe that paravertebral nerve block can be used as an alternative anaesthetic technique for MRM in a resource-limited setting for patients who are expected to have a high risk of perioperative complications under GA.
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