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   Table of Contents - Current issue
May-August 2020
Volume 6 | Issue 2
Page Nos. 95-205

Online since Thursday, August 27, 2020

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COVID preparedness at a tertiary care hospital in India: A new road to travel, a long way to go Highly accessed article p. 95
Raghav Bansal
The sudden explosion of the coronavirus pandemic all over the world has taken everybody at all levels aback in an unprecedented manner. The health-care facilities face multiple challenges and huge responsibility for performing the herculean task of ramping up the COVID preparedness to fight the epidemic. All India Institute of Medical Sciences, New Delhi, is the apex medical institution of India and has organized a response in these testing times. This discussion brings around the important aspects of this response and the challenges faced. There is no perfect strategy to fight this pandemic, and the strategies continue to evolve as we learn from our success and failures.
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Heart failure and self-care during the COVID-19 pandemic Highly accessed article p. 102
Santoshi Kumari, Pallavi Rai, PD Subeen
India and many other countries are facing the challenge and threat posed by the growing pandemic of COVID-19. Patients with chronic conditions such as heart failure (HF) are at greater risk of getting the infection. Since the HF patients are at greater risk and hospital outpatient department facilities have also stopped temporarily, patients need to be prepared for self-care for HF. The objective of this article is to integrate practices and recommendations for self-care, in order to maintain well-being and prevent patients from getting infected. HF patients are encouraged to practice preventive and protective measures to limit the risk of COVID-19. HF nurses should focus on self-care education teaching also about medications, personal and environmental hygiene, mask management, social and personal distancing, psychosocial aspect, and diet in HF. All the patients are advised and encouraged to use teleconferencing, virtual, and other means of electronic communications to avoid direct contacts with others. All HF patients should be advised to stay at home and follow the government advisories.
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Cardiothoracic surgery practice at a tertiary center during the COVID-19 pandemic Highly accessed article p. 105
Milind Hote, Sanjoy Sen Gupta
A COVID-19 pandemic has been declared by the WHO since January 2020. In this crisis, cardiac surgeons have to ensure that essential cardiac surgery is available while ensuring that inadvertent COVID-19 does not spread among patients or to the surgical team.
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Recommendations of the INSHLT task force for thoracic organ transplant during COVID-19 pandemic in India Highly accessed article p. 108
Alla Gopala Krishna Gokhale, KR Balakrishnan, Julius Punnen, R Ravi Kumar, UM Nagamalesh, K Vijil Rahulan, Chintan Sheth, Sarvesh Pal Singh, Sandeep Seth
The emergence of COVID-19 has impacted heart transplantation worldwide. The pandemic has impacted donor availability and also raised issues of safety of receipients and surgical teams. In these recommendations, the Indian Society of Heart and Lung Transplantation (INSHLT) has discussed the issues related to the testing and safety issues related to the donor and the recipient as well as the surgical teams. The INSHLT recommends COVID-19 testing once consent for organ donation is obtained of both the donor and the receipient. The INSHLT also recommends high-resolution computed tomography of the chest before organ donation, especially for lung donation.
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Myocarditis in Coronavirus disease 2019: Not an equivalent to troponinitis Highly accessed article p. 111
Saikrishna Reddy, Bharath Kidambi, Sampath Madapati
Coronavirus disease 2019 (COVID-19) has affected around 5 million people and is on raising trend. It has overwhelmed the health-care systems of all specialties including cardiology. Cardiac involvement has been seen based on the early reports from China showing elevation of troponin and especially in the critical cases varying form 7%–28%. Speculations were made about the possibilities of myocarditis based on those reports. This short review attempted to methodologically look at available clinical evidence on the true incidence of myocarditis in COVID-19. The data suggest that troponin elevation is not equal to either ischemic heart disease or myocarditis and is some form of nonischemic myocardial injury and a marker of higher morbidity. It is related to the cytokine storm, but more information is needed on its pathogenesis.
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F-test of overall significance in regression analysis simplified p. 116
Onchiri Sureiman, Callen Moraa Mangera
Regression analysis is using the relationship between a known value and an unknown variable to estimate the unknown one. Here, an estimate of the dependent variable is made corresponding to given values of independent variables by placing the relationship between the variables in the form of a regression line. To determine how well the regression line obtained fits the given data points, F-test of overall significance is conducted. The issues involved in the F-test of overall significance are many and mathematics involved is rigorous, especially when more than two variables are involved. This study describes in details how the test can be conducted and finally gives the simplified approach of test using an online calculator.
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Basic principles of sample size calculation p. 123
Shivam Pandey
The calculation of sample size helps a medical researcher to assess cost, time, and feasibility of his project besides scientific justification and validity. Although frequently reported in journals, the details or the elements of sample size calculation are not consistently provided by the authors. Sample size calculations reported do not match with replication of sample size in many studies. Most trials with negative results do not have a large enough sample size. Hence, reporting of sample size and power needs to be improved. The sample size calculation can be guided by previous literature, pilot studies, and past clinical experiences. The collaborative effort of the researcher and the statistician is required at this stage. Estimated sample size is our best guess. Issues such as anticipated loss to follow-up, large subgroup analysis, and complicated study designs, demand a large sample size to ensure power throughout the trial. The present article will help the reader understand the importance of pilot study in sample size estimation, second understand the relationship between primary objective and sample size of a study, third understand the essential components required in a sample size estimation, and fourth calculate sample sizes using real-life examples using an online software.
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How to run the cardiology service in COVID times? A practical guide p. 132
Anish Kapil, Sivasubramanian Ramakrishnan
Coronavirus disease 2019 (COVID-19) has placed an enormous strain on the health-care systems. In this systematic review, we briefly review the cardiovascular manifestation of COVID and how a cardiology service can be geared to tackle the COVID pandemic. These guidelines are based on how our hospital is being run based on guidelines which have come out from time to time from the Indian Council of Medical Research, WHO, Centers for Disease Control and Prevention, and other health authorities. COVID-19 is more severe in patients with cardiovascular disease and hypertension and may be associated with myocarditis like illness and shock. Patients with preexisting comorbidities have to be handled with extra care, and the manifestation of COVID-19 has to be distinguished from cardiovascular problems. Running a cardiology service requires ensuring preventing cross infection between patients, preventing patients from infecting health-care personal, and this requires precautions at all levels including the outpatient, ward, echocardiography, angiography, and during surgery. All these aspects are discussed. Different wards and different procedures carry a different level of risk requiring different levels of protection which are outlined. There have to be triage areas to screen patients while the COVID reports are coming in, keeping in mind that the patients can be COVID positive even if the reports are negative. Each hospital has to have guidelines in place to handle different cardiac emergencies.
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An alternative to standard personal protective equipment during emergency cardiac procedures in catheterization lab p. 140
Sudhir Suryakant Shetkar
Personal protective equipment (PPE) are likely to fall short as the COVID pandemic increases, and the availability will especially not be there for COVID-negative or untested patients. This brief report describes an indigenous method of improvising a PPE for use especially during emergency procedures in the cardiology catheterization lab if a full PPE is not immediately available and COVID-19 status of the patient is not known. While a proper PPE should be used for COVID-positive patients, for other patients, this kind of improvisation should provide reasonable protection from biohazards.
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Hospital resource planning for the COVID pandemic p. 144
Sameer Kaura, Navreet Singh, Nitish Naik, Ambuj Roy, Sandeep Kaushal, Rajesh Mahajan, Garima Gupta, Gurpreet S Wander, Bishav Mohan
Introduction: Throughout the history of world, we have witnessed many epidemics and pandemics associated with considerable morbidity, mortality which has resulted in economic crisis and a massive collateral damage to humanity. In the backdrop of the policies and guidelines to handle any pandemics or epidemics, it is imperative that we strengthen the core public health infrastructure. In this article, we have made an attempt to highlight the requirement of a health care facility which should have the capacity to handle 250 patients amidst an ideal and resource limited setting of containment and mitigation. Aims and Objective: To run a health care facility for treating 250 COVID-19 positive patients categorised into 3 levels. To use manpower in an ideal and resource limited scenario. Methods and Material: The hospital is divided into 3 levels and depending upon the severity. 150 beds are given to mildly symptomatic with risk factors (diabetes, hypertension, CKD, immunocompromised, age >60, requiring oxygen therapy and monitoring). 60 beds are given to patients moderately sick {mild ARDS patients}with continue requirement of oxygen by different other modes (high flow nasal cannula, protected non-invasive ventilation, active use of prone position) not responding to usual management. 40 beds are reserve for the patient requiring ventilatory support. Conclusion: The pandemic of COVID because of its infectious nature has burdened the healthcare system as well as safety of the care givers. The economic burden of consumable is far-far less as compared to the requirement of human resources and this challenge is faced globally.
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Does angiographic profile and outcome of diabetic patients among Asian Indians correlate with presenting glycated hemoglobin during acute ST-elevation myocardial infarction? DECIPHER study p. 148
Vishal Sharma, Kamal Sharma, Zeeshan Mansuri, Sharad Jain, Sanjeev Bhatia, Krutika Patel
Background: The risk of myocardial infarction (MI) is high in patients with diabetes mellitus. The study aimed to evaluate the risk factors focusing on presenting glycated hemoglobin (HBA1C) and the angiographic profile of diabetic patients with ST elevation myocardial infarction (STEMI) and in-hospital 3-point major adverse cardiac event (MACE). Materials and Methods: Two hundred consecutive diabetic patients presenting with STEMI were enrolled for prospective observational study. Each patient underwent investigations including HbA1C, electrocardiogram, echocardiography, and coronary angiography with SYNTAX 1 SCORE (SS1) with intent to early revascularization. Continuous variables were compared using the unpaired Student's t-test. A receiver operator characteristic analysis was performed to determine a cutoff point for HbA1c value for predicting disease severity and prognosticate in-hospital 3-point MACE using multivariate analysis after normalizing the confounders. Results: Of the total 200 patients, 70 (35%) had single-vessel disease, 58 (29%) had the double-vessel disease, while 72 (36%) had triple-vessel disease. Among these patients, left main coronary artery was involved in 22 (11%) of patients. Hypertension (73.8% vs. 60%), obesity (35.4% vs. 18.4%), and left ventricular (LV) dysfunction (13.7% vs. 2.9%) were risk factors associated with disease severity with an odds ratio of 1.88 (95% confidence interval [CI]: 1.01–3.49; P = 0.04), 2.4 (95% CI: 1.19–4.84; P = 0.01), and 5.46 (95% CI: 1.23–24.29; P = 0.03), respectively. Receiver operating characteristic analysis of HbA1c with respect to 3P-MACE of in-hospital death, recurrent MI, and CV stroke revealed HBA1C <8.9 g% as cutoff for lower MACE as compared to those with >8.9 g% (95% CI: 0.66–0.79; P = 0.0004) with 65% sensitivity and 76.7% specificity. HbA1c >7.9 g% were more likely to have multivessel disease and SS1 >33. Patients with surgical site infection >33 were more likely to be hypertensive and had severe LV dysfunction and higher 3P MACE. Conclusion: Diabetic Asian Indian patients with STEMI with HbA1c >7.9 g% were more likely to have a multivessel disease and SYNTAX 1 Score >33. There was a significant association between presenting HbA1c >7.9 g% and disease severity and higher 3-P MACE among presenting with HbA1c >8.9 g%.
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Primary percutaneous coronary intervention in elderly (age ≥75 years) Indian population – Immediate- and short-term results p. 153
Ankur Gautam, Jamal Yusuf, Vimal Mehta, Saibal Mukhopadhyay
Background: Primary percutaneous coronary intervention (PCI) is the best reperfusion strategy for patients presenting with ST-segment elevation myocardial infarction (STEMI). Limited data exist on outcomes of primary PCI in elderly patients due to frequent exclusions of this cohort from the trials. The aim of the present study was to evaluate the acute and short-term outcomes of primary PCI in STEMI patients aged ≥75 years. Material and Methods: A total of 50 elderly patients undergoing primary PCI were prospectively enrolled between December 2017 and May 2019. Inhospital and 6-month outcomes of patients were recorded and analyzed. Results: The mean age of the patients was 78.32 ± 3.1 years (range = 75–90 years), and 38.0% were women. Almost half of the patients had triple-vessel disease, and the most common infarct-related artery was left anterior descending artery. Angiographic success was achieved in 78% of the patients, and inhospital mortality rate was 8%. Complete heart block at presentation, Killip Class III, delayed presentation (>6 h), moderate-to-severe left ventricular systolic dysfunction, slow-flow or no-reflow phenomenon, diabetes, and nonresolution of ST segment were major predictors of inhospital mortality. Conclusion: We demonstrate the favorable immediate- and short-term outcomes of primary PCI in elderly patients aged ≥75 years presenting with STEMI and conclude that it can be safely and successfully performed in this population with acceptable rate of complications.
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A prospective single center study to assess the incidence and risk factors associated with cardiorenal syndrome with respect to its subtypes p. 162
Medikonda Parameswara Reddy, Nagamalesh Udigala Madappa, Anupama Hegde, VS Prakash
Background: Cardiorenal syndrome (CRS) is an evolving complex clinical condition of cardiac–renal dysfunction, for which incidence and risk factors remain to be fully assessed in the Indian subcontinent. The study determined the incidence of and risk factors for CRS and its impact on in-hospital mortality and readmission in a tertiary care hospital. Materials and Methods: This single-center prospective observational study included 158 patients with CRS. Sociodemographic, laboratory, and echocardiography parameters were recorded. Heart failure and acute–chronic kidney injuries were diagnosed, and the patients were accordingly classified. Data were statistically analyzed using software R version 3.6.3 and Microsoft Excel. Results: The study included 106 (67.1%) and 52 (32.9%) males and females, respectively, with a mean age of 62.87 ± 13.99 years. Eighty-five (53.8%) patients suffered from CRS Type 1. Dyspnea (n = 149) was the most common complaint. Diabetes mellitus (DM), rheumatic heart disease, chronic obstructive pulmonary disease, and chronic kidney disease were the common risk factors. Conclusion: In South India, CRS is associated with increasing age; hypertension; DM; relevant cardiovascular and kidney diseases; abnormal levels of blood urea nitrogen, creatinine, potassium, and albumin; and low estimated glomerular filtration rate, leading to poor patient outcomes. CRS Type 2 results in relatively less stability, high readmissions with heart failure, and higher mortality in patients. Given the diverse cultural background of India, the study proposes that although CRS is clinically diagnosed, it remains poorly characterized in India, mainly in South India. The present study found that COPD affects CRS, which is a rare finding.
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A case of heart failure and polycythemia: Treated with phlebotomy p. 169
Ashwin Kodliwadmath, Dibbendhu Khanra
Polycythemia in heart failure (HF) is known but rarely encountered. A 76-year-old male presented with New York Heart Association Class III HF symptoms leading to secondary polycythemia. He had underlying ischemic cardiomyopathy not amenable to revascularization and thus was put on optimal medical therapy. However, after being refractory to medical management, he was treated with phlebotomy showing a significant improvement in his symptoms as well as a drop in hemoglobin level. Diagnostic algorithm and management of polycythemia related to HF are discussed.
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Device closure of postmyocardial infarction ventricular septal rupture – Winning the battle but losing the war! p. 172
Dibbendhu Khanra, Shishir Soni, Bhanu Duggal
Ventricular septal rupture (VSR) after acute myocardial infarction is rare and associated with high mortality despite surgical repair. Percutaneous transcatheter device closure has emerged as an alternative to surgical repair in high-risk patients or as a bridge to delayed surgical repair. Not only the timing but also the morphology of defect matters, and in patients with serpiginous ventricular septal defect, device deployment is challenging. We report a patient with cardiogenic shock due to serpiginous VSR following myocardial infarction who underwent percutaneous transcatheter device closure successfully but expired on the 3rd day following the procedure due to sepsis and multiorgan failure.
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Our first encounter with a COVID-19 patient in cardiology ward: Lessons learned p. 176
Mahidhar Jeedigunta, Javaid Ahmad, Sivasubramanian Ramakrishnan
COVID-19 is an ongoing global pandemic caused by a betacoronavirus named SARS-CoV-2. Within few months after the first index case is identified in Wuhan city of China, it attained a global pandemic status due to its unique epidemiology and pathophysiology. It typically presents with signs and symptoms of viral pneumonia. Patients with cardiac disease are at increased risk of COVID disease and create a diagnostic dilemma in differentiating from respiratory illnesses for the cardiologists. Furthermore, ST-segment changes in electrocardiogram and troponin elevation which form a key diagnostic point in the diagnosis of acute coronary syndromes are frequently seen in COVID-19 patients. This is a matter of utmost concern as the diagnostic dilemma caused may lead to many patients who may not have epicardial coronary artery disease that may be taken up for invasive angiography. Moreover, the prejudice caused by the COVID-19 is leading to fewer admissions for acute coronary syndromes and fewer primary percutaneous transluminal coronary angioplasty leading to inappropriate management of deserving patients with genuine acute coronary syndromes. These patients form a very important chunk of population as on the one hand, they are more likely to spread the infection if they are improperly triaged, and on the other hand, they are less likely to receive proper guideline-directed treatment of cardiovascular syndromes increasing the mortality from primary cardiac pathology. The following case highlights the above-mentioned issues faced in triaging and treating a patient who presented a diagnostic dilemma. Our patient a 53-year-old lady who is a known case of chronic coronary syndrome with effort-induced angina on exertion for the last 4 months on medical management presented to the emergency department, after being rejected admission by three hospitals, with features of chest pain at rest 5 days prior to admission associated with dyspnea and nonproductive cough along with elevated troponin and ST elevation. She was initially diagnosed as acute coronary syndrome with acute heart failure and was taken up to the cardiology ward where a proper clinical examination suggesting right middle lobe localized crackles and chest X-ray findings prompted the suspicion of COVID-19, testing for which by a viral RNA-based test came as positive. This case illustrated the unique challenge posed by the COVID-19 for the cardiologist and the importance of clinical examination and a high index of suspicion needed along with prompt isolation of any suspected case. She was shifted to the COVID ward from where she was discharged after 5 weeks.
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Reactive thrombocytosis leading to stent thrombosis p. 180
Piyush Kalantri, Aniruddha Kaushik, Rahul Singla, Arun Bade, Narendra Omprakash Bansal
Percutaneous coronary intervention is associated with many complications, and stent thrombosis is the most feared among them. Common etiologies of stent thrombosis include high angiographic thrombus burden, inadequate antiplatelet dosing, total stent length, diabetes, and renal diseases. Rarely, it can be associated with thrombocytosis. We report a rare case of stent thrombosis associated with reactive thrombocytosis. Although acute coronary events have been documented due to essential thrombocytosis, very few cases of reactive thrombocytosis leading to acute coronary syndrome are reported. Thrombocytosis as a possible etiology is suspected when other risk factors including antiplatelet resistance is ruled out. In these cases, adequate treatment of both stent thrombosis and thrombocytosis needs to be administered simultaneously and the possible etiology of thrombocytosis should be sorted out and treated.
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An interesting case of hypertrophic cardiomyopathy with dystrophic calcification p. 184
Anand Palakshachar, Darshan P Thakkar, Rangaraj Ramalingam, CN Manjunath
Hypertrophic cardiomyopathy (HCM) with left ventricular non-compaction (LVNC) is unusual. Atherosclerotic coronary artery disease in these is rare. We reported a case of HCM with LVNC presenting as stable angina pectoris. Multimodality imaging studies will help to diagnose and guide the management of this uncommon condition.
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Ventricular tachycardia, rheumatic heart disease, and bilateral coronary pulmonary artery fistula: A rare association p. 187
Pankaj Jariwala, Karthik Jadhav, Satya Sridhar Kale
Coronary-pulmonary artery fistulas are rare congenital or acquired anomalies of the coronary artery that may originate from any of the three major coronary arteries and drain into the right-sided cardiac chambers and or large vessels draining into the pulmonary circulation. A triple combination of ventricular tachycardia, rheumatic heart disease, and bilateral coronary pulmonary fistula is a rare association. A rare combination of observations was detected in a single patient with three distinct etiopathogenesis that is not described in the literature.
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Evaluation of serum vitamin D Level as a prognostic marker in the clinical manifestations of acute coronary syndrome patients p. 192
Mahmood Dhahir Al-Mendalawi
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In a Fix p. 193
Harshit Arora
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Cheer up heroes! p. 194
Samdisha Dua
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Accepting donors for heart transplant in the shadow of COVID-19 p. 195
Sarvesh Pal Singh
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The earth is speaking, are you listening? p. 197
Saurabh Nagpal
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COVID chronicles p. 198
Udbhav Seth
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Pediatric cardiac surgery in the hills: A curvy road p. 199
Anish Gupta, Anshuman Darbari, Namrata Gaur, Ajay Kumar, Raja Lahiri, Deepak Kumar Satsangi, Sandeep Gautam
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The gods of copybook headings p. 204
Anunay Gupta, Amit Malviya
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