At present, the determination of brain stem death for the declaration of death in India is a clinical practice followed only in the context of organ donation. It has still not evolved into a standard clinical practice in the intensive care units for determination of death. The probable explanation for this could be that, in India, the declaration of death by determination of brain stem death is mentioned only in the Transplantation of Human Organs and Tissues Act, 1994. Even after 25 years of application of this legislation and the definition of brain stem death in place, no uniform guidelines on the procedure to be followed in the determination of brain stem death have been issued either by the statute or by a national or state authority. The article tries to analyze the lacunae existing in the legal framework in relation to the certification of brain stem death in India.

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Dental indices are tools used to quantify dental diseases thereby cross comparisons can be made based on disease burden and treatment efficacy. In dental literature, there exists an ambiguity on selecting the ideal scale or index to measure dental diseases. This is because of the availability of different indices and the lack of standardization among dental associations in measuring diseases. This warrants the need for a critical assessment of available indices commonly used in dental research and clinical practice. The critical appraisal of indices used for measuring oral hygiene, dental caries, gingival disease, periodontal disease, dental fluorosis, malocclusion, enamel defects, and tooth wear is attempted in this study.

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Brain stem death (BD) is a pathological process which has a profound effect on hemodynamic balance, hormone levels and functioning of other organ systems. It also triggers a systemic inflammatory response. Knowledge about the changes that occur during brain stem death is necessary for subsequent management. This article discusses the pathophysiological changes in the body after brain stem death.

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Meleney’s gangrene is a rapidly spreading gangrene of skin, subcutaneous tissue, and fascia. It has the highest mortality approximately 40% and more in immunocompromised and diabetic patients. The initial presentation mimics cellulitis and most of the cases are misdiagnosed. Delayed diagnosis and treatment increase mortality by approximately 100%. Our case is initially diagnosed as bull gore injury and underwent treatment of the same. Later patient developed extensive Meleney’s gangrene of the entire anterior abdominal wall and genitalia. Even with extensive wound debridement with antibiotic coverage fails to save the patient life. Therefore, early diagnosis and prompt surgical debridement in boll gore injury will reduce the chance of developing Meleney’s gangrene.

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Brain stem death has remained a topic of contention among physicians and laypersons for many years. The evolution of the current definition of brain stem death has been the end result of decades of scientific study and deliberation. Although the concept has been known historically, a scientific probe into the matter had been made possible only during the late 20^th century. This led to a healthy discussion regarding the obscure nature of brain stem death among experts on different continents, leading to the current definition provided by the American Association of Neurology in 2010. This review article aims at shedding light on the institution of brain stem death and the evolution of the definition, as we know it today. Brain stem death has remained a topic of contention among physicians and laypersons for many years. The evolution of the current definition of brain stem death has been the end result of decades of scientific study and deliberation. Although the concept has been known historically, a scientific probe into the matter had been made possible only during the late 20^th century. This led to a healthy discussion regarding the obscure nature of brain stem death among experts on different continents, leading to the current definition provided by the American Association of Neurology in 2010. This has proved to be a boon for the organ transplantation program; providing the system with a new, ethical donor pool and making available healthy organs that could change the lives of people living with organ failure. All this progress is relatively new and comes hand in hand with controversies. This review article aims at shedding light on the institution of brain death and the evolution of the definition, as we know it today.

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Hearing loss may be caused by certain viral infections. The hearing loss due to viral infection can be congenital or acquired, bilateral or unilateral. The viral infections typically cause sensorineural hearing loss (SNHL), although conductive or mixed hearing loss can be found. The corona virus disease 2019 (COVID-19) infection has deleterious impact on the cochlear hair cells. The hearing loss will not improve even patient recovered from COVID-19 infections. This is probably a neuro-auditory involvement in COVID-19 infections. The current COVID-19 is caused by severe acute respiratory syndrome corona virus 2. The audiologic and radiologic investigations are helpful for evaluation of the hearing loss in COVID-19 patients. Hearing loss due to COVID-19 infections is rarely reported in medical literature so far. Hearing loss specifically SNHL is often challenging to the clinicians in this current pandemic. The mechanism for this deleterious effect on the cochlear hair cells requires further research. There is a large gap in the understanding of the etiopathogenesis, epidemiology, and clinical presentations such as hearing loss and human transmission of this disease. There should be a continuous monitoring of the hearing loss and tracing of this COVID-19 infection is needed to ensure the detail understanding of this inner ear pathogenesis. This review article provides an overview of COVID-19 infections and its impact on hearing loss.

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Context: This was a comparative prospective study. Aims: (1) To characterize acoustic reflex decay (ARD) and acoustic reflex latency threshold (ARLT) profiles in cerebellopontine angle (CPA) tumors. (2) To correlate ARD and ARLT test results with the type, size, and extent of tumors. Study Design: Comparative prospective study. Setting: Primary versus Tertiary referral center. Subjects: The clinical group comprised 98 patients with CPA tumor and the control group comprised 100 normal hearing subjects. Subjects and Methods: ARD and ARLT were estimated at 500 Hz and 1000 Hz both ipsilaterally and contralaterally for both the groups. Statistical Analysis Used: Statistical analysis for clinical group versus control group was carried out using analysis of covariance for age and gender covariates. For discrete clinical groups, analysis of variance followed by post hoc (Turkey) test was used. An independent sample t-test was used for the statistical analysis of tumor ear versus nontumor ear. Results: Test results indicated that the proportion of ears with abnormal reflex decay (0%–25%) was less compared to those with normal findings (75%–100%) in the patient group reflecting the poor efficacy of ARD to identify the presence of CPA tumors. Statistical analysis for ARLT was possible mainly for nontumor ear stimulation and it did not give any clear indications regarding the presence of brain stem compression. Conclusions: In the present study, an estimation of ARD and ARLT did not appear to be useful indices for CPA tumor identification.

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Deceased organ donation (OD) involves a complex interplay of government policy, involvement of hospitals and health-care professionals (HCPs), and public support. When the Transplantation of Human Organs Act was passed in 1994 in India, acceptance of brain stem death and understanding about the deceased donation process was poor, both among the public and HCPs. While government support along with training of HCPs, public–private–nongovernmental organization partnerships, and public advocacy has enabled the deceased OD rate to move up from 0.16 per million population (pmp) in 2012 to 0.65 pmp in 2017, there is still much that needs to be done. A review of the literature undertaken to assess the knowledge, attitude, and practice of the public and HCPs toward brain stem death and OD in India revealed the need for interventions at multiple levels.

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The anaesthetic management of retrosternal thyroid swellings has many associated problems. Positioning and induction may cause severe cardiorespiratory decompensation. Intubation may be difficult and may require all the gadgets for difficult intubation procedure. Rarely patients may require cardiopulmonary bypass to save life. Extubation may be difficult in patients with tracheomalacia. Post-operatively patients may require tracheostomy and ventilatory support. This is a case report outlining successful management of a patient with retrosternal goiter who underwent total thyroidectomy following partial sternotomy.

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Medical education is going through a new learning experience of its own due to the impossibility of physical classes in the present pandemic situation. This article describes in detail the conceptualization and development of a questionnaire for the specific purpose of studying the perception of undergraduate students of a medical college toward the online education program.

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Background: Chronic pancreatitis (CP) patients are at high risk of malnutrition due to malabsorption. Sulfur amino acids (SAAs) being important antioxidant could affect pancreatic function. In this study, we have analyzed blood SAAs and its relation to antioxidant levels. Methods: One hundred and seventy-five CP patients and 113 healthy normal controls were prospectively studied. Disease characteristics and imaging features were recorded. Plasma SAAs were estimated using high-performance liquid chromatography. Erythrocyte reduced glutathione (GSH), GSH peroxidase, superoxide dismutase, plasma Vitamin C, erythrocyte thiobarbituric acid reactive substance (TBARS), urinary inorganic sulfate, and creatinine were estimated by spectrophotometry. Results: Plasma SAAs, urinary inorganic sulfate/creatinine ratio, and blood antioxidant levels were lower, whereas TBARS was higher in CP patients as compared to controls. Plasma methionine and TBARS were inversely correlated, whereas plasma cysteine and GSH level were directly correlated. Plasma cysteine and Vitamin C levels were lower, whereas TBARS was higher in CP patients with atrophy as compared to patients without atrophy. No statistical difference in these parameters between diabetic and nondiabetic CP patients was observed. Conclusion: Deficiency of SAAs appears to be associated with oxidative stress in CP patients. Possible benefit of supplementation of SAAs needs to be elucidated.

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This article will focus on a step by step description of the process of brain stem death testing as per Indian Society of Critical Care Medicine (ISCCM) guidelines. This will be followed by a narrative on how the testing criteria differ among the various international guidelines. The importance of identifying a potential brain stem dead patient and confirming the same, zeroes down to two reasons. First and foremost, confirmation of death is needed for both the treating team of doctors and relatives to make informed decisions regarding ongoing care, including futility. The second is that it opens the opportunity to discuss the possibility of organ donation with the relatives. The criteria to diagnose brain stem death follows a stringent protocol and is laid in a fool proof manner so that the chances of making an error is infinistically minimal.

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Introduction: Integration of yoga in health-care management has beneficial effects in the management of many health-related issues with improved outcomes with no added cost. We conducted a pilot study to study the feasibility of yoga in the integrated management of patients with localized prostate cancer undergoing robotic-assisted radical prostatectomy. Methods: This prospective pilot study included twenty patients who underwent robotic-assisted radical prostatectomy between June 2019 and November 2019. The overall effects of yoga on health-related quality of life, recovery of urinary continence, and erectile function were the primary endpoints of our study. Results: Patients in the yoga group had significantly better continence rates at 1 month (90% vs. 50%) with better functional outcomes as compared to the control group at 1-month follow-up. The difference in sexual recovery was not significant in each group at 1-month follow-up.Conclusion: Yoga can be safely integrated in the postoperative management of patients undergoing radical prostatectomy with no short-term adverse side effects on overall outcomes.

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Background: India is a country with very high mortality rates due to road traffic accidents (RTAs). Two-wheelers are the most common vehicle involved in the RTAs. This study aimed to describe the overall characteristics of RTAs. Objective: The objective was to study the clinical profile of trauma patients presenting to the emergency department of a tertiary care center. Methodology: A total of 200 patients were enrolled in the study. A preorganized datasheet was prepared for each patient attending the Emergency Department of Amrita Institute of Medical Sciences. It contains data about sociodemographics, trauma data, clinical evaluation result, as well as treatment strategies. Results: Most (31%) of the patients were aged between 20 and 30 years. The mean age of the patients was 35.8 years. There were 156 males (78%) and 44 females (22%). More than half of the patients were from urban areas. Most patients (82%) were injured by two-wheelers. Sixteen patients did not wear helmet, in which eight patients (50%) had a head injury. Conclusion: Trauma is a major health problem, especially in the young population in our country. Two-wheelers are the most common vehicle involved in the RTAs. Trauma is the leading cause of morbidity and mortality among all age groups, and injuries from RTA is the most common cause of disability in the developing world.

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Religion plays a major role in the life of most people from the Indian subcontinent. Although religions originated many centuries years ago, the concepts of brain stem death and organ donation are less than a 100 years old. While acknowledging that religions have various denominations and may have varying opinions within them, this article attempts to provide a balanced view of how the major religions in India view these concepts of modern medicine.

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Socioeconomic inequalities in oral health can be defined as the differences in the prevalence or incidence of oral health problems. We assessed the pooled estimate of prevalence of oral diseases among different socioeconomic status (SES) in India by including all articles published up to December 2016 with the prevalence of the oral diseases in SES population using the confined research terms in databases of PubMed and Google Scholar. All articles which had assessed the dental caries, periodontal disease, malocclusion, and oral cancer in different socioeconomic groups were collected. Out of 209 articles retrieved, 19 studies were included. The pooled estimate for mean DMFT for upper, middle, and lower SES status was 3.1 (95% confidence interval [CI] 3–3.1), 2.6 (95% CI 2.6–2.9) and 3.05 (95% CI 3.05–3.04). The prevalence of periodontal disease for (upper SES 12 [95% CI 11–12], middle SES 28 [95% CI 28–29] and lower SES status 60 (95% CI 59–60)] and in (Kuppuswamy scale Upper SES 22 [95% CI 21–22], middle SES 24 (95% CI 23–24] lower SES status 28 [95% CI 27–28]). Our analysis shows that the SES was inversely proportional to the oral diseases. There was a minor variation between DMFT between groups which may be attributed to the lack of large number of studies assessing the SES and dental caries. The pooled estimate of the mean DMFT across the SES status was inconsistent.

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Organophosphorus pesticide self-poisoning is an important clinical problem in rural regions of the developing world and kills an estimated 200,000 people every year. Unintentional poisoning kills far fewer people but is a problem in places where highly toxic organophosphorus pesticides are available. Medical management is difficult, with case fatality generally more than 15%. However, consensus suggests that early resuscitation with atropine, oxygen, respiratory support, and fluids is needed to improve oxygen delivery to tissues. The role of oximes is not completely clear.

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Background: India is a country with multiracial societies having diversity in culture. This can have a significant role in influencing patient's perception related to appearance, ethnicity, quality of dental care, and verbal and nonverbal communication of dentists. This research principally focused on the assessment of patient's perceptions with regard to dentist's demeanor and its role in nonverbal communication which, in turn, will affect their future dentist–patient relationship. Aims and Objective: To assess attitude of children and adults toward's the physical attributes of dentist and its association with reliability, comfortability and anxiety.Materials and Methods: 600 children and 1500 adults participated in a cross sectional observational study to assess the perception of patients regarding the physical characteristics of dentist. A set of questionnaire dealing with the physical attribute was designed in English, local (Marathi) and national language (Hindi). The participants were also asked to assess the reliability, comfortability and their anxiety level based on the persona of the dentist. Results: Results of the study showed that male dentist with short hair, clean shaven and fair complexion was most desirable. Male dentist with dark complexion, stubble and bald was least preferred. Female dentist having fair complexion wearing light makeup, jewellery with hair tied neatly was found to be most desirable. Dark complexion female wearing heavy makeup and jewellery with coloured hair was found to be least desirable. Conclusion: These results will help in developing a proper professional dentist persona for effective and efficient patient management. Limitations of the study are considered.

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Background: Patients with chronic liver disease (CLD) may be more susceptible to drug-induced liver injury (DILI) through reduced drug clearance, aberrant metabolism, altered excretion, or impaired adaptive responses. The diagnosis of DILI may identify a reversible cause for acute decompensation. Aim: The aim was to study the profile and outcomes of DILI in CLD patients. Patients and Methods: A total of 400 consecutive in patients with CLD who had been received antibiotic therapy between September 2015 and April 2016 were prospectively studied for features suggestive of DILI. The Naranjo Adverse Drug Reaction (ADR) Probability Scale was used for identifying ADRs in CLD patients. Results: Sixty-three (15.8%) patients were identified by Naranjo Scale. The most common etiology of CLD in these patients was alcohol (49.2%); hepatitis C virus (7.9%), NASH (4.3%), cryptogenic (14.3%), and hepatitis B virus (5.6%) were other common causes. DILI was more common in Child class C (52.4%) as compared to Child B (30.2%) and Child A (17.4%). Thirteen (20.6%) patients had hepatitic, 17 (27%) had cholestatic, and 33 (52.45) had a mixed pattern. There were six cases with DILI due to anti-tubercular treatment. Clarithromycin (9 cases), clindamycin (9 cases), amoxicillin-clavulanate (7 cases), and co-trimoxazole (5 cases) were the most common antibiotics causing DILI in CLD patients. Forty-three (68.2%) recovered, 11 (17.4%) expired, 3 (4.7%) developed acute on chronic liver failure, and 2 (3.1%) underwent liver transplant. Conclusions: Definitive diagnosis of DILI in CLD patients is difficult, and it is often a diagnosis of exclusion. Exposure to a potentially hepatotoxic agent, the temporal profile of liver function test changes after initiation and withdrawal of antibiotics is useful pointers. Early diagnosis of DILI, even if not definitive, may help in timely intervention and affect outcomes in CLD patients.

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Background: As community-based surveys require energy and time, information surveillance of nutrition rehabilitation centers (NRCs) can be used to assess the nature and degree of risk factors for children with severe acute malnutrition (SAM). Therefore, the current study was planned to assess the degree of association of known risk factors for SAM among children admitted in NRC of a tertiary hospital from the northern state of India. Materials and Methods: Case–control study design was adopted where 50 children with SAM (cases) were recruited from NRC and 50 without SAM (controls) were from an immunization clinic of a tertiary center. A pretested structured interviewer-administered questionnaire was used to collect data from cases and controls. Results: Type of house, status of water and sanitation, simple exponential smoothing, method of birth, birth order, initiation and frequency of breastfeeding, colostrum intake, and profile of diarrhea and acute respiratory infection were statistically similar among cases and controls. Logistic regression analysis observed SAM had significantly high odds for risk factors like mean age of mother at birth (1.4, 1.0–1.9), low birth weight (LBW) (8.7, 2.1–35.3), and bottle feeding (6.3, 1.2–14.2), whereas exclusive breastfeeding (0.2, 0.4–0.4) and fully immunization (0.07, 0.5–0.001) had significantly low odds. Conclusion: Advancing age of mother at the time of delivery, LBW, poor rate of exclusive breastfeeding, and high rate of bottle feeding are significant associated factors for SAM in the study area. Reasons for LBW and reasons for bottle feeding need to be targeted in the study area to reduce SAM among children <5 years of age.

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Objective: Stroke is one of the largest public health challenges in India. Several factors have been implicated for stroke. The present paper aims to explore associated factors from nationally representative data. Among different variables, smoking, alcohol, smokeless tobacco (SLT), second-hand smoking (SHS), use of clean fuel, and economic condition were considered. Methods: Data were taken from three reports – National Family Health Survey 4, Global Adult Tobacco Survey 2: India 2016–17, and India: Health of the Nation's States. The state-wise analysis was done. Spearman's correlation coefficient and multivariate linear regression were used. Results: Five states from the eastern part of India, viz., West Bengal, Odisha, Tripura, Assam, and Chhattisgarh, recorded the highest burden of stroke. The use of SLT was significantly related to stroke burden (r 0.476). Clean fuel and better economic conditions were found to reduce stroke burden (r S722;0.449 and − 0.363, respectively). SLT (B 21.029, P = 0.011) and SHS at work (B 25.905, P = 0.030) were associated with stroke burden significantly. Conclusion: States with the highest proportion of SLT need special intervention to reduce stroke burden in the country.

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Introduction: Basic education about nutrition can be extremely beneficial for medical and dental professionals. It is very important that, dental students are taught about nutrition during their course of study as this will help in developing a holistic approach in treating patients. As limited literature is available regarding the nutritional knowledge among dental students, the present study was done to assess the same among students in a dental teaching institution. Materials and Methods: The awareness of dietary recommendations, knowledge of food sources and nutrients and diet–disease relationship was assessed among clinical students of a dental teaching institute in Kerala, through a 13-point self-administered questionnaire. Analysis was done based on two groups (undergraduate [UG] students and post-graduate [PG] students). Results: A total number of 140 responses were obtained. UG students comprised 31.4% while PG students comprised 68.6% of the study population. Majority (>75%) of the participants in both groups (UG and PG) felt that there is a need to consume more vegetables and fibers and less amounts of sugary and fatty foods. Among the PG students, most respondents (36%) opined that sugar contained more calories for the same weight while 34% of PG students and 44% of UG students reported that starchy food contained more calories. While more than 95% of participants associated diabetes to sugar consumption, there was a mixed response for kidney disease (47.7% in PG and 53.1% in UG; P < 0.026) and heart diseases (40.9% in PG and 38.5% in UG), respectively. Conclusion: The knowledge among dental students about dietary recommendations, knowledge of food sources and nutrients and diet–disease relationship was found to be satisfactory.

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Diabetic wounds, especially with exposed bones, are notorious to cause complications. Various drugs and substances have been tried by different researchers in their quest for early painless healing. We report our patient with peripheral vascular disease (PVD) and chronic nonhealing wound with exposed bone successfully treated with autologous platelet-rich fibrin (PRF). Our patient with a diabetic foot ulcer and PVD underwent an amputation of the great toe. His wound could not be closed, and there was exposed bone on the floor of the ulcer. Regular treatment may have caused nonhealing, osteomyelitis, and spreading gangrene. His PVD contraindicated a vascular flap cover. Hence, we tried the use of autologous PRF on the wound. The hospital stay was minimized, adjuvant procedures were not needed, and the wound healed well in 4 weeks. PRF is a very economical and safe adjuvant in the fight to treat difficult wounds.

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Background: Basic science subjects are usually taught during the first and second academic years of the Undergraduate training with minimum or no integration with the clinical subjects, thereby creating a compartmentalization within the curriculum. The students have difficulty in understanding the concepts and depend on their ability to memorize facts for diagnosing various disease conditions. Aims and Objectives: To evaluate and compare the Effectiveness of Integrated teaching on diagnostic accuracy in Oral radiology among dental students. Material and Methods: A total of 46 students were randomly divided into 2 groups – Integrated basic science group (BSG) and segregated group (SG). Learning materials included sets of intraoral periapical radiographs and lecture based classes on radiographic features of a normal tooth, periapical abscess, periapical granuloma and periapical cyst. BSG students were taught regarding the radiographic appearance and the cause for such appearance in the radiograph. SG students were only explained regarding the radiographic features of these entities. Following the discourse, two tests - Diagnostic test (multiple-choice questions) on the day of lecture, followed by a memory test (spot diagnosis and match the following) one week later - were done to assess the level of understanding among the students. Statistical analysis was done using Students's t – test. Results: BSG students outperformed both in diagnostic test and memory test when compared to SG students. Conclusions: Integrated teaching has been found to be an effective method in enhancing diagnostic accuracy in Oral radiology and also improving the ability to memorize concepts among dental students.

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Background: As per the World Health Organization Global Tuberculosis (TB) Report 2019, there were an estimated 10.0 million new TB cases worldwide in 2018, with India (27%) having the maximum burden of the disease. Drug-induced liver injury (DILI) due to antitubercular treatment (ATT) is a serious adverse effect and a major cause of discontinuation of ATT, leading to increased drug resistance, morbidity, and mortality. Methodology: This was an observational study that was conducted at a tertiary care center in South Maharashtra having a dedicated TB nodal center. All newly detected cases of pulmonary and extrapulmonary TB and cases of TB after relapse/failure/treatment after default, who reported to this nodal center from January 2019 to June 2019 and in whom Category 1 and Category 2 ATT was started as per the Revised National Tuberculosis Programme protocol, were enrolled in this study. Results: Out of 100 enrolled patients, 10 (10%) were diagnosed to have ATT-induced DILI, which is concordant with other studies. No deaths were recorded. However, there was no statistically significant difference between male and female patients who developed DILI (12% males vs. 8% females). No correlation was found with body mass index or alcohol consumption. Conclusion: A fine balance should be struck between unnecessary discontinuation of ATT and continued safe treatment. Patient and staff education, careful selection of regimen, and close monitoring of risk factors will minimize cases of DILI.

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