COVID -- ANTISEPTIC JOURNAL

 

 

 

 

 

 

 

 

40 + 15  HYPOXIA  TEST  in  COVID-19

 

RAMA  PRASAD  T.

 

Dr. T. Rama Prasad,  

Formerly:  Medical Superintendent (Special) of RTS & IRT Perundurai Medical College and Research Centre, 

Perundurai, Tamil Nadu, India.

  

Presently:  Director of ‘PAY WHAT YOU CAN’ Clinic, Perundurai, Erode District, TN – 638052.  drtramaprasad@gmail.com

 

 

 

 

 

 

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       A MONTHLY JOURNAL OF MEDICINE AND SURGERYSN 

Vol. 117     No. 12     DECEMBER  2020    ISSN  0003 5998

             Indexed in  IndMED       Email: admin@theantiseptic.in    www.theantiseptic.in

 

THE ANTISEPTIC - A MONTHLY JOURNAL OF MEDICINE & SURGERY 

Vol 117 No 12                     CONTENTS                  DECEMBER 2020 

(Pages : 1-52) 

EDITORIAL:                 
Reflex Sympathetic Dystrophy ........................................................07 

GENERAL
:

Excipients ingredients in the Medication world    Sanjay Agarwal ......................................08 

Why NMC is required if there was already an MCI?    Rishi Kant Gupta, Vijay Thawani .....11 

40 + 15  HYPOXIA TEST  in COVID - 19
        Rama Prasad T . ..............................................13

CASE REPORT: 

Idiopathic Livedo Reticularis in Covid Pandemic Era
Subbu G.R., Anita Nambiar, Hari K...18

ALTERNATIVE MEDICINE
:

Relevance of Indian butter tree as a resource of herbal medicine      Nautiyal B.P. ............21 

The role of herbal agent (Cryptolepis buchanani) in bone healing Richa Gupta, Vibha Singh, Amiya Agrawal, Ranajana Singh,
Abhaya Narayan Tiwari, Mahesh Pal .....................................24 

Obesity: Ayurvedic Perpespective
Anuradha D. Kamble, Kishan Sabale ................ ...............31 

Use of Swarna Prashana as an Immune Modulator in Post Operated Cases of Neuroblastoma: A Conceptual Study
Mahadev P. Mangane, Kaveri Hulyalkar, Preeeti Agraharkar, Somanath Ginni .

Gout: A clinical approach
Abhay Mahavir Khot, Raviteja Pandurang Mane, Amit Ramchandra Shedge ........35 Human Gut Microbiota and Health : A Review
Thamizh Selvam N., Sudhakar D. ..

Occasional Review .....................................................................................................................42 Gleanings ....................................................................................................................................43 Glimpse into history .....................................................................................................................44  Case of the month .......................................................................................................................45  Medi Quiz ....................................................................................................................................46  Index ............................................................................................................................................47

4 

THE ANTISEPTIC   Vol. 117  •  December 2020 

40 + 15 HYPOXIA TEST  in  COVID-19

 

RAMA PRASAD T

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Dr. T. Rama Prasad,  

Formerly:  Medical Superintendent (Special) of RTS & IRT Perundurai Medical College and Research Centre, 

Perundurai, Tamil Nadu, India

 

Presently:  Director of PAY WHAT YOU CAN Clinic, Perundurai, Erode District, TN – 638052.  drtramaprasad@gmail.com

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Specially Contributed to “The Antiseptic”  Vol. 117,  No. 12,  P: 13 – 17,  December 2020

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Abstract

Amidst the doom and gloom,  in its peregrinations and fury, the devil of the vicious virus is marching the mankind to mortuaries, across the globe.  The confounding and perplexing finding is that unidentified hypoxia is the leading cause for the onset of ‘cytokine storms’.  A simple and inexpensive way of detecting the ‘latent hypoxia’ early by a new ‘avatar’ of the old-time exertional desaturation test is described here.  And a brief comment is made on some related aspects of the test.  The test may be used to identify the ’high-risk-prone’ patients among the huge lot of the mild cases of COVID-19 who may be apparently normal at rest, but who may dive down into fatal complications very soon later.  The test may be done even at home and may be helpful in handling other lung and heart diseases too.

 

Keywords:  Latent hypoxia,  Exertional desaturation,  Walk tests,  COVID-19 fatalities

 

 

Introduction

 

The quintessential tough virus alerted health care systems worldwide to focus on identifying the 14% of the COVID-19 patients who may have only mild symptoms but may develop potentially fatal illness rapidly.  It is found that this segment of the patients has hypoxia which does not manifest in symptoms like dyspnea (breathlessness) or discomfort while at rest.  This is called ‘latent hypoxia’ or ‘silent hypoxia’ or ‘happy hypoxia’.    Hypoxia, in this context,  means a degree of oxygen saturation in blood (SpO₂) of less than 94% or an absolute drop of more than 3% from the base line, on physical exertion.  The word ‘hypoxia’ is mostly used to mean ’hypoxemia’, though there is a technical distinction between the two.  Hypoxia relates to insufficient supply of oxygen to the tissues in the body whereas hypoxemia means a low level of oxygen in the blood.  If hypoxia can be detected in the early phase of the disease,  timely interventions can be instituted to save numerous lives. 

 

 It is confusing and confounding that this virus ‘short-circuits’ these patients from OPD to ICU by deteriorating them into dire complications swiftly without letting them exhibit the usual warning signs.  It may be due to an unusual and speedy drop in blood oxygen level.   Perhaps, if the ‘latent hypoxia’ was detected at an early stage (and if the US didn’t rest on a parade of fallacies and follies in combating Corona), as many as 230,000 Americans might not have died within a short span of some months due to a single disease in a country which has the supreme status of crème-de-la-crème of medical care on the planet.   SARS-CoV-2 virus which causes COVID-19 disease has the protean ability to cause myriad clinical manifestations ranging from mild illness to speedy death.  But some of the deaths can be prevented by  ‘unmasking latent hypoxia’ by a simple test which seems to be a key triage guideline.  Hence,  it is imperative to have an easy tool to screen for the ‘latent hypoxia’ at the earliest, at the primary care centre or even at home. 

 

It is in this context that a ‘hybrid hypoxia’ test, ‘40 + 15 Hypoxia Test’ (‘40+15 HT’), is conceived by me.  This is just a variant and a combination of the old tests for ‘Oxygen Desaturation’ like ‘Walk Test’ and ‘Step Climbing Test’ which are used for preliminary assessment of submaximal level of cardio-respiratory functional capacity in chronic lung diseases.  This may have a sense of déjà vu about it. The test is purposed to identify mainly the ‘latent hypoxia’ in patients of mild COVID-19  of whom some may require a swift shift into ICUs – a kind of stratification.  

 

The test involves walking 40 steps briskly on an even surface (plain floor) and then going up and down a 6-inch-high step for 15 times and measuring SpO₂, heart rate and blood pressure before and after the test.  If there is a fall of more than 3% of the SpO₂, the patient is better be taken up for further investigations and higher care.   A disease of this fury was never encountered in my half-a-century of practice in respiratory medicine.  I had used this test for my online patients and the results are gratifying.  The data may be published in The Antiseptic  in due course of time.  It is suggested to the doctor-readers and researchers to try this test and report their findings, as the ‘40+ 15 HT’ requires validation and documentation.

 

Technical aspects of the ‘40 + 15 HT’

 

·      The patient has to briskly walk (not jog or run) 40 steps on an even surface (plain floor), followed by going up and down a step (a 6-inch-high stool or a wooden box or a step) for 15 times. 

 

·      Oxygen saturation (SpO₂ % by pulse oximetry), pulse, blood pressure, scale of dyspnea and fatigue (see the Borg scale below) before and after the test,  and other elements as listed in the APPENDIX below are to be recorded in the ‘Worksheet and Report’.  If available, ECG may be taken before and after the test.  Results of D-dimer, serum ferritin, CRP, Lactic dehydrogenase, prothrombin time, IL6, etc., if already available, may be entered in the worksheet.

 

·      If the patient develops chest pain, leg cramps, severe breathlessness, severe sweating or giddiness during the procedure, the test is to be aborted.

 

·      The consistent recommendation that the patients and the technicians wear a mask cannot be ignored for this test.  Inevitably, mask-wearing may affect the subjective feeling of dyspnea and the objective measurement of oxygen saturation to some extent.

 

Interpretation

 

·      The test is considered positive for hypoxia if the SpO₂ drops to below 94% or drops absolutely by 3% or more from the baseline, after the physical exertion.  A positive test   calls for intensive supervision and high medical care.

 

·      Another parameter is the subjective feeling of dyspnea and fatigue (on a scale of 0 to 5 on a modified Borg scale:   0 = Nil;  1 = Very slight; 2 = Slight;  3 = Moderate;  4  = Severe;  5 = Very severe).  The patients whose self-scoring is on the higher side require special medical care.  The changes in the heart rate and blood pressure would be taken into consideration by the doctor.

 

APPENDIX

 

‘40 + 15  HT’  Worksheet  and  Report

 

Patient’s Name:  _______________________              Patient’s  ID  #  __________

 

Gender:  ________      Age:  _____  years      Race:  _________  Date:  __________

Height:   ______ cm     Weight:  _____ kg       

 

Medications taken before the test  (dose & time):  _________________________

Supplemental oxygen during the test:    Nil        Yes   L / min,  type   ____________

 

                                 BASELINE                                             END  OF  TEST

 

SpO₂                   _________   %                                        __________       %

Heart Rate       _________   / minute                            __________       / minute

Blood Pressure  ________   mm Hg                               __________       mm Hg

 

Dyspnea (breathlessness):  _____________               __________        (Borg Scale)

Fatigue:   ___________________________               ___________       (Borg Scale)

 

Stopped before 40 + 15:         Yes       No       If yes, reason:  __________________

 

Other symptoms at the end of exercise:  Angina (chest pain);  Dizziness;  Leg pain

( if present, the character and severity:  ________________________________ )

 

Number of walking steps:  ________             Number of climbing steps:  ________

Note other tests, if done:  ECG;  BMR;  BMI;  BF%; Body type:  Lean / Normal / Obese

                                      CRP; D-dimer; Ferritin; IL6, etc.

Technician’s comment:  ________________________________________

INTERPRETATION:  SpO₂  ________   Dyspnea:  _________    Fatigue:  _________

 

Doctor’s  comment:  ___________________________________________

 

The need for the test

 

One of the important clinical assessments in the management of COVID-19  is to identify this critical hypoxiaearly to initiate a higher level of care at the earliest.  The rationale of this simple ‘40 + 15 HT’ testing of overall function of lungs, heart and circulation is to identify those among the mild cases of COVID-19 who are likely to progress to severe illness, and to make a timely transfer of them to a higher level of care.

 

There is a dire need to ‘risk-stratify’ those likely to recover uneventfully from those who most likely require advanced medical care.  Every one of the huge numbers can’t be evaluated by advanced technology and quickly, and it would certainly be a prodigal waste of meagre resources to do so.   What is practicable and desirable is to make use of the simple and inexpensive tests for oxygen desaturation which are already in use to monitor and manage chronic lung diseases over a long time.   These are only compromising substitutes and complementary to standard cardiopulmonary exercise testing, not a replacement for it.  This situation calls for a cost-effective, reliable and simple screening test.  It is here, in this context, that the simple oxygen desaturation test,  ‘40 + 15 HT’,  fits in to measure inducible hypoxia.   If appropriate escalation of level of care and treatment is initiated at this stage based on the results of this simple test, numerous lives can be saved.  

 

Indications

 

·      The test is indicated in all COVID-19 positive / suspected patients and in all patients of lung and heart problems, who are not hypoxic and short of breath at rest. 

 

·      Progress may be assessed for in-patients on a day-to-day basis and when the test becomes positive, the patients may be shifted to ‘High Dependency Unit (HDU)’ or ‘Intensive Care Unit (ICU)’.  The test may also prompt the doctors to seek additional laboratory tests like CRP, D-dimer, Ferritin and IL6.

 

·      This test may be used as a guidance to decide about the fitness of a patient for discharge from the hospital.

·      At present, due to the risk of infection involved to the technician and others around,   during the procedure,  the classic Pulmonary Function Test (PFT) is being avoided during this ‘Corona period’.  Breathing in and out forcibly into the PFT machine (along with the possibility of a violent cough) may transmit the disease. In such circumstances,  the ‘40 + 15 HT’ may be done safely to evaluate the lung function to some extent. 

 

·      The ‘40 + 15 HT’ may be used as part of a routine general medical check-up.

 

Contraindications

 

·      The patients whose SpO₂ is less than 94% should straight away be referred for higher care without doing this test.  

 

·      So also, the patients who are breathless at rest, or known to be having unstable angina, heart disease of valves, pulmonary hypertension or Eisenmenger’s  syndrome may be sent to specialists without doing the test.  A resting heart rate of more than 120, a systolic blood pressure of more than 180 mm Hg,  a diastolic blood pressure of more than 100 mm Hg,  pregnancy,  and those suffering from joint problems of lower limbs are relative contraindications. 

 

Rationale of  ‘40 + 15 HT’

 

The rationale of combining ‘walking’ and ‘step climbing’ is twofold.   Firstly,  it provides for incremental load of exertion -- increases the intensity of the exercise gradually  (walking is less strenuous;  step climbing is tough) --  giving a chance not to proceed to the ‘step climbing’ (which may result in precipitation of cardiopulmonary compromise) when the patient feels very breathless and fatigued while walking itself or after climbing up and down a few steps.  

 

Secondly, the combination may have the ‘hybrid advantage’ of optimizing the two forms of physical exercise.  Some studies are based only on ‘walking’ and some on ‘climbing steps’.  The “40 + 15 HT” is the only one combining these two.

 

This test may be used routinely in all the respiratory care centres what with the possibility of COVID-19 becoming a SYNDEMIC (a combination of epidemics due to different microbes), especially in winters.

 

The merit of the ‘40 + 15 HT’ is not yet publicly documented and validated, though my private studies testify its usefulness.  Further studies are required to establish its usefulness in COVID-19 and other lung diseases.   Despite the vast differences between the advanced cardio-pulmonary exercise tests and the simple ‘oxygen desaturation’ tests,  some good correlations between them were reported.  For example, a significant correlation was found between the simple test, ‘6 MWT’ and the ‘peak oxygen uptake’ test in patients with end-stage lung diseases (r = 0.73).^{1, 2} Moreover, a study indicated that these simple tests provided more information that may be a better index of the patients’ ability to perform daily activities compared to what was provided by ‘peak oxygen uptake’ assessment.³

 

To some extent,  a global assessment of the cardio-pulmonary reserves and the cardio-respiratory effort tolerance is possible with this oxygen desaturation test, ‘40 + 15 HT’.  The test may also predict, though not precisely,  the anaerobic threshold which is a reflection of the combined efficiency of heart, lung and circulation and may mark the onset of anaerobic metabolism due to oxygen deficit.    While it is naïve to draw conclusions, there is an indirect correlation.

 

Advantages of  ‘40 + 15 HT’

 

·      This ‘40 + 15 HT’ test can be carried out quickly at almost no cost in an ordinary clinical set up by a health worker to identify the highly vulnerable COVID-19 patients who may be looking apparently normal while at rest having more than 94% of SpO₂,  but who may run into serious problems within hours or days.   Their oxygen saturation may fall down by 3% even on slight physical exertion without making them significantly breathless which is the peculiarity of COVID-19.   This test unmasks the latent hypoxia.

 

·      Available are very sophisticated and hugely expensive tests to determine ‘exertional oxygen desaturation’ and to objectively evaluate functional exercise capacity – pulmonary function tests,  maximal cardiac stress testing (Bruce protocol), blood gas analysis, etc.  They provide a very complete high-tech assessment of all the systems involved in exercise performance, but the downside of them, obviously, is that they are unreachable both by distance, time and money for most of the population in the vast swathes of the country.  Hence, the ’40 + 15 HT’ may prove to be a desirable substitute.

 

·      There is no need to measure the distance walked or keeping an eye on the time as is the case with other ‘walk tests’(oxygen desaturation tests).  In fact, the classic ‘6- minute walk test (6-MWT)’, approved by the Board of Directors of the American Thoracic Society, does not essentially measure SpO₂, but evaluates the function by the distance walked.⁴   It is because the ‘6-MWT’  and other similar tests (2 MWT / 1 STST / 15 step climbing / 40 step walk test / Shuttle walk test / 10 minute cycling test, etc.) are meant for guidance in chronic lung diseases rather than to identify vulnerable COVID-19 patients. 

 

·      This test doesn’t require sophisticated emergency backup,  as serious complications are unlikely to occur.   For this reason and because of the simplicity of the test, it can be done quickly at home for ‘home-quarantined’ patients to alert them in time,  or as a precautionary check-up for anybody at home.  All the same,  though this test can safely be done by a health worker,  availability of a physician nearby is desirable for emergency care when dealing with patients who are moderately ill. 

 

·      The ’40 + 15 HT’  would also be useful to certify fitness required to discharge a patient.  This test is more dependable to assess hypoxia than those developed for risk stratification like  ‘National Early Warning Signs 2 (NEWS 2) or SOFA score.  This test may be used advantageously in general health check-ups too.

 

 

Dyspnea, fatigue and pathogenesis

 

The ‘40 + 15 HT’ records the Borg scale of DYSPNEA (breathlessness) and FATIGUE at the beginning and end of the test.  During the past eight months (March to October 2020),  there has been a new problem of dyspnea and fatigue at rest and /or on exertion, and also before, during or after treatment for COVID-19.  These symptoms have become more pronounced, during this period, in ‘non-Covid’ cases (like COPD, asthma and other lung diseases) too, perhaps, owing to interruption in treatment schedules due to lockdowns.  

 

The presently available data indicate that the numerous patients recovered from COVID-19 are also facing the problem of shortness of breath and fatigue.  It can be a huge chronic problem in the years to come.  Already, some ‘Covid respiratory rehabilitation centres’ have sprung up anticipating a humongous deluge of respiratory cripples.   And, 'syndemics' (combination of epidemics due to different microbes) may add their own might to our misery.

 

Dyspnea and fatigue may be an expression of disruption of pulmonary and cardiac function.  Dyspnea in COVID-19 is not as simple to explain away as in the cases of COPD, asthma or interstitial lung disease (idiopathic pulmonary fibrosis)  which are diseases mostly of ventilation.  On the other hand,  in COVID-19,  the patients may have near normal ventilation but have significant problems with perfusion and oxygen diffusion because of  inflammatory pneumonitis rather than the classical pneumonia.⁵   There seems to be two main handicaps -- heart’s inability to step up cardiac output and lung’s incapacity to maintain diffusion due to infiltration by COVID-19 and / or due to alveolar capillary micro thrombi in the pulmonary circulation (pulmonary vascular endotheliitis) and myocarditis.  The lung and heart have abundant ACE2 receptors to which SARS-CoV-2 virus gets bound.  

 

The COVID-19 may be comparable to pneumocystis carinii pneumonia (PCP) which shares to some extent the ‘Covid features’ of pathophysiology, acuteness, silent hypoxia, cough, exertional desaturation and CT scan abnormalities.  Both these are diseases mostly of perfusion, not ventilation.  Most importantly,  exertional oxygen desaturation may be demonstrated in most of the cases of COVID-19 in contrast to cases of bacterial pneumonia, tuberculosis or pulmonary candidiasis which may not so clearly show up the desaturation. ^5,6  

 

As such, COVID-19 is a peculiar disease characterized by a tendency for oxygen  desaturation on minimal exertion with disproportional breathlessness.  That’s why we see sudden unexplainable deaths of  ‘happy hypoxia patients’ who are not seriously ill apparently.  It is increasingly becoming clear that many patients have normal pulse oximetry at rest whose readings deteriorate on exertion, though.  A fall of 3% or more in pulse oximetry on exercise is a red signal for intensive care.  

 

Many of the existing patients of chronic lung diseases are an easy prey for a devastating superinfection by COVID-19.  And the cardio-respiratory functions of this segment of the population deteriorate rapidly when attacked by SARS-CoV-2 virus.  It is in this context that ‘tests for oxygen desaturation’ like ’40 +15 HT’ have come to the fore.  They identify potentially serious underlying abnormality and thus save lives through early interventions, not only of COVID-19 victims but also of the other chronically ill cripples.

 

Bitter realities

 

Perplexingly, during this ‘pandemic-induced tailspin’ of economy,  clinical condition of seemingly stable patients deteriorated rapidly, resulting in skyrocketing hospital bills and unexpected fatalities.  One recent typical example is of the internationally popular music maestro, SPB who walked into a huge corporate hospital in Chennai with only mild symptoms.   He rapidly slipped into serious problems and couldn’t come out alive despite intervention with ‘Extracorporeal Membrane Oxygenation (ECMO)’   and 52 days of in-patient treatment.  Chest computerized tomography (CT) imaging abnormalities may occur even in mostly asymptomatic patients, with rapid evolution from a focal unilateral lesion to diffuse bilateral extensive ground-glass opacities in the lungs within a few days.  And, in about a week, severe hypoxemia necessitating ICU care may supervene. 

 

Uncertainty

 

There is no certainty of when this pandemic would be contained.  None knows certainly about specific drugs or a safe and effective vaccine.  There is no silver bullet and absolutely no blitzkrieg to declare a victory over the virus.  The ‘risk-stratification’ strategy and the other suggestions in this paper rely on the application of Bayesian principles in clinical care.   The ’40 + 15 HT’ test may be modified and varied depending on experience and results.   Given the paucity of understanding of the dynamics of COVID-19, as of today,  nothing can be rigid or dogmatic.   Everything that is being done currently in the field of COVID-19  is mostly based on best guesses !   Real world cohorts and algorithms are still in the process of evolution.  COVID-19 has become synonymous with uncertainty.  Bafflingly, a ‘Covid patient’ with mild symptoms is like a ‘Schrodinger’s cat’ – both ALIVE and DEAD !!!

 

References

1.     Cahalin L, Pappagianopoulos P, Prevost S, Wain J, Ginns L. The relation- ship of the 6-min walk test to maximal oxygen consumption in trans- plant candidates with end-stage lung disease. Chest 1995;108:452–459. 

2.     Guyatt GH, Thompson PJ, Berman LB, Sullivan MJ, Townsend M, Jones NL, Pugsley SO. How should we measure function in patients with chronic heart and lung disease? J Chronic Dis 1985;38:517–524. 

3.     Guyatt GH, Townsend M, Keller J, Singer J, Nogradi S. Measuring functional status in chronic lung disease: conclusions from a random con- trol trial. Respir Med 1991;85(Suppl B):17–21. 

4.     https://www.thoracic.org/statements/resources/pfet/sixminute.pdf

5.     Gattinoni L, Chiumello D, Caironi P, et al. COVID-19 pneumonia: different respiratory treatments for different phenotypes? Intensive Care Medicine 2020:1.

6. Smith D, Wyatt J, McLuckie A, et al. Severe exercise hypoxaemia with normal or near normal X-rays: a feature of Pneumocystis carinii infection. The Lancet 1988;332(8619):1049-51.

 

 

 

 

 

A  short list of some of the published articles in The Antiseptic (a premier Medical & surgical journal), 

  The Hindu (a national Newspaper), etc. authored by  Dr. T. Rama Prasad.

 

  1.     DIGITAL  CLUBBING  and  HYPERTROPHIC  PULMONARY  OSTEOARTHROPATHY -  Pathogenesis --
          The  Antiseptic,  Vol. 76.  pp.  213-215,  1979.

  2.     CHILDHOOD  TUBERCULOSIS  - Part I --   The Antiseptic, Vol. 76, pp.  449 - 504, 1979

  3.     CHILDHOOD  TUBERCULOSIS  - Part II --  The Antiseptic, Vol. 76,  pp. 567 - 574, 1979

  4.     STEVENS-JOHNSON  SYNDROME  and  THIOACETAZONE --  The Antiseptic,  Vol. 77,   pp.  99 -102, 1980

  5.     HIGHLY  PURIFIED  INSULINS  -  An Assessment --  The Antiseptic,  Vol. 77,  pp. 3455-347, 1980

  6.     IS  THE  "LOCKDOWN   MEDICINE" TOO  TOXIC ?  --  The Antiseptic,  Vol.117,  No.10,  pp. 13 -15,  2020

  7.     ANTISEPTICS,  DISINFECTANTS   and COVID-19  --  The Antiseptic,  Vol.117,  No.11,  pp. 26 - 28,  2020

  8.     40+15 HYPOXIA  TEST  in  COVID-19 --  The Antiseptic,  Vol.117,  No.12, pp.13 –17,  2020

  9.     THE  CONUNDRUM  of  COVID-19  VACCINES  – The Antiseptic, Vol. 118,  No. 1,   2021

 

  10.     HEALTH  CHECK-UP:  how healthy is it ?  -  The Hindu, Open Page, January 15, 2012 --  

          ……http://www.thehindu.com/opinion/open page/article2801701.ece

  11.     THE  ‘GOOGLE  EFFECT’:  may be good, may be bad  -  The Hindu, Open Page, April 22, 2012 -- 
          ...http://www.thehindu.com/opinion/open-page/article3340116.ece

  12.     OF  TEA,  COFFEE  and  COMMERCE  -  The Hindu,  Open Page,  January 12, 2014  --

          …  http://www.thehindu.com/opinion/openpage/of-tea-coffee-and-commerce/article5567951.ece.

  13.     A  BAD  PATCH  - The Hindu, Open Page,  March 15, 2020 -- 

          https://www.thehindu.com/opinion/open-page/a-bad-patch/article31069356.ece

 

  14.    YELLOW  NAIL  SYNDROME - Chest (U.S.A.), Vol. 77,  p.580, 1980 

            https://journal.chestnet.org/article/S0012-3692(16)40458-7/fulltext

  15.    YELLOW  NAIL  SYNDROME - The Indian Journal of Chest Diseases & Allied Sciences, Vol. 22,  pp. 69-72,  1980.

  16.     DRUG  RESISTANCE  in  TUBERCULOSIS  -  Journal of the Indian Medical Association,  Vol.  64, pp. 264-267,  1975.

 

 References to more articles by Dr. T. Rama Prasad may be found in:  http://drtramaprasad.blogspot.com

                                                                                                                 www.rama-scribbles.com