Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
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Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Professor and Head
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Saraswati Dental College
Lucknow
On Sep 2018




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Best regards,
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Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
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Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2012 | Month : April | Volume : 6 | Issue : 2 | Page : 239 - 242

Transabdominal Saline Contrast Sonohysterography: Can It Replace Hysterosalpingography In Low Resource Countries?

Ademola A. Aremu, Victor A. Adetiloye, Bolanle O. Ib itoye, Da niel A. Adeka nle, Tope O.Bello

1. Corresponding Author, 2. Radiology Department Professor, 3. Radiology Department, 4. Gynaecology department, 5. Radiology Department, Ladoke Akintola University of Technology Teaching Hospital, Osogbo, Osun State Nigeria

Correspondence Address :
Ademola A. Aremu
FWACS, FMCR, M.B ch.B, Radiology Department,
Ladoke Akintola University of Technology Teaching Hospital,
Osogbo, Osun State, Nigeria
Phone: 234(0)8034061218
E-mail: lamode70@yahoo.com

Abstract

Objective: The objective of the study was to assess the accuracy of transabdominal saline contrast sonohysterography (TASCSH) compared to Hysterosalpingogaphy (HSG) in an (our) environment where the gold standard modalities are not readily available.

Study Design: One hundred consecutive patients referred to the radiology unit for Hysterosalpingography and who gave consent for TASCSH as well HSG were included in the study. Sensitivity specificity, positive and negative predictive values of TASCSH were calculated using the widely used HSG as the gold standard.

Results: TASCSH had 100% sensitivity, specificity and positive predictive value for uterine synechiae, hydrosalpinges and bilateral tubal blockade but 31% sensitivity for unilateral tubal blockade. TASCSH also showed 100% concordance with HSG in submucous masses (polyps & Fibroids) and found to be less painful by 80% of the patients.

Conclusion: The readily available, easy to interpret TASCSH is not only safer and cheaper but it’s as accurate as HSG in evaluating the fallopian tubes and uterine cavity in infertile patients. We advocate its use as replacement for HSG in environment like ours where Hysteroscopy, MRI, positive contrast sonohysterography, transvaginal probes and skill are not readily available.

Keywords

Transabdominal, Saline contrasts Sonohysterography, Hysterosalpingography, infertility, developing countries.

Introduction
Female infertility is associated with high incidence of uterine cavity and fallopian tube pathology (1),(2). therefore various methods are available for structural evaluation of female reproductive system. Although, Hysterosalpingography used to be the mainstay of evaluation of the female genital tract for several decades, Hysteroscopy and laparoscopy with chromopertubation (HLC) is now the gold standard because of its improved ability to assess the uterine cavity, establish the tubal status and possibility to proper treatment (3). Also, it (HLC) does not utilize ionizing radiation.

HLC and Magnetic resolution Imaging (MRI) are not readily available in Nigeria and other low resource (developing nations) and their cost is beyond the reach of the poor and middle class who constitute the majority of the population. However, a good alternative to HLC and MRI is sonohysterography (though not presented as the gold standard) because of its similar diagnostic accuracy with hysteroscopy, its less invasiveness, absence of radiation and non utilization of iodine contrast (4). Although Sonohysterography was first described by Parson and Lence in 1993, (5) using saline contrast infusion and transvaginal scan, the procedure had undergone several modifications from the initial use of first generation agents (air ± Saline) to second generation agents like Sonovue and Definity with less solubility and diffusibility but longer duration of visualization allowing for easier evaluationof the tubal course (6).

Furthermore, contrast-tuned imaging (CnTI) Biosound ultrasound software has been developed to detect only sound waves from the positive contrast agents thereby limiting interference from bowel gas and other hyperechoic signals from pelvic organs (3). Sonohysterography has replaced Hysterosalpingoraphy as the first line investigation in the developed countries because of its numerous advantages (4) and advancement (3). However, in Nigeria, the positive contrast agents are not available, transvaginal probes are only found in few tertiary institutions and skilled personnel are not many; hysterosalpingography still remains the mainstay and frontline investigation of infertile patients in our environment while sonohysterography is rarely done. We therefore decided to assess the diagnostic accuracy of the available transabdominal saline contrast sonohysterography (TASCSH) with the Hysterosalpingography (HSG) with the aim of taking a small step forward to replace HSG with TASCSCH as the first line diagnostic test in our environment.

Material and Methods

Most of Two hundred and fifty consecutive patients referred to the radiology department of Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife for Hysterosalpingography who consented were recruited for HSG and TASCSH. Ethical approval was obtained from the hospital’s ethical committee. One hundred patients were included in this study after excluding those whofailed to complete the two procedures , those with acute pelvic inflammatory disease, bleeding per vaginam, recent dilatation and curettage and refusal to be recruited for the study.

TASCSH and HSG were conducted for the same patient by different radiologists, each blinded to the results of the other study. TASCSH was performed in the early mild proliferative menstrual cycle as previously described (7). Preliminary transabdominal scan was done in full bladder with a 3.5MHz curvilinear probe to assess the uterus, adnexae and Pouch of Douglas. Through an aseptic procedure, a folley’s catheter with introducer (size 8-12 FG) was introduced into the cervix with sterile water distention of its balloon for retention. Warmed normal saline (to room temperature) was introduced by an assistant while the radiologists did the scanning and reporting. HSG was performed on the 10th day of menstrual cycle to avoid radiation of unfertilized ovum, damage to organ genesis in the recently implanted embryo (8). This technique of hysterosalpingography had been previously described (9). Stastical analysis was done using SPSS 13 and positive/negative predictive value, sensitivity and negativity etc were calculated; the findings on both procedures. (TASCSH and HSG) were also compared looking for concordant and discordant features.

Results

In this prospective study, one hundred patients had both TASCSH and HSG and were included. The mean age of 30.25 ± 4.5with the age range of 20-45years and majority of the patients i.e 55(55%) were between 26-30years of age. All the patients complained of pain during HSG; ranging from mild 20 (20%)patients; moderate in 10 (10%) patients and severe seventy patients (70%) in contrast to TASCSH in which majority (85%) of the patients complained of mild pain and 15 (15%) complained of moderate pain, (Table/Fig 1). Twenty minutes after HSG, 20(20%) patients still complained of pain while only 2 (2%) patients complained of abdominal pain, twenty minutes after TASCSH. A significant proportion 80 (80%) of the patients, described HSG as being more painful while 10(10%)patients felt the experience was the same and the remaining 10(10%) patients were unsure. However, none of the patients felt TASCSH was more painful than HSG.

Uterine synechiae were demonstrated by the two procedures and they showed 100% concordance rate (Ten patients in both studies). The sensitive, specificity and positive predictive value of TASCSH in this regard was 100% respectively. For tubal pathologies, both studies showed 100% concordance and 100% sensitivity, specificity and positive predictive value for bilateral tubal blockades seen in 5 patients; and for Hydrosalpinges in twenty patients. However for unilateral tubal blockade, the sensitivity of TASCSH is rather low 31%. A total number of thirty (30) leiomyomas/polyps were seen in 24 patients with 3 of the patients having multiple lesions. TASCSH and HSG showed 100% concordance in submucous lesions (fibroids/polyps) – eight lesions, though differentiation into submucous polyps (2) and submucous fibroid (6) by TASCSH was not possible on HSG. For extracavitary fibroids, six of the twenty-two visualized on TASCSH were not seen on HSG.

Discussion

Although the technique of Sonohysterograhy had undergone several modifications and improvement ever since its advent in 1993 (3),(5), usage of specialized catheters to introduce positive or negative contrasts during transvaginal scan remain a constant feature. Also, most authors agree that sonohysterography should be carried out in the early/mid proliferative phase of the menstrual cycle because the endometrium would be thinnest at this period and focal lesions would easily be detected and false positive finding avoided (9). The TASCSH in this study was carried out at the same phase of menstrual cycle. HSG, also, was done around the 10th day of the menstrual cycle to avoid radiation to unfertilized ovum and damage to organ genesis (10).

However, unlike most investigators our ultrasound scanning was done with a 3.5mH2 curvilinear transabdominal probe which is the most commonly seen in our environment and the patients had full urinary bladder. Also, Foley’s catheters with introducer sizes 8-12 FG and/or Leach Wilkinson’s cannulae were used instead of special catheters like 5F HSG Catheter (3),(9), cervical vacuum cup cannula2, HSG double lumen catheter (2),(5) F Hysterosonography Elliptosphere catheter set (11) etc. The discomfort from the full urinary bladder, non utilization of conventional catheters which necessitated the use of tenaculum might have resulted in mild to moderate pain felt by the patients in TASCSH. The pain however disappeared in almost all the patients within twenty minutes of completing the investigations while in HSG, the pain was more (than TASCSH) and persisted in 20% of the patients, twenty minutes after. The positive contrast agents and special ultrasound soft wares described by Danielle E et al (3) are not available in our environment so the cheap, readily available normal saline was used.

In this study, pelvic inflammatory disease (P.I.D) was ruled out by taking relevant history and carrying out vaginal examination to reduce cost. However, some authors actually did microscopy, culture and sensitivity of endo cervical swabs before the procedure (9) while others like Sergio Res Soares (4) placed the patients on prophylactic antibiotics.

Neither antibiotics nor analgesic were used in our study and none of the patients had post preoceedure infection though some researches placed their patients on analgesics (4),(9). All authors with similar study used hysteroscopy as the gold standard (3),(4) but this is hardly available in the country. TASCSH showed 100% concordance with HSG in the detected intrauterine adhesion (synechiae), therefore the sensitivity, specificity and positive predictive value of 100%. Sergio Res Soares et al (4) also reported same accuracy for TVSCSH and HSG in their study with Hysteroscopy as the gold standard.

Samuel E. Brown et al (12) had also reported no significant differences in diagnostic accuracy of saline infusion hysterosalpingography, HSG and outpatient Hysteroscopy in their prospective, randomized study of infertile patients. Other authors (5),(13) have also proved that sonohysterography showed 100% concordance with hysteroscopic diagnoses of uterine synechiae. It could therefore be inferred that the accuracy of TASCSCH in assessment of uterine synechiae is comparable to TVSCSH (and HSG). The synechiae seen in this study showed similar appearances to previously described features (4),(5),(7),(13). TASCSH and HSG showed 100% concordance in submucous masses (polyps/fibroid) seen although TASCSH was able to differentiate polyps, described as being of mostly homogenous echoes from fibroid. Soares (4) reported that the diagnostic accuracy of SCSH for submucous masses was the same with Hysteroscopy and better than HSG while Samuel E. Brown et al (12) did not record significant difference in the detected submucous masses for both procedures and operative hysteroscopy.

For extracavity fibroid (subserous and intramural), we found that some of the visualized twenty-two lesions were not seen on HSG. This was because of their relatively small size and /or eccentric location (away from the cavity) in the intramural region. Goldberg JM et al reported similar cases of extracavity myomas demonstrated by sonohysterography but not visualized on HSG (9). The fact that no congenital anomaly was seen in the two procedures in our study was not surprising considering their rarity (7). De Fence et al (2) found HSG more accurate in describing the six congenital anomaly seen in their study. However, Artur Ludoin et al (14) stated that SCSH correctly identified actuate, septate, bicornuate uterus and showed highest positive correlation with hysterolaparoscopy obtained diagnosis. They further stated that SCSH showed perfect accuracy, better sensitivity and specificity (compared to HSG) in septate and bicornuate uterus.

Both studies showed 100% concordant for bilateral tubal blockade. Similar finding was reported by Danielle E et al (3) in evaluation of 102 fallopian tubes with sonohysterography (done with positive contrast with special ultrasound soft ware) and HSG after hysteroscopic sterilization. The three cases of unilaterally tubal blockade seen on HSG were missed on TASCSH. This was because in each case, the contralateral (patent) fallopian tube would have shown spillage into the POD/peritoneal cavity. A positive ultrasound contrast would have made a difference in this respect, but it’s not available in our country (3),(12). Both studies showed 100% concordance in Hydrosalpinges, with sensitivity, specificity and positive predictive value of 100% for SHG. The mucosal folds’ thickening seen in some of the hydrosalpinges were shown by the two procedures. Perifmbrial and pelvic adhesion were seen in ten (10%) of our patients on HSG but not appreciatedon ultrasound. Also, only one case of suggestive ovarian cyst was seen on HSG while TASCSH showed ten cases of ovarian cysts.

Debrah et al (10) and Goldberg et al (9) also reportedly visualized adnexal masses, hitherto unnoticed on HSG, on SHG in their studies. Though Samuel E Brown et al (12) did not find significant difference in duration of the two procedures (5.3min for HSG and 6.1min for SIS), the average time for HSG in our centre was found to be 20minutes while an average of 10 minutes was spent on TASCSH. The difference might be due to the waiting time for HSG film to be processed with automatic processors and the cumbersomeness in passing the unconventional catheters used. TASCSH cost N 5,000 (about 33US Dollars) while HSG cost about N 10,000 (66US Dollars) proving again the cheapness of the former.

Conclusion

The cheaper, readily available, time-saving, less painful and safer
means of evaluating the uterine cavity and fallopian tubes is SCSH.
Its diagnostic accuracy; even when done through a transabdominal
scan is remarkably high and compared positively with HSG. We
therefore advocate its routine use as first time investigation of
infertile patients in our environment.

References

1.
Ibekwe PC, Udensi A.M, Imo A.O Hysterosalpingographic findings in patients with infertility in South Eastern Nigeria. Niger J Med 2010 April – June; 19 (2) : 165-7.
2.
De Fence C, Porfiri L.M, Savelli S et al. Infertility in Women: Combined Sonohysterography and Hysterosalpingography in the evaluation of the Uterine cavity. Ultraschall in Med 2009; 30:52-57.
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DOI and Others

DOI: JCDR/2012/2942.3986:2007

DECLARATION ON COMPETING INTERESTS:
No competing Interests.


Date Of Submission: Jan 15, 2012
Date Of Peer Review: Feb 02, 2012
Date Of Acceptance: Feb 15, 2012
Date Of Publishing: Apr 15, 2012

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