Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 
  • Users Online: 212
  • Home
  • Print this page
  • Email this page


 
 Table of Contents  
ORIGINAL RESEARCH REPORT
Year : 2020  |  Volume : 17  |  Issue : 4  |  Page : 120-126

The clinical profile and outcome of children with acute malnutrition in a tertiary health center in North-West Nigeria: A 1-year retrospective review


1 Department of Paediatrics, Aminu Kano Teaching Hospital/Bayero University, Kano, Nigeria
2 Federal Medical Centre, Birnin Kudu, Nigeria
3 Department ofFamily Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
4 Department of Paediatrics, Aminu Kano Teaching Hospital, Kano, Nigeria
5 Department of Paediatrics, Federal Medical Centre, Nguru, Yobe State, Nigeria

Date of Submission17-Oct-2019
Date of Acceptance13-Jul-2020
Date of Web Publication19-Oct-2020

Correspondence Address:
Dr. Ibrahim Aliyu
Department of Paediatrics, Aminu Kano Teaching Hospital/Bayero University Kano
Nigeria
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcls.jcls_55_19

Rights and Permissions
  Abstract 


Background: Acute malnutrition is broadly classified as severe acute malnutrition (SAM) or moderate acute malnutrition (MAM). It affects almost 20 million children worldwide, with majority of the cases in developing countries. In Africa, it was estimated that about 5%–15% of deaths in children age ranging from 0 to 59 months are due to SAM. Therefore, this study sought to determine common clinical features and outcome in children with acute malnutrition. Methods: A retrospective descriptive study was conducted at the Federal Medical Centre Birnin Kudu, Jigawa State. Case files of patients admitted into the Emergency Pediatric unit and Ppediatric Medical Ward over the period of 1 year (January–December 2017) with a diagnosis of acute malnutrition were reviewed. Results: There were 123 cases of acute malnutrition during the study period: 53 (43.1%) males and 70 (56.9%) females. There were 103 (83.7%) cases of SAM and 20 (16.3%) cases of MAM. Among the SAM cases, there were 70 (56.9%) cases of marasmus, 10 (8.1%) cases of kwashiorkor, and 23 (18.7%) cases of marasmic kwashiorkor. Infection was the most common morbidity associated with SAM. Relatively death was mostly witnessed in the marasmic kwashiorkor subgroup (17.4%). However, majority of the subjects who spent 1–2 weeks on admission were discharged without complications, while death occurred mostly in those who spent <7 days on admission and this observation was statistically significant (Fisher's exact = 32.351, P = 0.001). Conclusion: Marasmus remains the most common form of SAM, and infection is a common comorbidity; however, majority of our cases were discharged without any noticeable complication.

Keywords: Acute malnutrition, clinical manifestations, complications, moderate acute malnutrition, severe acute malnutrition


How to cite this article:
Aliyu I, Ibrahim HU, Idris U, Michael GC, Ibrahim UA, Mohammed A, Ahmad I, Habib JM. The clinical profile and outcome of children with acute malnutrition in a tertiary health center in North-West Nigeria: A 1-year retrospective review. J Clin Sci 2020;17:120-6

How to cite this URL:
Aliyu I, Ibrahim HU, Idris U, Michael GC, Ibrahim UA, Mohammed A, Ahmad I, Habib JM. The clinical profile and outcome of children with acute malnutrition in a tertiary health center in North-West Nigeria: A 1-year retrospective review. J Clin Sci [serial online] 2020 [cited 2020 Nov 29];17:120-6. Available from: https://www.jcsjournal.org/text.asp?2020/17/4/120/298457




  Introduction Top


Malnutrition is essentially classified into overnutrition, undernutrition, and micronutrient deficiency; however, in most developing countries, the burden of disease is more with undernutrition. Undernutrition is further grouped into severe acute malnutrition (SAM) and moderate acute malnutrition (MAM).[1],[2] MAM precedes SAM; therefore, early identification and treatment will significantly reduce under-five mortality. SAM is common in children under the ages of 5 years affecting nearly 20 million children worldwide, with majority of the cases in developing countries.[1] In Africa, it was estimated that about 5%–15% of deaths in children age ranging from 0 to 59 months are due to SAM, accounting for about 1–2 million deaths yearly.[3] Children with SAM are nine times more likely to die than well-nourished children, and it is recognized as one of the top three nutrition-related causes of death in children under the age of 5 years.[4] In sub-Saharan Africa, the prevalence of SAM in children is about 2%.[5] The Nigeria National Demographic Health Survey in 2013 documented a prevalence of wasting of 18% among Nigerian children with a northwestern region having a higher prevalence of wasting of 27%.[6]

SAM manifests either as severe wasting – defined as mid-upper arm circumference (MUAC) <11.5 cm or a weight-for-height/length <−3 Z scores of the WHO standard growth chart in children aged 6–59 months – or nutritional edema – defined as bilateral pitting edema.[7],[8]

MAM is defined as weight for height between −3 and −2 Z scores.

The etiology of SAM is multifactoral, infections (such as measles, HIV, and diarrhea disease),[9] ignorance, and poverty playing significant roles. Furthermore, chronic morbidities such as congenital heart diseases[10] and chronic kidney disease may predispose to secondary growth failure. Chiabi et al.[3] in Yaounde, Cameroon, found the prevalence of SAM to be 2.72%, with an age group of 6–12 months accounting for 34.6%. The researchers found respiratory infection as the most common comorbidity (21.5%), followed by malaria (15.1%).[3] Uncommon metabolic derangements such as hyperinsulinemia and rickets have been reported in patients with SAM.[11],[12]

SAM affects various systems; depressed immunity and cutaneous abrasions[13],[14] heighten the risk of infection;[15] weak and flabby heart increases the risk of heart failure: realizing these facts is very important in the successful management of cases. Severe forms of acute malnutrition had been classified using the Wellcome classification (kwashiorkor, marasmus, and marasmic kwashiorkor)which has a good clinical application; however, the Z-score has a much profound population-based application.[1]

There is a paucity of literature in this environment on the clinical profile and outcome of children with acute malnutrition. Therefore, this current study was designed to

  1. Determine the clinical profile of children admitted with MAM and SAM
  2. Determine the outcome of children admitted with MAM and SAM.



  Materials and Methods Top


Study design

This was a retrospective descriptive study.

Study area/population

This study was conducted at the Federal Medical Centre (FMC) Birnin Kudu, Jigawa State. All children admitted with acute malnutrition during the year under review (January 1, 2017, December 31, 2017) were included in the study.

Ethical considerations

Approval of the Ethics and Research Committee of the FMC, Birnin Kudu, was obtained before commencement of this study.

Data collection

The case files of the patients admitted into the Emergency Pediatric Unit and Pediatric Medical Ward of FMC Birnin Kudu over the period of 1 year (January–December 2017) were retrospectively reviewed. Information that was extracted from the case files included:

  1. Sociodemographic characteristics of the patients, age and gender
  2. Clinical data: Anthropometric parameters (weight, height/length, MUAC and occipitofrontal circumference [OFC]), signs and symptoms on admission, clinical forms of acute malnutrition, complications, and comorbidities while on admission
  3. Data on the outcome: Number of days of hospitalization, residual problem(s) at discharge, and number of deaths.


Study protocol

Acute malnutrition was defined and classified according to the WHO guidelines[16] and the modified Wellcome classification.[17] The WHO inpatient treatment protocol for the management of SAM was adopted[16],[18] such as use of F75, then transiting to F100; use of ReSoMal for rehydration; Vitamin A; and use of antibiotics for treating infection. MAM patients were treated with locally prepared energy-dense maize-based gruel; WHO hypo-osmolar oral rehydration solution and zinc tablet were used for diarrhea disease.

Statistical analysis

The data collected were entered into an Excel sheet and analyzed using the Statistical Package for the Social Sciences for Windows version 20 (IBM Co, Armonk, NY, USA). Descriptive statistics such as mean, median, and standard deviation were used to summarize quantitative variables such as age, weight, and height. Categorical variables were described as frequencies and percentages. Fisher's exact test (where necessary) was used to determine the statistical significance of the clinical profile and outcome of the patients. P < 0.05 was considered statistically significant, which was set at a 95% confidence interval.


  Results Top


No patient with incomplete case file was recorded in this study because it was preplanned before the commencement of this review to ensure that all relevant information were contained in patients, file as a checklist; this has been our routine practice in the unit; therefore, each file had a checklist attached. There were 842 admissions into the units during the study period; among these, 123 (14.6%) were cases of acute malnutrition. There were 53 (43.1%) males and 70 (56.9%) females with a male-to-female ratio of 1:1.3. The ethnic distributions were 71 (57.7%) Hausas, 30 (24.4%) Fulanis, 9 (7.3%) Igbos, 1 (0.8%) Yoruba, while 12 (9.8%) cases were of the minority tribes. Eighty-seven (70.7%) of the respondents lived in rural settings, while 36 (29.3%) lived in urban settings. There were 103 (83.7%) cases of SAM and 20 (16.3%) cases of MAM. Among the SAM cases, there were 70 (68.0%) cases of marasmus, 23 (22.3%) cases of marasmic kwashiorkor, and 10 (9.7%) cases of kwashiorkor.

The age of the subjects ranged from 1 to 120 months, with a mean of 23.36 ± 14.84 months. Most patients were in the age group of 12–36 months. Their weight ranged from 2 to 16 kg, with a mean of 6.75 ± 2.40 kg. The OFC ranged from 33.5 cm to 51.0 cm, with a mean of 45.0 ± 3.3 cm. Length/height ranged from 37 cm to 107 cm with a mean of 73.5 ± 11.5 cm. The MUAC ranged from 6 to 14.5 cm, with a mean of 11.3 ± 1.4 cm.

Marasmus was the most common form of SAM; this was followed by marasmic kwashiorkor. Infection was the most common morbidity associated with SAM, this was followed by electrolyte derangement and diarrhea disease; however, HIV infection was the least recorded [Table 1].
Table 1: Common forms of malnutrition according to the modified Welcome's classification and associated morbidities

Click here to view


Duration of hospital stay was from 1 to 41 days with a mean of 9.0 ± 6.1 days, and most spent between 1 and 2 weeks on admission, while majority were discharged home without any residual complication [Table 2].
Table 2: Age group, hospital stay, and the outcome of the subjects

Click here to view


[Figure 1] shows that the month of July recorded the highest cases of SAM, followed by June and May, while the lowest case was recorded in March.
Figure 1: The monthly frequency distribution of severe acute malnutrition. 1 = January (7), 2 = February (10), 3 = March (3), 4 = April (7), 5 = May (13), 6 = June (15), 7 = July (28), 8 = August (12), 9 = September (5), 10 = October (10), 11 = November (4), and 12 = December (9)

Click here to view


Almost half (48.6%) of the marasmus subgroup were discharged without complication; relatively more deaths were mostly witnessed in the marasmic kwashiorkor subgroup (17.4%). However, majority of the subjects who spent 1–2 weeks on admission were discharged without complications, while death occurred mostly in those who spent <7 days on admission and this observation was statistically significant (Fisher's exact = 32.351, P = 0.001) [Table 3].
Table 3: Comparing the types of malnutrition according to the modified Wellcome classification, age range, and duration of hospital stay with outcome

Click here to view


Infection, diarrhea, and electrolyte derangement were quite prevalent among those that died, while those who were discharged without complications had less comorbidities. However, those discharged with complications had more cases infection and diarrhea, though the observations were not statistically significant [Table 4].
Table 4: Comparing the observed morbidities with outcome

Click here to view


Patients with MAM had better outcomes and shorter duration of hospital stay [Table 5]; however, among the SAM subgroup, those in the kwashiorkor group had a relatively better outcome, but they all had a similar pattern of duration of hospital stay [Table 6].
Table 5: Classes of malnutrition and admission outcome

Click here to view
Table 6: Classes of malnutrition and duration of hospital stay

Click here to view



  Discussion Top


This study explored the common clinical complaints associated with acute malnutrition in our rural health facility. The hospital incidences of SAM differ significantly from various centers. Our study reported a prevalence of 14.6%; this differed from lower reports from most hospitals in Southwest Nigeria. Laditan and Tindimambwa[19] reported 4.5% in Ife, whereas Bamgboye and Familusi[20] documented 4.39% in Ibadan. Theirs were almost similar to the 5.4% reported in Kano by Adeleke et al;[21] however, our findings were almost similar to that of John et al. in North-Central, Nigeria,[22] who reported 10.6%. This disparity may be attributed to variation in the time of the studies and regional differences in wealth and socioeconomic status.

Security challenges in Nigeria, with farmers–herders conflict resulting in increasing internally displaced persons and less farming activities, are mostly experienced in Northern Nigeria; therefore, increasing cases of SAM will not be surprising.

There were more female patients in our study; this observation was in contrast to previous reports.[21],[22] The reason for this difference is not completely clear; however, previous reports probably did not truly reflect the gender representation. Adeleke et al.[21] in their submission attributed male preponderance in hospital cases to higher values given to the male child which is a common practice in many African cultures; therefore, in circumstances of financial constraint, the male child will preferentially be taken to the hospital; however, UNICEF, WHO, and many NGOs are currently involved in the management of children with SAM at no cost to the parents; therefore, this might explain the observed change in the health-seeking behaviors of parents as witnessed in this study.

Marasmus was the predominant form of SAM, this observation was similar to that of Adeleke et al.[21] and Wamanda and Adeleke[23] but differed from those of Laditan and Tindimambwa[19] and Alegbejo and Yakubu[24] who reported predominance of kwashiorkor and marasmic kwashiorkor, respectively.

Choudhary et al.[8] in India found fever to be the most common presenting symptom in children with SAM accounting for 70.7%, followed by vomiting (52%), loose motion (46.7%), cough (46.7%), and loss of appetite or weight loss (30.7%). In the same study, 85.3% of the patients presented with anemia, while 21.3% had hypoglycemia.[8]

Infection and diarrhea disease are the most common comorbidities associated with MAM and SAM patients; this observation was consistent with the findings of John et al.,[22] Syed Tariq et al.,[25] and Kumar et al.[26] However, only 1.6% of the patients were HIV positive, this figure was lower than the 10.7% and 21.5% reported by Adeleke et al.[21] and John et al.,[22] respectively, while Bunn et al.[27] reported a 43% HIV infection rate among children with SAM in Malawi.

The mean duration of hospital stay was 9 ± 6.1 days and most of the patients spent between 1 and 2 weeks. Our finding showed a shorter duration of hospital stay than those reported by John et al.;[22] the duration of hospital stay was also shorter than the recommended period reported by the Sphere Standard/World Food Programme/UNHCR.[22],[28] This is possibly due to early presentation of the patients; therefore, majority were discharged without complication.

Sixty-two percent of the patients were discharged home; this was lower than 75% reported by Syed Tariq et al.[25] but it was higher than 58% reported by Adeleke et al.[21] however those leaving against medical advice (LAMA) rate was 25.2% which was higher than 8.9% reported by Adeleke et al.[21] The challenges of managing home dynamics were of a major concern among the caregivers; they often complained of inadequate support for other children left at home, therefore resulting in early demand for discharge; however, no patient/caregiver absconded in this study, this was a better outcome when compared to abscond rates of 16.8% and 4.1% reported by John et al.[22] and Adeleke et al.,[21] respectively. John et al.[22] attributed the high abscond rate in their study to the high HIV infection rate among their SAM patients, hence the fear of stigmatization; however, only 1.6% of our patients had HIV infection; furthermore, a healthy patient–health worker working relation should improve patient compliance. A mortality rate of 8.9% was recorded in this study; a similar rate of 9% was reported by Ahmed et al.,[29] ] but our mortality rate was higher than that of Syed Tariq et al.[25] who reported only one death; furthermore, it was lower than 29% reported by Adeleke et al.[21] in Kano, Nigeria, 13% by John et al. in Nasarawa, Nigeria,[22] 25.8% by Gernaat et al.[30] in Zambia, and 25.2% by Tolboom et al.[31] in Lesotho. A better understanding of the treatment protocol and adequate staffing and staff training might explain the observed lower mortality.

Higher mortality was recorded among patients with edematous SAM (15.2 vs. 8.8%), this observation was similar to the reports of Adeleke et al.[21] and Laditan and Tindimambwa.[18] Furthermore, multiple complications such as infection, diarrhea disease, hypoglycemia, and electrolyte derangement were prevalent among the mortality cases.

The months of June, July, and August recorded the highest patient burden; this corresponded to the rainy season and planting period; caregivers from agrarian communities usually have limited supply of foodstuffs and money during this period;[32] this is similar to the monsoon period in Asian countries; therefore, similar observation by Hossain et al.[28] was comparable.


  Conclusion Top


SAM constitutes a huge disease burden in our center. However, this study showed that nonedematous SAM (marasmus) was the most prevalent. We equally had good outcomes in terms of successful discharges when compared to other centers, but the cases of LAMA were quite significant; furthermore, our mortality rate was <10% and most patients that died had other comorbidity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Guildeline: Updates on the Management of Severe Acute Malnutrion in Infants and Children. 2013. Available from: https://www.who.int/publications-detail/9789241506328. [Last accessed on 2017 Jan 20].  Back to cited text no. 1
    
2.
Sachdeva S, Dewan P, Shah D, Malhotra RK, Gupta P. Mid-upper arm circumference v. weight-for-height Z-score for predicting mortality in hospitalized children under 5 years of age. Public Health Nutr 2016;19:2513-20.  Back to cited text no. 2
    
3.
Chiabi A, Malangue B, Nguefack S, Dongmo FN, Fru F, Takou V, et al. The clinical spectrum of severe acute malnutrition in children in Cameroon: A hospital-based study in Yaounde, Cameroon. Transl Pediatr 2017;6:32-9.  Back to cited text no. 3
    
4.
UNICEF. Management of Severe Acute Malnutrition in Children: Working Towards Results at Scale; 2015. Available from: https://reliefweb.int/report/world/management-severe-acute-malnutrition-children-working-towards-results-scale-unicef-2015. [Last accessed on 2017 Jan 20].  Back to cited text no. 4
    
5.
Collins S, Dent N, Binns P, Bahwere P, Sadler K, Hallam A. Management of severe acute malnutrition in children. Lancet 2006;368:1992-2000.  Back to cited text no. 5
    
6.
National Population Commision/ICF International 2014. Nigeria Demographic and Health Survey; 2013. Available from: https://dhsprogram.com/pubs/pdf/FR293/FR293.pdf. [Last accessed on 2016 Dec 10].  Back to cited text no. 6
    
7.
Williams PC, Berkley JA. Severe Acute Malnutrion update: Current WHO Guidelines and the WHO Essential Medicine List for Children; 2016. Available from: https://www.who.int/selection_medicines/committees/expert/21/applications/s6_paed_antibiotics_appendix7_sam.pdf?ua=1. [Last accessed 0n 2017 Jan 15].  Back to cited text no. 7
    
8.
Choudhary M, Sharma D, Nagar RP, Gupta DB, Nagar T, Pandita A. Clinical profile of severe acute malnutrition in Western Rajasthan: A prospective observational study from. India J Pediatr Neonatal Care 2015;2:1-7.  Back to cited text no. 8
    
9.
Aliyu I. Clinical findings and outcome of measles outbreak in an African city. Sifa Med J 2016;3:1-4.  Back to cited text no. 9
  [Full text]  
10.
Asani MO, Aliyu I, Gambo S. Parental knowledge and impact on growth in children with congenital heart diseases in Aminu Kano Teaching Hospital Nigerian. Niger J Paediatri 2016;43:162-5.  Back to cited text no. 10
    
11.
Aliyu I. Hyperinsulinemia with acute severe malnutrition Sahel Med J 2016;19:168-9.  Back to cited text no. 11
    
12.
Ibrahim ZF, Aliyu I. Severe acute malnutrition and rickets: A diagnostic dilemma. Sudan Med Monit 2017;12:31-2.  Back to cited text no. 12
  [Full text]  
13.
Aliyu I, Mado S. Ichthyosis and severe acute malnutrition. EJDV 2018;38:95-6.  Back to cited text no. 13
    
14.
Ibrahim ZF, Aliyu I. When the skin changes in severe acute malnutrition appear as burns. Indian J Burns 2017:25:88-9.  Back to cited text no. 14
    
15.
Ibrahim UA, Aikhionbare HA, Aliyu I. Urinary tract infection in children with protein-energy malnutrition in Aminu Kano Teaching Hospital. Niger J Basic Clin Sci 2019;16:64-9.  Back to cited text no. 15
  [Full text]  
16.
Ashworth A, Khanum S, Jackson A, Schofield C. Guidelines for the Inpatient Treatment of Severely Malnourished Children. World Health Organization; 2003. Available from: www.who.int/entity/nutrition/./severemalnutrition/guide_inpatient_text. [Last accessed on 2011 Jul 10].  Back to cited text no. 16
    
17.
Ubesie AC, Ibeziako NS, Ndiokwelu CI, Uzoka CM, Nwafor CA. Under-five protein energy malnutrition admitted at the University of Nigeria Teaching Hospital, Enugu: A 10 year retrospective review. Nutr J 2012;11:43.  Back to cited text no. 17
    
18.
Guideline for the Integrated Management of Severe Acute Malnutrition. Available from: http://www.actionagainsthunger.org. [Last accessed on 2019 Jul 18].  Back to cited text no. 18
    
19.
Laditan AA, Tindimambwa G. The protein energy malnourished child in a Nigerian University Teaching Hospital. J Trop Paediatr1983;29:61-4.  Back to cited text no. 19
    
20.
Bamgboye EA, Familusi JB. Mortality pattern at a children's emergency ward, University College Hospital, Ibadan, Nigeria. Afr J Med Med Sci 1990;19:127-32.  Back to cited text no. 20
    
21.
Adeleke SI, Asani MO, Belonwu RO, Gwarzo GO. Children with protein energy malnutrition: Management and out-come in a Tertiary hospital in Nigeria. Sahel Med J 2007;10:84-8.  Back to cited text no. 21
  [Full text]  
22.
John C, Abdu H, Ukata P. Severe acute malnutrition in a tertiary hospital in north-central Nigeria, A review of hospitalized cases. J Med Trop 2012;2:142-6.  Back to cited text no. 22
    
23.
Wammanda RD, Adeleke SI. Protein energy malnutrition: Analysis of admission and outcome. Ann Afri Med 2002;1:79-83.  Back to cited text no. 23
    
24.
Alegbejo JO, Yakubu AM. Protein energy malnutrition, a 10 year retrospective study (1980-1990). Nig Med Pract 1993;25:30-2.  Back to cited text no. 24
    
25.
Syed Tariq A, Suhail Ahamad N, Wasim Rafiq A, Saleem R. Demographic, clinical profile of severe acute malnutrition and our experience of nutrition rehabilitation centre at children hospital Srinagar Kashmir. Int J Contemp Pediatr 2015;2:233-7.  Back to cited text no. 25
    
26.
Kumar R, Singh J, Joshi K, Singh HP, Bijesh S. Co-morbidities in hospitalized children with severe acute malnutrition. Indian Pediatr 2014;51:125-7.  Back to cited text no. 26
    
27.
Bunn J, Thindwa M, Kerac M. Features associated with underlying HIV infection in severe acute childhood malnutrition: A cross sectional study. Malawi Med J 2009;21:108-12.  Back to cited text no. 27
    
28.
Hossain MI, Dodd NS, Ahmed T, Miah GM, Jamil KM, Nahar B, et al. Experience in managing severe malnutrition in a government tertiary treatment facility in Bangladesh. J Health Popul Nutr 2009;27:72-9.  Back to cited text no. 28
    
29.
Ahmed T, Ali M, Ullah MM, Choudhury IA, Haque ME, Salam MA, et al. Mortality in severely malnourished children with diarrhoea and use of a standardised management protocol. Lancet 1999;353:1919-22.  Back to cited text no. 29
    
30.
Gernaat HB, Dechering WH, Voorhoeve HW. Mortality in severe protein-energy malnutrition at Nchelenge, Zambia. J Trop Pediatr 1998;44:211-7.  Back to cited text no. 30
    
31.
Tolboom JJ, Ralitapole-Maruping AP, Kabir H, Molatseli P, Anderson J. Severe protein energy malnutrition in Lesotho, death and survival in hospital, clinical findings. Trop Geogr Med 1986;38:351-8.  Back to cited text no. 31
    
32.
Food Agriculture Organization of the United Nation. The Future of Food and Agriculture. FAO; 2017. Available from: http://www.fao.org. [Last accessed on 2020 May 21].  Back to cited text no. 32
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed165    
    Printed4    
    Emailed0    
    PDF Downloaded56    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]