Home  |  About us  |  Editorial board  |  Current issue  |  Archives  |  Submit article  |  Instructions |  Search  |   Subscribe  |  Advertise  |  Contacts  |  Login 
  Users Online: 678Home Print this page Email this page Small font sizeDefault font sizeIncrease font size  

 Table of Contents      
ORIGINAL ARTICLE
Year : 2013  |  Volume : 4  |  Issue : 3  |  Page : 175-180

Knowledge, attitude, and practices toward ayurvedic medicine use among allopathic resident doctors: A cross-sectional study at a tertiary care hospital in India


Department of Pharmacology and Therapeutics, 1st Floor Main building, Above Dean's office, Seth G.S. Medical College, KEM Hospital, Parel, Mumbai, Maharashtra, India

Date of Web Publication22-Jul-2013

Correspondence Address:
Suchita R Gawde
Department of Pharmacology and Therapeutics, 1st Floor Main building, Above Dean's Office, Seth G.S. Medical College, KEM Hospital, Parel, Mumbai, Maharashtra
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-3485.115380

Rights and Permissions
   Abstract 

Context: Ayurveda is most commonly practiced form of complementary and alternative medicine (CAM) in India. There are very few studies showing the knowledge, attitude, and practices (KAP) of allopathic doctors about Ayurvedic drugs and its use. Aims: The study was initiated to assess KAP toward Ayurvedic medicine use among allopathic resident doctors. Settings and Design: Cross-sectional and prospective study. Materials and Methods: After obtaining permission from the Institutional Ethics Committee, allopathic resident doctors from clinical departments were approached personally. They were given pre-formed validated questionnaire to assess KAP toward Ayurvedic medicine use. Statistical Analysis Used: Descriptive statistics. Results: Allopathic residents had little knowledge about basic concepts of Ayurveda, that is, 'panchakarma' and 'tridosha'. Majority residents (99%) had no opportunity to learn basics of Ayurveda, but 67% residents prescribed Ayurvedic medicines to patients. However, many residents (76%) mentioned that cross practice should not be allowed due to lack of knowledge. One resident knew that cross-practice was not allowed by law. The commonly prescribed proprietary Ayurvedic medicines were Liv-52 (39%), Shatavari (13%), Cystone (12%) and common ailments for which these medicines prescribed were liver disorders (34%), arthritis (18%), cough and cold (13%), kidney stones (11%), and piles (10%). Nearly 76% residents felt incorporation of Ayurveda with modern medicine would attract more patients and at the same time most residents (92%) agreed that Ayurvedic medicines need scientific testing before use. Though 50% of the residents agreed for voluntary training in Ayurveda, 80% denied compulsory training. Nearly 63% residents recommended Ayurveda among all CAMs. Most of residents heard of Ayurveda from their colleagues. Conclusions: This study reveals that allopathic resident doctors had little knowledge about Ayurveda and Ayurvedic medicine use but engaged in prescription of Ayurvedic medicines. So some interventions should be taken to increase the knowledge and awareness of allopathic resident doctors about Ayurvedic medicine use.

Keywords: Allopathy, Ayurveda, cross-practice, knowledge, attitude, and practices study, residents


How to cite this article:
Gawde SR, Shetty YC, Pawar DB. Knowledge, attitude, and practices toward ayurvedic medicine use among allopathic resident doctors: A cross-sectional study at a tertiary care hospital in India. Perspect Clin Res 2013;4:175-80

How to cite this URL:
Gawde SR, Shetty YC, Pawar DB. Knowledge, attitude, and practices toward ayurvedic medicine use among allopathic resident doctors: A cross-sectional study at a tertiary care hospital in India. Perspect Clin Res [serial online] 2013 [cited 2017 Oct 23];4:175-80. Available from: http://www.picronline.org/text.asp?2013/4/3/175/115380


   Introduction Top


Ayurveda is most commonly practiced form of complementary and alternative medicine (CAM) in India. About 80% of Indian patients use Ayurvedic therapy. [1] It aims to integrate and balance the body, mind, and spirit to help prevent diseases and promote wellness. Recently Ayurvedic therapy is becoming more and more noticeable from the point of view of dissatisfaction with modern medicine. Although the therapeutic value of several Ayurvedic medicines has been established; for many others, this is not the case, often because the research has not been done. Their efficacy can be tested in clinical trials much like synthetic drugs, yet numerous methodological and logistical problems exist. [2] Many consumers believe that Ayurvedic medicines are natural and therefore safe, but this is a dangerous oversimplification. According to a study, one-fifth of both US-manufactured and Indian-manufactured Ayurvedic medicines purchased via the Internet contain detectable lead, mercury, or arsenic. [3] Ayurvedic medicines are associated with adverse effects, which include interactions with prescribed drugs. A recent survey found that 15% of patients receiving conventional pharmacotherapy also take herbal products or Ayurvedic products and, among these, potential adverse herb-drug interactions were observed in 40% of patients. [4]

Recently integrative medicine approach recently came forward with the optimism of providing an affordable and practical solution to the global healthcare crisis, especially in developing countries like India. Department of AYUSH, under the Ministry of Health and Family Welfare proposed a new approach by integrating of Ayurveda, Siddha, Unani, and homoeopathy with Allopathic system to ensure health for all citizens across the country. [5]

The success of the new, 'integrative', approach will lie in its capability to identify the respective values, beliefs, fundamentals, practices, strengths, and weaknesses of all the systems. China has effectively incorporated practices from both traditional and modern medicine through a bottoms-up approach. Medical students in China take compulsory courses in both modern and traditional medicine, and apply their knowledge in practice. Therefore, Chinese physicians are aware with the pros and cons of both medical systems and can opt for the right combination to make best use of the both systems. However, the role of integrative medicine is still at infancy level in India. [6]

The scope of integration between Ayurveda and allopathic medicine in the future will be greatly influenced by the attitudes of allopathic physicians, especially postgraduate residents. Their attitudes and beliefs may have a strong impact on the way they ultimately practice medicine. In previous studies done in developed countries, medical students have consistently expressed interest in gaining more exposure to CAM [7],[8] and medical colleges are becoming aware of the need to provide CAM-related education and training. [9] However, there is no study done to evaluate knowledge, attitude, and practice (KAP) of allopathic doctors toward Ayurvedic drugs and its use. Hence the present study was undertaken to ascertain the beliefs of a sample of Allopathic resident doctors about Ayurveda and their knowledge base, attitude and practice regarding common Ayurveda therapy and integrative medicine.


   Materials and Methods Top


Study design

It was a cross-sectional, questionnaire-based study conducted by the Department of Pharmacology and Therapeutics of Seth GS Medical College and King Edward Memorial VII Hospital, Mumbai (India) between November 2010 and February 2012.

Ethics committee approval

The Institutional Ethics Committee permission was taken prior to initiation of the study (EC No: EC/OA-79/2010 dated October 14, 2010). As the research has minimal risk involved so the ethics committee allowed us to take verbal consent. The script of the verbal consent was used to take consent of the residents. The resident doctor involved was identified with a code number and privacy and confidentiality was maintained regarding the data throughout the study and also during the publication.

Sample size

Allopathic resident doctors from clinical branches of this institute were identified and included in the study. Other resident doctors from nonclinical branches were excluded. A total of 100 resident doctors (minimum 10% of total 750 residents required) were randomly selected by using computer generated charts.

Data collection tool

We developed a pretested, structured questionnaire based on our study objectives, taking guidance from the previous literature. [10],[11] It was subjected to a thorough peer review by three senior teachers from the college. It was subsequently modified as per suggestions of the teachers and the final questionnaire consisted of 19 multiple choice questions and open ended questions.

The questionnaire was prepared to assess KAP toward Ayurvedic medicine use. Each participant was allotted 20 minutes to answer the questions in the form of options which he/she feels is appropriate to answer.

The questionnaire consisted of several parts. The first part pertained to a collection of demographic information of the residents: Age, gender, academic year, and faculty. The questions in the second part of the questionnaire assessed the residents' knowledge about Ayurvedic drugs and therapy, and their attitude toward Ayurveda practice. The third part of the questionnaire addressed questions related to their clinical practices related to Ayurveda.

Statistical analysis

Statistical analysis was done by using descriptive statistics. Data were collected in a predesigned Microsoft® Excel 2007. Continuous variables were presented as mean values ± standard deviation (SD), and categorical variables were presented as percentages.


   Results Top


A total of 112 residents were approached, out of which 100 agreed to fill the questionnaire form, resulting in response rate of 89%. Total 73% of residents were male. Out of 100 residents, 57 residents were working in medicine and allied departments, for example, pediatrics, skin, psychiatry, etc., and remaining 43 were from surgical departments, for example, orthopedics, ear, nose, and throat (ENT), ophthalmology, etc., Average age of residents is 26.47 ± 1.65 years. Out of the 100 resident doctors interviewed, 48% had knowledge and could answer about Doshas, 52% had no knowledge. When asked about Panchkarma in Ayurveda, 81% did not have knowledge about it. The major source of information of Ayurvedic medicines for the residents was as shown in [Figure 1]. The common proprietary Ayurvedic preparations known to allopathic residents are mentioned in [Figure 2]. When asked for the common ailments for which Ayurvedic medicines are prescribed along with modern medicines, the responses given was as mentioned in [Table 1].
Figure 1: Sources of information about Ayurvedic medicines for Allopathic residents


Click here to view
Figure 2: Common proprietary Ayurvedic preparations known to allopathic residents

Click here to view
Table 1: Common ailments for which Ayurvedic medicines used along with modern medicines by allopathic doctors


Click here to view


The questions and the respective responses for testing attitude of the resident doctors are given in the [Table 2].
Table 2: Response of allopathic doctors towards attitude questions


Click here to view


Majority residents (49%) felt that >20-40% of the population uses Ayurvedic medicine in routine practice.

Almost all (99%) residents did not have any opportunity to learn basics about Ayurveda. The residents felt that if there is any condition for which opinion or referral to Ayurvedic doctor is necessary, 46% agreed to this referral, but 35% disagreed to this fact. Majority (92%) of the residents felt that Ayurvedic medicines need more scientific testing before being used. Total 60% of the residents agreed that incorporation of Ayurveda therapies into the practice would result in increased patient satisfaction and attract more patients. Around 60% agreed to the fact that Physician's knowledge of Ayurveda practices leads to better patient outcome. On the contrary there was no consensus reached on voluntary course of 6 months in training in Ayurveda after completion of Medical graduation.

On questioning about compulsory training in Ayurvedic medicine use during post graduation, 80% of them disagreed. Nearly 68% felt that Ayurveda and modern medicine should be integrated, but again 32% disagreed to this integration.

In regards to ever referring a patient to an Ayurvedic outpatient department (OPD) running in our hospital, 93% disagreed, but 94% agreed that they came across patients approaching Ayurvedic doctors and taking Ayurvedic drugs before attending to allopathic doctors. Nearly 71% did not felt of consulting an Ayurvedic physician but 29% felt like consulting them. Allopathic doctors (69%) have prescribed branded Ayurvedic preparations but 31% said no to this practice. The most recommended CAM treatment as per resident doctors is mentioned in [Figure 3].
Figure 3: Commonly recommended CAM by allopathic doctors

Click here to view


Seventy-six (76%) allopathic residents felt that they should not be allowed cross-practices of Ayurveda. The common reasons given against cross practice were as shown in [Table 3].
Table 3: Common reasons given by allopathic doctors for not allowing cross practice


Click here to view


Twenty-four (24%) allopathic doctors said that it should be allowed. The common reasons given for allowing cross practice were as shown in [Table 4].
Table 4: Common reasons given by allopathic doctors for allowing cross practice


Click here to view



   Discussion Top


This study investigated the level of KAP of allopathic resident doctors regarding Ayurvedic medicine use. Among the resident doctors, only (48%) had knowledge about Doshas. When asked about Panchkarma in Ayurveda, 81% did not have knowledge about it. This shows how allopathic residents are unaware about the facts of Ayurveda. This is further justified by the fact that the major source of information of Ayurvedic medicines for the residents was colleagues (67%) and promotional literature. This shows the peer pressure and strong belief on the reliability of information of colleagues. The allopathic resident doctors in their busy schedule rely for information on promotional literature, which can be fabricated without study background and industry oriented. [12]

The residents knew the names of the Ayurvedic preparations. LIV 52 was found to be frequently used medicine by the resident. LIV 52 use can be attributed to common liver disorders, drug-induced hepatitis among the population. [13] Higher incidence with no definitive treatment available in modern medicine can make the doctors think of Ayurvedic drug use. Liver disorders (hepatitis, cirrhosis) form the major chunk of Ayurvedic medicine use by the allopathic residents followed by arthritis (rheumatoid arthritis, osteoarthritis), cough/cold, kidney stones, piles, skin disorders, and others (dyspepsia, constipation, menstrual disorders, chronic pain, anorexia, dementia, anemia, diabetes mellitus, asthma, inflammatory bowel disease, and urinary tract infection). The disorders are varied for the Ayurvedic drug use, but there are few like liver disorders. Arthritis, skin disorders, chronic pain, diabetes mellitus, asthma, inflammatory bowel disease, which have no curative treatment in allopathy.

The resident felt that 20-40% of the population uses Ayurvedic medicine in routine practice, which is also shown by Frank et al. [14] This shows the popularity of Ayurvedic medicines in the community as shown by Shankar et al. [15] Majority of the residents felt that among the CAM treatment, the most recommended treatment was Ayurveda (63%) followed by Homeopathy (13%), Yoga (4%), Unani (1%), and Siddha (1%).

Majority of the residents (68%) felt that Ayurveda and modern medicine should be integrated. Total 60% of the residents agreed incorporation of Ayurveda therapies into the practice and better physician knowledge about Ayurveda would result in increased patient satisfaction and attract more patients. This again emphasizes the growing popularity and belief in Ayurvedic medicines. The rapidly spreading public enthusiasm for CAM, coupled with the increasing acceptance of a consumerist and market-driven approach to health care, may push some doctors to respond to the patients' requests without having appropriate training. [16]

Our study revealed that total 99% of the residents did not have any opportunity to learn basics about Ayurveda, as in present curriculum of MBBS and MD, Ayurveda is not included. The resident felt that if there is any condition for which opinion or referral to Ayurvedic doctor is necessary, 46% agreed to this referral, but 35% disagreed to this fact. This shows that even if the students are not knowledgeable, they feel referring a patient to Ayurvedic physician can bring out some positive results. But again 93% of the resident doctors never referred a patient to an Ayurvedic OPD running in the hospital. Nearly 71% resident doctors did not feel of consulting an Ayurvedic physician but 29% felt like consulting them. This finding is in the line with that of Wahner-Roedler et al. [10] Majority of residents (94%) agreed that they came across patients approaching Ayurvedic doctors and taking Ayurvedic drugs before attending to allopathic residents.

In our study there was no consensus reached on voluntary course of 6 months training in Ayurveda after completion of Medical graduation. Most of the doctors (80%) disagreed to compulsory training in Ayurvedic medicine use during post graduation. As doctors are overburdened with their routine hectic schedule and studies, they do not want another addition in it. However, 86% felt that doctors should have knowledge about the most common Ayurveda therapies.

Majority of the residents felt that Ayurvedic medicines need more scientific testing before being used as there are very few randomized controlled trials done and published about Ayurvedic drugs. This finding is confirmed by Thatte et al. [17] The residents themselves are very confused about accepting Ayurveda as a science and reap its benefits. This was shown by Janamian et al., [18] in her study. GPs are open to integrating CAMs into their clinical practice. They are not comfortable in referring patient to any other specialty.

Total 69% of Allopathic residents have prescribed branded Ayurvedic preparations. This finding is in agreement with previous studies done in India. In a study by Verma et al., in North India, it has been observed that, the prescriptions of Allopathic doctors contained 88% allopathic and 12% Ayurvedic drugs. [1] Another study by Kumar reported that Ayurvedic drugs were prescribed by 5.26% of allopathic-practitioners. [19] Hence, even without knowledge, training, allopathic physicians do not want to refer patients to Ayurvedic doctors but want to prescribe Ayurvedic drugs on their own to the patients. This behavior of allopathic doctors can be life threatening for the patients, as all Ayurvedic medicines are not free of side-effects.

This study also investigated: should allopathic doctors be allowed to cross-practice Ayurveda? Nearly 76% felt that the allopathic doctors should not be allowed cross-practices. This is right as per the law; allopathic doctors are not allowed to practice Ayurveda. [20] However, 24% felt that they should be allowed to cross-practice. Positive experiences in this field have been reported from Italy. [21]


   Conclusion Top


First, while the study suggests a high popularity of Ayurvedic medicines among the allopathic resident doctors, they considered Ayurveda therapy not being evidence-based system. From a government point of view, it suggests that for implementation of integrative medicine more research is required, particularly high quality clinical trials that evaluates the mechanisms, safety and cost-effectiveness of Ayurvedic therapies. Lack of studies assessing the efficacy of Ayurvedic therapy may be the major obstacle for integration.

Second as cross-pathy practice was found to be common; there should be stringent laws by the government at health care centers for the allopathic residents to not prescribe Ayurvedic drugs. The study also indicates that there is an urgent need to undertake educational and reorientation programs for residents regarding various Medical council of India (MCI) rules and regulations to avoid unnecessary exposure of population to their harmful effects.

As pharmacology subject has been included in the curriculum of BAMS (Bachelor of Ayurvedic Medicine and Surgery) as they anyways practice Allopathy, [22] the same can be included in the 2 nd year MBBS syllabus to Allopathy doctors who in nutshell practice Ayurveda (Ayurvedic therapy). In internship there can be orientation program giving practical guidelines for Ayurveda Therapy to Allopathy doctors. In addition, regular CMEs (Continuing Medical Education) should be arranged, where in the disease specific platforms experts in Ayurveda should be called to speak on the same domain.

Moreover, large scale epidemiological studies should be conducted both in the urban and rural parts of the country, comparing the trend of cross-pathy practices among qualified physicians of both the systems of medicine. The benefit of the patient lies in the optimal balance and evidence-based use of both the systems and this need to be encouraged especially in developing countries like India with inadequate doctor patient ratio.

Limitations of study

The sample was representative of a single tertiary care hospital of Mumbai, and thus the results may not be generalizable to other medical colleges in India. Although the response rate was relatively good for a survey instrument, it was sufficiently small that there is undoubtedly a self-selection bias, which possibly skews the findings. Since the study is cross sectional rather than longitudinal, we do not have information on the actual change in knowledge and attitudes of any specific cohort of residents over time.

 
   References Top

1.Verma U. Allopathic vs. Ayurvedic practices in tertiary care institutes of urban North India. Indian J Pharmacol 2007;9:52-4.  Back to cited text no. 1
    
2.Ernst E. Herbal medicines: Balancing benefits and risks. Novartis Found Symp 2007;282:154-67.  Back to cited text no. 2
[PUBMED]    
3.Saper RB, Phillips RS, Sehgal A, Khouri N, Davis RB, Paquin J, et al. Lead, mercury, and arsenic in US- and Indian-manufactured Ayurvedic medicines sold via the Internet. JAMA 2008;300:915-23.  Back to cited text no. 3
[PUBMED]    
4.Izzo A, Ernst E. Interactions between herbal medicines and prescribed drugs: An updated systematic review. Drugs 2009;69:1777-98.  Back to cited text no. 4
    
5.Report by Ayush: National Policy on Indian Systems of Medicine and Homoeopathy-2002. Available from: http://www.whoindia.org/LinkFiles/AYUSH_NPolicy-ISMandH-Homeopathy. [Last cited on 2012 Aug 14].  Back to cited text no. 5
    
6.Bodeker G. Lessons on integration from the developing world's experience. BMJ 2001;322:164-7.  Back to cited text no. 6
[PUBMED]    
7.Munstedt K, Harren H, von Georgi R, Hackethal A. Complementary and alternative medicine: comparison of current knowledge, attitudes and interest among German medical students and doctors. Evid Based Complement Alternat Med 2011;2011:790951.  Back to cited text no. 7
    
8.Greiner KA, Murray JL, Kallail KJ. Medical students interest in alternative medicine. J Altern Complement Med 2000;6:231-4.  Back to cited text no. 8
[PUBMED]    
9.Astin JA, Soeken K, Sierpina VS, Clarridge BR. Barriers to the integration of psychosocial factors in medicine: Results of a national survey of physicians. J Am Board Fam Med 2006;19:557-65.  Back to cited text no. 9
[PUBMED]    
10.Wahner-Roedler DL, Vincent A, Elkin PL, Loehrer LL, Cha SS, Bauer BA. Physicians' attitudes toward complementary and alternative medicine and their knowledge of specific therapies: A survey at an academic medical center. Evid Based Complement Alternat Med 2006;3:495-501.  Back to cited text no. 10
[PUBMED]    
11.Fujiwara K, Imanishi J, Watanabe S, Ozasa K, Sakurada K. Changes in attitude of Japanese doctors towards Complementary and Alternative Medicine- Comparison of survey in 1999 and 2005 in Kyoto. Evid Based Complement Alternat Med 2011;2011:608921.  Back to cited text no. 11
[PUBMED]    
12.Rohra DK, Gilani AH, Memon IK, Perven G, Khan MT, Zafar H, et al. Critical evaluation of the claims made by pharmaceutical companies in drug promotional material in Pakistan. J Pharm Pharm Sci 2006;9:50-9.  Back to cited text no. 12
[PUBMED]    
13.Handa SS, Sharma A, Chakroborti KK. Natural products and plants as liver protecting drug. Fitoterapia 1986;57:307-51.  Back to cited text no. 13
    
14.Frank E, Ratanawongsa N, Carrera J. American Medical Students' Beliefs in the effectiveness of alternative medicine. Int collab res internal med public health 2010;2:292-305.  Back to cited text no. 14
    
15.Shankar PR, Das B, Partha P, Shenoy N. Medical students' opinions about complementary and alternative medicine: a questionnaire based survey. J Inst Med 2002;25:9-12.  Back to cited text no. 15
    
16.Giannelli M, Cuttini C, Da Fre M, Buiatti E. General practitioners' knowledge and practice of complementary/alternative medicine and its relationship with life-styles: a population-based survey in Italy. BMC Fam Pract 2007;8:30.  Back to cited text no. 16
    
17.Thatte UM, Rege NN, Phatak SD, Dahanukar SA.The flip side of Ayurveda. J Postgrad Med 1993;39:179-82,182a-b.  Back to cited text no. 17
    
18.Janamian T, O'Rourke P, Myers SP, Eastwood H. Information resource need and preference of queensland general practitioners on complementary medicines: Results of a need assessment. Evid Based Complement Alternat Med 2011;2011:810908. Available from: http://www.hindawi.com/journals/ecam/2011/608921/. [Last cited on 2012 Aug 14].  Back to cited text no. 18
    
19.Kumar D. Recognition and management of ARI-A knowledge attitude and practice (KAP) study on private medical practitioners. Indian J Pediatr 1997;64:237-42.  Back to cited text no. 19
[PUBMED]    
20.Code of Ethics Regulations. Medical Council of India Notification: New Delhi 2002. Available from: http://www.mciindia.org/RulesandRegulations/CodeofMedicalEthicsRegulations2002.aspx. [Last cited on 2012 Aug 14].  Back to cited text no. 20
    
21.Laken MP, Cosovic S. Introducing alternative/complementary healing to allopathic medical students. J Altern Complement Med 1995;1:93-98.  Back to cited text no. 21
[PUBMED]    
22.Ayush doctors can practice allopathy after studying. eMedinews 2012. Available from: http://emedinews.org/ayush- doctors-can-practice-allopathy-after-studying-pharmacology- maharashtra-government-4747. [Last cited on 2012 Nov 11].  Back to cited text no. 22
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

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


This article has been cited by
1 Indonesian provisional clinical psychologistsę knowledge, attitudes, and behaviours towards complementary-alternative medicine (CAM)
Andrian Liem,Peter A. Newcombe
Complementary Therapies in Clinical Practice. 2017;
[Pubmed] | [DOI]
2 Prevalence of obesity and associated hypertension and diabetes in Delhi, metropolitan city of India
H. Aggarwal,H. Kaur,R. Saklani,N. Saba,S. Choudhary,S. Dogra,S. Srivastava,R. Mathur,S.K. Gupta
Indian Journal of Medical Specialities. 2015; 6(3): 82
[Pubmed] | [DOI]
3 Cultural consonance, constructions of science and co-existence: a review of the integration of traditional, complementary and alternative medicine in low- and middle-income countries
J. K. Lakshmi,D. Nambiar,V. Narayan,T. N. Sathyanarayana,J. Porter,K. Sheikh
Health Policy and Planning. 2014;
[Pubmed] | [DOI]



 

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
    Viewed3379    
    Printed58    
    Emailed1    
    PDF Downloaded483    
    Comments [Add]    
    Cited by others 3    

Recommend this journal