Home  |  About us  |  Editorial board  |  Ahead of print  | Current issue  |  Archives  |  Submit article  |  Instructions |  Search  |   Subscribe  |  Advertise  |  Contacts  |  Login 
  Users Online: 90Home Print this page Email this page Small font sizeDefault font sizeIncrease font size  

 Table of Contents      
ORIGINAL ARTICLE
Year : 2018  |  Volume : 9  |  Issue : 2  |  Page : 76-82

Drug prescription behavior: A cross-sectional study in public health facilities in two states of North India


1 Centre for Operational Research, International Union Against Tuberculosis and Lung Disease, The Union South East Asia Office, New Delhi; School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication24-Apr-2018

Correspondence Address:
Dr. Shankar Prinja
School of Public Health, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh - 160 012
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/picr.PICR_75_17

Rights and Permissions
   Abstract 

Background: Poor prescription practices result in increased side effects, adverse drug reactions, and high cost of treatment. The present study was undertaken to describe the drug-prescribing patterns in two North Indian states through prescription auditing.
Materials and Methods: The study was carried out in 80 public health facilities across 12 districts in two states of Haryana and Punjab (6 in each) covering all levels of care. The information from prescription slips was abstracted on a structured pro forma for all patients who visited the pharmacy of the health facility.
Results: A total of 1609 prescriptions were analyzed. On an average, 2.2 drugs were prescribed per patient. Nearly 84% of the drugs were prescribed from the essential drug list (EDL). Antibiotics were prescribed in 45.3% of prescriptions, followed by vitamins (34.8%) and nonsteroidal anti-inflammatory drugs (33.9%). Drugs were prescribed in their generic names in 70% of cases. Diseases of the ear, nose, and throat (18%) were most common followed by the diseases of the gastrointestinal and renal (17%) and musculoskeletal system (16%). Only 40% of children suffering from diarrhea received oral rehydration salts while 80% of them received antibiotics. Among cases of upper respiratory tract infection, nearly 75% received antibiotics.
Conclusion: The results of this study raise concerns about the overuse of antibiotics although most of the drugs (84%) were from the EDL and in generic names (70%). There is lack of data regarding prescription practices which necessitates real-time prescription monitoring through online data entry and transmission.

Keywords: Antibiotic abuse, drug prescriptions, India, prescription drug misuse, rational drug therapy


How to cite this article:
Tripathy JP, Bahuguna P, Prinja S. Drug prescription behavior: A cross-sectional study in public health facilities in two states of North India. Perspect Clin Res 2018;9:76-82

How to cite this URL:
Tripathy JP, Bahuguna P, Prinja S. Drug prescription behavior: A cross-sectional study in public health facilities in two states of North India. Perspect Clin Res [serial online] 2018 [cited 2019 Sep 23];9:76-82. Available from: http://www.picronline.org/text.asp?2018/9/2/76/231103


   Introduction Top


Prescription of medicines is a crucial component of patient care. Rational use of drugs has become an important public health issue because of inappropriate drug prescribing.[1],[2] Worldwide, >50% of all medicines are prescribed, dispensed, or sold improperly and 50% of patients fail to take them properly.[3] It has been frequently observed that doctors are resorting to polypharmacy promoting unnecessary use of tonics and other medications under the influence of drug companies and overlooking drug interactions. This has resulted in increased side effects, adverse drug reactions, and high cost of treatment.[3],[4] Overuse of drugs such as antibiotics, painkillers, injections, and cough and cold preparations is quite common.[5],[6] Injections, still considered as powerful and quick-acting, are widely overused.[7],[8] There is enough evidence to suggest that poor-quality prescription writing increases the risk of serious medication errors.[9] A combination of prescription audit and feedback has been shown to be a successful technique which improves the quality of prescribing.[10] Prescription audit forms a part of drug utilization studies. It is a potential tool for promotion of rational drug therapy. In view of the plethora of issues related to rational drug prescription and scarcity of data available with regard to drug prescribing, the present study was undertaken to describe the drug-prescribing patterns in two North Indian states through prescription auditing. The World Health Organization (WHO) core drug use indicators for outpatient facilities were used to study the prescribing practices.

The states of Punjab and Haryana have recently institutionalized drug procurement models to provide uninterrupted access to essential medicines free of cost in all public hospitals and health centers and also established standard treatment guidelines for evidence-based practice and rational drug therapy. In this context, the present study reflects the baseline situation and will also serve as a reference to evaluate the impact of various reforms on prescription practices.


   Materials And Methods Top


Study design

This is a cross-sectional study involving review of prescription slips.

Study setting

The study was carried out in selected districts of two North Indian states, namely, Haryana and Punjab. The state of Haryana is one of the wealthier states of India with the third highest per capita income in the country in the year 2012–2013. Nearly two-thirds of the 25 million population of the state reside in rural areas.[11] Punjab is a prosperous agricultural state with a population of 28 million and about two-third residing in rural areas.[12]

Study population

A multistage stratified random (probabilistic) sampling was followed for district selection. In the first stage, all districts were stratified in three categories based on the human development score, i.e., high, medium, and low status of development.[13] Two districts were selected randomly from each stratum in each state. The selected set of districts (12 in numbers) also ensured a geographical representation of the state.

In the second stage, a total of 80 public health facilities were chosen for the study so as to cover all levels of health-care delivery system, i.e., primary, secondary, and tertiary. The study sample included 1 medical college (MC) from each state and 1 district hospital (DH) from each selected district. We selected almost 30% of community health centers (CHCs) in each district and two primary health cares (PHCs) under each CHC randomly (probabilistic sampling). Overall, within each state, 1 MC, 6 DHs, 11 CHCs, and 22 PHCs were selected for the study. The final sample thus comprised of 2 tertiary care MCs, 12 DHs, 22 CHCs, and 44 PHCs for the two states.

Data collection

A trained team of investigators visited the selected health facilities with data capture tools. The investigators were postgraduates with previous experience of social science research in health system. Moreover, one member of the team who collected the data was a medical officer. This study is part of a larger study also involving assessment of drug procurement, management, distribution, and pricing. One-week training was undertaken for field investigators to train them on data collection methods and tools. Information from prescription slips was abstracted on a structured schedule for all patients who visited the pharmacy of the health facility. A consecutive selection strategy was adopted. Recruitment was done at the level of pharmacist so that patients from all specialties in a secondary or tertiary health facility could be captured. In case of primary health facility, this ensured that males, females, and children on the day of survey are captured. Besides abstracting information from the prescription slip on a structured schedule, a photograph of the prescription slip was also obtained so as to match the information recorded in case of any clarification. A total of 1609 prescriptions were obtained with an average of nearly 20 per health facility. The data were entered in Excel and exported to SPSS version (Armonk, NY: IBM Corp) 19 for analysis. The WHO core drug use indicators for outpatient facilities were used to study the prescribing practices.

Some of the prescribing indicators that were measured included:

  1. The average number of drugs prescribed per encounter was calculated to measure the degree of polypharmacy
  2. Percentage of encounters in which an antibiotic was prescribed was calculated to measure the overall use of antibiotics
  3. Percentage of drugs prescribed from an essential drug list (EDL)
  4. The percentage of prescriptions with errors in prescribing (drug dosage and frequency).


Ethics

This study was approved by the Ethical Review Board of Public Health Foundation of India. Necessary administrative approvals were obtained before conducting the study.


   Results Top


A total of 1609 prescriptions were analyzed with 877 and 732 prescriptions in Haryana and Punjab, respectively [Table 1]. Majority of them were females (57%) and belonged to the age group of 30–50 years (569, 35.5%), followed by the age group of 15–30 years (443, 27.7%). According to the level of health facility, most of the prescriptions were from the PHCs (821, 51.0%), followed by the CHCs (462, 28.7%) [Table 1].
Table 1: Basic demographic characteristics of patients and type of public health facility in the state of Haryana and Punjab, India 2015

Click here to view


Overall, an average number of 2.2 drugs were prescribed per patient with similar figures in both the states. The males are prescribed higher (2.3) number of drugs than females (2.2) in Haryana whereas it was similar for both sexes in Punjab. According to the level of health facility, overall, the CHCs prescribed the maximum number of drugs (2.4), followed by the DH (2.2). The average number of drugs prescribed for a patient aged >50 years and between 30 and 50 years was maximum (2.3). Children <5 years are prescribed minimum number of drugs (1.9) [Table 2].
Table 2: Average number of drugs prescribed by age, sex, and level of facility in Haryana and Punjab, India 2015

Click here to view


A total of 84% of the drugs were prescribed from the EDL with 83% in Punjab and 85% in Haryana. In Haryana, MC prescribed the maximum proportion of non-EDL drugs (50%) and PHC the minimum (10%) [Figure 1]. However, in Punjab, CHC prescribed the maximum number of non-EDL drugs (22%) and PHC the minimum (13%) [Figure 2].
Figure 1: Proportion of drugs prescribed from state's essential drug list in public health facilities in Haryana, India 2015. PHC = Primary health care, CHC: Community health center, DH = District hospital, MC = Medical college

Click here to view
Figure 2: Proportion of drugs prescribed from state's essential drug list in public health facilities in Punjab, India 2015. PHC = Primary health care, CHC: Community health center, DH = District hospital, MC = Medical college

Click here to view


Out of the total prescriptions analyzed, a total of 1111 (69%) prescriptions had drugs from the EDL only, whereas 404 (25%) of them had some drugs from the EDL and another 83 (5%) of them had no drugs out of the EDL. The proportion of EDL prescription was slightly higher in Haryana (71%) than in Punjab (67%) [Table 3]. Overall, the proportion of EDL prescription was highest in a PHC (77%) and lowest in a MC (39%). MC prescribed the maximum proportion of non-EDL prescriptions. The proportion of both EDL and non-EDL prescription was highest in the age group of 0–5 years. Prescription practices were similar across both sexes [Table 3]. Nearly half of the prescriptions (48.8%) had 2 drugs followed by 3 drugs (27.0%). Only 1.6% of the prescriptions had 5 drugs [Table 4]. Among the various classes of drugs, antibiotics were prescribed in 45.3% of prescriptions, followed by vitamins (34.8%), nonsteroidal anti-inflammatory drugs (33.9%), and antipyretics (27.6%) [Table 5]. Out of the total drugs prescribed, 69.6% of them were prescribed in their generic names. Among children <3 years who were suffering from diarrhea, only 40% received oral rehydration salts while 80% of them received antibiotics. Among cases of upper respiratory tract infection, nearly 75% received antibiotics.
Table 3: Prescription practices according to age, sex, and level of facility in Haryana and Punjab, India 2015

Click here to view
Table 4: Incidence of polypharmacy in selected public health facilities of Haryana and Punjab, India 2015

Click here to view
Table 5: Prescribing frequency of chosen drug groups in public health facilities of Haryana and Punjab, India 2015

Click here to view


Overall, inappropriate prescribing was found to be 9.2% and 3.0% based on drug dosages and frequency [Table 6].
Table 6: Inappropriate prescribing (based on drug dosage and frequency) by age, sex, and level of facility in public health facilities of Haryana and Punjab, India 2015

Click here to view


Out of the total 1609 prescriptions, 18% (291) of them had no diagnosis over them. In the remaining 1318 prescriptions, 1342 diagnoses were made. A total of 2.5% (33) of the prescriptions had diagnosis written in illegible language or in abbreviated form beyond comprehension. Out of the diagnoses made, nearly 52.4% (703) were nonspecific complaints or symptoms rather than specific diagnosis. The most common categories were upper respiratory infection (URI) (13.6%), nonspecific pain (8.2%), pregnancy (4.9%), allergy (4.6%), abdominal pain (4.6%), dental problems (4.6%), hypertension (4.2%), and injury (3.3%). According to the organ system affected, diseases of the ear, nose, and throat (18%) were most common followed by the diseases of the gastrointestinal and renal (17%), musculoskeletal system (16%), and skin and subcutaneous tissue (11%) [Figure 3].
Figure 3: Classification of diseases according to organ system involvement in public health facilities in Punjab and Haryana, India 2015. DM = Diabetes mellitus, HTN = Hypertension, COPD = Chronic obstructive pulmonary disease, BA = Bronchial asthma, GIT = Gastrointestinal, ENT = Ear, nose, and throat

Click here to view



   Discussion Top


This is one of the very few studies in India which has looked at prescription practices across different levels of public health facilities. Most other studies have reviewed prescribing pattern in a single center, usually a tertiary care facility.[14],[15],[16],[17],[18],[19],[20] This study also looks at the utilization of drugs in the EDL and prescription by generic names in public health facilities. The results of this study raise concerns about the overuse of antibiotics, especially in childhood diarrhea and upper respiratory tract infection and warrant urgent intervention. However, the reassuring fact was that most of the drugs (84%) were from the EDL, and in 70% of cases, drugs were prescribed in their generic names, contrary to the common belief.

The average number of drugs per prescription is an important index for review of prescription practices. In the present study, the average number of drugs per prescription was similar to the study by Srishyla et al. (2.17); however, it was above the ideal standards (1.6–1.8).[16],[21] Most of the studies in the literature have reported higher prescription rates ranging from 2.4 to 3.52.[2],[4],[15] Another study reported high average number of drugs per prescription (4.22) probably because the study setting was a tertiary care teaching hospital.[14] A study of the pattern of drug use in 12 developing countries reported mean number of drugs per prescription ranging from 1.3 in Zimbabwe and Ecuador to 3.8 in Nigeria.[22] Higher figures always ought to be justified because of the increased risk of drug interactions and errors of prescribing with polypharmacy. A high average number of drugs might be due to financial incentives to prescribers to prescribe more, lack of training of prescribers, or shortage of appropriate drugs.[15]

High incidence of antibiotic prescription in cases of illnesses such as upper respiratory tract infection or diarrhea is an urgent public health and patient safety priority. Such overuse of antibiotics causes avoidable adverse events, contributes to antibiotic resistance, and unnecessary treatment costs. The present study reveals higher antibiotic prescription rates than the ideal rates (20.0%–26.8%).[21] Drug use evaluation should be done to evaluate whether the antibiotics were prescribed appropriately or not. Other studies have also reported higher rates of antibiotic prescriptions.[2],[5] In the drug use pattern study in 12 developing countries, the percentage of encounters in which an antibiotic was prescribed ranged from 23% in Bangladesh to 63% in Sudan.[22] There is recent evidence which shows broad-spectrum antibiotic prescribing when either no therapy is required or when narrower-spectrum alternatives are appropriate.[23],[24] Antibiotic prescription policy should be instituted in every facility and monitored closely through prescription audits.

It has been demonstrated that serial prescription audits and active feedback along with training programs improve prescription behavior and reduces prescribing errors.[10] Efforts to promote rational use of drugs have been mainly targeted at the health-care provider level to improve drug prescribing through educational interventions, standard treatment guidelines, EDLs, etc. However, correct prescribing alone does not guarantee appropriate use of drugs. Nonadherence to prescribed drugs and self-medication is very common on the part of the consumer and also needs attention.[25]

Some of the prescriptions had diagnosis or medications written in illegible handwriting beyond comprehension. From the patient's perspective, it can delay treatment, lead to unnecessary tests, and inappropriate doses or even wrong medication which, in turn, can result in further worsening of the illness and death.[26]

Providing diagnosis on a prescription helps in evaluating a patient's illness history when he visits the same physician or any other. It also aids in patient safety by improving dispensing accuracy.[27] In the present study, however, nearly 18% of prescriptions had no diagnosis written over them. Educational interventions such as in-service training have been significantly shown to improve the number of prescriptions containing diagnosis nearly three times.[27],[28] Studies in Nigeria have shown that the prescriber's level of training or lack of training is one factor that would influence drug prescribing in health facilities.[29]

The prescribing errors in terms of drug dosage and drug frequency were 9.2% and 3.0%, respectively, which is slightly higher than the figures reported by Joshua et al.[30] These errors were more among the children than the adults similar to the previous study. This highlights the importance of training the physicians on drug dosages for children.

The major limitation in this study was that we were unable to account for the drop-outs, namely, patients who did not require drugs after consultation and patients who did not purchase drugs from the hospital pharmacy. Data were collected over a 2-week period, and although no reason was identified that this was different from any other periods, there is a possibility that drug shortages during the period of data collection could perhaps influence prescribing. There was a lack of data regarding appropriateness of prescription such as drug dosage, frequency, duration, and selection because of incomplete and illegible prescription writing.


   Conclusion Top


The results of this study raise concerns about the overuse of antibiotics which calls for antibiotic prescription policy in each facility. However, most of the drugs (84%) were from the EDL and in their generic names. There is a lack of pharmacoepidemiological data of this kind for continuous monitoring of prescription behavior. Real-time monitoring of prescription practices should be done through online data entry and transmission at the facility. Based on the observations of this preliminary study, it is proposed to carry out a prescription costing study as patient compliance in a developing country like India is primarily dependent on cost of treatment. Most of the interventions have focused on prescribers while a large part of irrational drug practice takes place at the consumer level, which needs further research. Evaluation of the impact of standard treatment guidelines and EDLs are future areas of research.

Acknowledgment

We gratefully acknowledge the role of Sakthivel Selvaraj and Pallav Bhatt in designing the study and developing tools for data collection. We are also thankful to Dr. Rakesh Gupta and the Haryana Health Department for the necessary facilitation in collection of health facility data.

Financial support and sponsorship

The study was funded by the Public Health Foundation of India, New Delhi. The funding agency had no role in collection of data, its analysis or interpretation, writing of this paper, or the decision to publish.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Spinewine A, Schmader KE, Barber N, Hughes C, Lapane KL, Swine C, et al. Appropriate prescribing in elderly people: How well can it be measured and optimised? Lancet 2007;370:173-84.  Back to cited text no. 1
[PUBMED]    
2.
Bhatnagar T, Mishra CP, Mishra RN. Drug prescription practices: A household study in rural Varanasi. Indian J Prev Soc Med 2003;34:33-9.  Back to cited text no. 2
    
3.
WHO. World Health Organization Promoting Rational Use of Medicines: Core Components. WHO Policy and Perspectives on Medicine No. 5 Document WHO/EDM/2002.3. Geneva: WHO; 2002.  Back to cited text no. 3
    
4.
Ansari KU, Singh S, Pandey RC. Evaluation of prescribing pattern of doctors for rational drug therapy. Indian J Pharmacol 1998;30:43-6.  Back to cited text no. 4
  [Full text]  
5.
Desalegn AA. Assessment of drug use pattern using WHO prescribing indicators at Hawassa University Teaching and Referral Hospital, South Ethiopia: A cross-sectional study. BMC Health Serv Res 2013;13:170.  Back to cited text no. 5
[PUBMED]    
6.
Calva J, Bojalil R. Antibiotic use in a periurban community in mexico: A household and drugstore survey. Soc Sci Med 1996;42:1121-8.  Back to cited text no. 6
[PUBMED]    
7.
Reeler A, Hematorn C. Injection Practices. A Case Study of Thailand. Geneva: World Health Organization; 1994.  Back to cited text no. 7
    
8.
World Health Organization. Injection Practices in the Developing World - Results and Recommendations from Field Studies in Uganda and Indonesia - EDM Research Series No. 020. Geneva: Switzerland; 1996.  Back to cited text no. 8
    
9.
Velo GP, Minuz P. Medication errors: Prescribing faults and prescription errors. Br J Clin Pharmacol 2009;67:624-8.  Back to cited text no. 9
[PUBMED]    
10.
Jyoti N, Kaur S. To analyze the impact of serial prescription audits with active feedback on quality of prescription behaviour. J Clin Diagn Res 2013;7:680-3.  Back to cited text no. 10
[PUBMED]    
11.
Haryana. In Wikipedia, The Free Encyclopedia. Available from: https://en.wikipedia.org/w/index.php?title=Haryana&oldid=604997516. [Last accessed on 2017 Jun 27].  Back to cited text no. 11
    
12.
Punjab. In Wikipedia, The Free Encyclopedia. Available from: http://www.en.wikipedia.org/w/index.php?title=Punjab&oldid=578684017. [Last accessed on 2017 Jun 27].  Back to cited text no. 12
    
13.
Ram F, Chander S. Ranking and Mapping of Districts. Mumbai: International Institute of Population Sciences (IIPS); 2006.  Back to cited text no. 13
    
14.
Abidi A, Gupta S, Kansal S. Prescription auditing and drug utilization pattern in a tertiary care teaching hospital of Western UP. Int J Basic Clin Pharmacol 2012;1:184-90.  Back to cited text no. 14
    
15.
Kuruvilla A, George K, Rajaratnam A, John KR. Prescription patterns and cost analysis of drugs in a base hospital in South India. Natl Med J India 1994;7:167-8.  Back to cited text no. 15
[PUBMED]    
16.
Srishyla MV, Krishnamurthy M, Naga Rani MA, Clare M Sr., Andrade C, Venkataraman BV. Prescription audit in an indian hospital setting using the DDD (Defined Daily Dose) concept. Indian J Pharmacol 1994;26:23-8.  Back to cited text no. 16
  [Full text]  
17.
Badar VA, Navale SB. Study of prescribing pattern of antimicrobial agents in medicine Intensive Care Unit of a teaching hospital in central India. J Assoc Physicians India 2012;60:20-3.  Back to cited text no. 17
    
18.
Dhanaraj E, Raval A, Yadav R, Bhansali A, Tiwari P. Prescription pattern of antihypertensive agents in T2DM patients visiting tertiary care centre in North India. Int J Hypertens 2012;2012:520915.  Back to cited text no. 18
[PUBMED]    
19.
Grover S, Kumar V, Avasthi A, Kulhara P. An audit of first prescription of new patients attending a psychiatry walk-in-clinic in North India. Indian J Pharmacol 2012;44:319-25.  Back to cited text no. 19
  [Full text]  
20.
Shah K, Solanki N, Rana D, Acharya K. Evaluation of antidiabetic prescriptions, cost and adherence to treatment guidelines: A prospective, cross-sectional study at a tertiary care teaching hospital. J Basic Clin Pharm 2013;4:82.  Back to cited text no. 20
    
21.
Isah AO, Ross-Degnan D, Quick J, Laing R, Mabadeje AF. The Development of Standard Values for the WHO Drug Use Prescribing Indicators. ICIUM/EDM: World Health Organization. Available from: http://www.archives.who.int/icium/icium1997/posters/1a2_txt.html. [Last accessed on 2017 Jun 27].  Back to cited text no. 21
    
22.
Hogerzeil HV, Bimo, Ross-Degnan D, Laing RO, Ofori-Adjei D, Santoso B, et al. Field tests for rational drug use in twelve developing countries. Lancet 1993;342:1408-10.  Back to cited text no. 22
[PUBMED]    
23.
Hersh AL, Shapiro DJ, Pavia AT, Shah SS. Antibiotic prescribing in ambulatory pediatrics in the united states. Pediatrics 2011;128:1053-61.  Back to cited text no. 23
[PUBMED]    
24.
Grijalva CG, Nuorti JP, Griffin MR. Antibiotic prescription rates for acute respiratory tract infections in US ambulatory settings. JAMA 2009;302:758-66.  Back to cited text no. 24
[PUBMED]    
25.
Homedes N, Ugalde A. Patients' compliance with medical treatments in the Third World. What do we know? Health Policy Plan 1993;8:291-314.  Back to cited text no. 25
    
26.
Sokol DK, Hettige S. Poor handwriting remains a significant problem in medicine. J R Soc Med 2006;99:645-6.  Back to cited text no. 26
[PUBMED]    
27.
Shah AR, Boesen MD, Harris-Salamone KD, Warholak TL. Adding diagnosis codes to prescriptions: Lessons learned from a quality improvement project. J Manag Care Pharm 2009;15:508-10.  Back to cited text no. 27
[PUBMED]    
28.
Howell RR, Jones KW. Prescription-writing errors and markers: The value of knowing the diagnosis. Fam Med 1993;25:104-6.  Back to cited text no. 28
[PUBMED]    
29.
Erah PO, Olumide GO, Okhamafe AO. Prescribing practices in two health care facilities in Warri, Southern Nigeria: A comparative study. Trop J Pharm Res 2003;2:175-82.  Back to cited text no. 29
    
30.
Joshua IB, Passmore PR, Parsons R, Sunderland VB. Appropriateness of prescribing in selected healthcare facilities in Papua New Guinea. Health Policy Plan 2014;29:257-65.  Back to cited text no. 30
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    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
    Viewed1527    
    Printed24    
    Emailed0    
    PDF Downloaded217    
    Comments [Add]    

Recommend this journal