Annals of African Medicine
Home About AAM Editorial board Ahead of print Current Issue Archives Instructions Subscribe Contact us Search Login 


 
Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 20  |  Issue : 2  |  Page : 132-137  

Assessment of health-related quality of life of vesicovaginal fistula patients attending a repair center in Northwest Nigeria


1 Department of Community Health, Usmanu Danfodiyo University, Sokoto, Nigeria
2 Department of Community Medicine, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
3 Department of Obstetrics and Gynaecology, Usmanu Danfodiyo University, Sokoto, Nigeria
4 Department of Obstetrics and Gynaecology, University of Ilorin, Ilorin, Kwara State, Nigeria

Date of Submission29-Apr-2020
Date of Acceptance30-Sep-2020
Date of Web Publication30-Jun-2021

Correspondence Address:
Mansur O Raji
Department of Community Health, Usmanu Danfodiyo University, Sokoto
Nigeria
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aam.aam_35_20

Rights and Permissions
   Abstract 


Introduction: Vesicovaginal fistula (VVF) has devastating effects on a woman's hygiene, self-esteem, interpersonal relationships, and environment disrupting all elements of her health. Despite VVF being a persistent condition, very few researches have been conducted in Nigeria to determine the quality of life (QoL) of these patients. This study was carried out with the aim of assessing the QoL of VVF patients receiving care in a repair center in Sokoto, Northwest Nigeria. Materials and Methods: This was cross-sectional study conducted at a VVF repair center in Sokoto. Study population comprised of patients who had undergone VVF repair at the health facility. The total number of study participants present at the facility was 81, and all were recruited into the study. The study assessed socio-demographics and QoL of the respondents. Data obtained were entered into IBM software package and subsequently analyzed. Level of significance was set at 5%. Results: The environmental domain had the highest mean score of 51.7 ± 11.8 while psychological domain had the least score of 41.3 ± 14.3. The mean overall QoL and general health were 49.5 ± 10.2. There was a moderate positive correlation between physical domain score and Age, (r = 0.258, P < 0.005). There was also a positive correlation between psychological domain score and Husband's educational status (rpb = 0.241, P < 0.05). Social relationship domain score positively correlated with being married (rpb = 0.414, P < 0.01). Conclusion: Older study participants had higher mean scores for physical and psychological domains, while younger study participants had higher overall QoL and general health scores compared with older study participants. Future research should compare the pre and postoperative QoL of women who undergo repair of obstetric fistula.

   Abstract in French 

Résumé
Introduction: La stula vésico-vaginale (VVF) a des effets dévastateurs sur l'hygiène, l'estime de soi, les relations interpersonnelles et l'environnement d'une femme, perturbant tous les éléments de sa santé. Bien que la FVV soit une maladie persistante, très peu de recherches ont été menées au Nigéria pour déterminer la qualité de vie (QoL) de ces patients. Cette étude a été réalisée dans le but d'évaluer la qualité de vie des patients VVF recevant des soins dans un centre de réparation à Sokoto, au nord-ouest du Nigeria. Matériaux et méthodes: Il s'agissait d'une étude transversale menée dans un centre de réparation VVF à Sokoto. Population de l'étude composée de patients ayant subi une réparation VVF dans l'établissement de santé. Le nombre total de participants à l'étude présents dans l'établissement était de 81, et tous ont été recrutés dans l'étude. L'étude a évalué les caractéristiques sociodémographiques et la qualité de vie des répondants. Les données obtenues ont été saisies dans le progiciel IBM et ensuite analysées. Le niveau de signification a été fixé à 5%. Résultats: Le domaine environnemental avait le score moyen le plus élevé de 51,7 ± 11,8 tandis que le domaine psychologique avait le score le moins élevé de 41,3 ± 14,3. La qualité de vie globale moyenne et l'état de santé général étaient de 49,5 ± 10,2. Il y avait une corrélation positive modérée entre le score du domaine physique et l'âge (r = 0,258, p <0,005). Il y avait également une corrélation positive entre le score du domaine psychologique et le niveau de scolarité du mari (rpb = 0,241, p <0,05). Le score du domaine des relations sociales est positivement corrélé au mariage (rpb = 0,414, p <0,01). Conclusion: Les participants plus âgés à l'étude avaient des scores moyens plus élevés pour les domaines physique et psychologique, tandis que les participants plus jeunes à l'étude avaient des scores globaux de qualité de vie et de santé générale plus élevés que les participants plus âgés. Les recherches futures devraient comparer la qualité de vie pré et postopératoire des femmes qui subissent une réparation de la fistule obstétricale.

Keywords: Northwest Nigeria, quality of life, vesico-vaginal fistula


How to cite this article:
Raji MO, Raji IA, Hassan M, Raji HO, Bashir AM, Suleiman IN, Abubakar HU. Assessment of health-related quality of life of vesicovaginal fistula patients attending a repair center in Northwest Nigeria. Ann Afr Med 2021;20:132-7

How to cite this URL:
Raji MO, Raji IA, Hassan M, Raji HO, Bashir AM, Suleiman IN, Abubakar HU. Assessment of health-related quality of life of vesicovaginal fistula patients attending a repair center in Northwest Nigeria. Ann Afr Med [serial online] 2021 [cited 2021 Sep 27];20:132-7. Available from: https://www.annalsafrmed.org/text.asp?2021/20/2/132/320042




   Introduction Top


Quality of life (QoL) has been defined as individuals' perceptions of their position in life in the context of the culture and value systems in which they live and concerning their goals, expectations, standards and concerns.[1] This definition reflects the view that QoL refers to a subjective evaluation embedded in a cultural, social, and environmental context. The World Health Organization QoL: Brief Version (WHOQOL-BREF) assesses QOL in four domains including physical health, psychological, social relationships and environment. Physical health domain is a reflection of an individual's activities of daily living, energy and fatigue, mobility, pain, discomfort, and work capacity. Psychological domain assesses self-esteem, positive feelings, bodily image and appearance, and ability to concentrate. Social relationship domain reflects personal relationships, social support availability, and sexual activity. Environmental domain assesses individual's financial resources, health and social care accessibility and quality, opportunities for acquiring new skills, participation in and opportunities for recreation/leisure activities etc.[2] QoL is therefore an important component of assessing people's health and can be affected by various factors including health or disease state.[3],[4]

Globally, about half a million women die yearly from causes related to pregnancy and delivery with 99% of these deaths occurring in developing countries; and for each maternal death, approximately 10–15 other women sustain severe morbidity, including vesicovaginal fistula (VVF) which has been termed the most dramatic maternal birth injury.[5],[6] About 2 million women suffer from VVF worldwide, with an estimated annual incidence of 50,000–100,000 cases.[7] In Africa, the incidence is about 2–5/1000 deliveries,[4] and in sub-Saharan Africa, 33,000 new cases of VVF occur annually.[4] In West Africa, the incidence ranges from 3 to 4/1000 deliveries.[8] In Nigeria, an annual an annual obstetric fistula incidence is estimated at 2.11/1000 births.[5] The condition cut across all parts of the country and is worse in the northern region.[5],[6]

VVF is a debilitating and devastating condition that seriously affects the QoL of women.[9] VVF is defined as an abnormal opening between the bladder and vagina, resulting in urinary incontinence.[4],[5] Although VVF dates back since antiquity, VVF from obstetric complications is no longer a problem in the developed world where it has been eradicated since the middle of the twentieth century through the provision of effective systems of obstetric care,[10] but persists in the developing nations.[11] The persistence of VVF in developing countries has been attributed to obstetric care not available, being inaccessible, underutilized, or of low quality. The most frequent cause of VVF in developing countries is obstructed labor from cephalopelvic disproportion without timely intervention from a trained physician.[12] Also associated with VVF include radiation therapies, uterine prolapse, cultural practices such as gishiri cuts and some complications of surgeries such as caesarian section and hysterectomies, as well as early marriage, poverty and illiteracy.[12] Women living with VVF in addition to suffering from urinary incontinence may also experience foot drop, skin excoriation, bladder stones, vaginal stenosis, and secondary infertility.[12]

VVF has devastating effects on a woman's hygiene, self-esteem, interpersonal relationships, and environment disrupting all elements of her health. VVF patients tend to live with its consequences which include medical, economic and psychosocial problems. The medical consequences of obstetric fistula include incontinence of urine and feces, foot drop, chronic skin irritation, bladder stone, vaginal stenosis, secondary infertility, among others.[12] The economic consequences arise because the afflicted patients are usually divorced by their husbands and rejected by their families and relations, have no education or means of livelihood, end up either begging or employed in casual work.[12] The psychological effect of obstetric fistula refers to the mental and social feelings impacting women suffering from obstetric fistula; consequent upon which the patients become stigmatized rejected, and socially isolated by the society in which they live.[12] Communities ostracize VVF patients, they are divorced or separated by their husbands or sexual partners, have an offensive odor (due to urine or/and stool leakage), and experience loss of libido.[12] Other associated psychosocial factors found to be experienced by obstetric fistula patients include; depression, feelings of low self-esteem, and embarrassment.[12] All these affect the QoL of VVF patients.[4],[9]

Despite VVF being a persistent condition in Nigeria and northwest of Nigeria in particular; and large numbers of women undergoing surgical repair annually, very few researches having been conducted in Nigeria and northwest in particular to determine the QoL of these patients. This study was carried out with the aim of assessing the QoL of VVF patients receiving care in a repair center in Sokoto, Northwest Nigeria.


   Materials and Methods Top


The study was conducted at Maryam Abacha Women and Children Hospital, located in Sokoto South Local Government Area of Sokoto state. It is a state-owned specialized service hospital, dedicated to VVF patients. Services at the health facility are free. The facility has one trained Resident VVF surgeon, a surgeon undergoing training, and 2 visiting VVF surgeons. These surgeons conduct routine VVF repairs twice a week. Fistula care (Engender Health) and Fistula Foundation (UNFPA) support the facility in carrying out these surgeries. A large number of patients present for pooled surgical efforts, which frequently takes place in the hospital. The combined surgical efforts are usually performed by many fistula surgeons who come from different parts of the country to operate patients that are pooled together from all over the country following announcement for such mass repair. The center runs their clinic from Monday to Friday, they see on the average 5–7 patients per week, including new and follow-up cases. The facility has a rehabilitation center where patients who have had successful surgery are rehabilitated.

This study used a cross-sectional analytical study design. The study population comprised of patients who had undergone VVF repair at the health facility and gave their consent to participate in the study. Ethical approval for the conduct of this research was obtained from the Sokoto State Health Research Ethics Committee. The minimum sample size was determined using the formula: n = Z2σ22. Allowing for a 90% response rate, we obtained a sample size of 81. The total number of VVF patients present in the health facility during the survey was 81, and we recruited all of them into the study.

The study instrument had two sections, a section that assessed Socio-demographics and another one that sought to determine the QoL of the respondents. The questions assessing QoL were adopted from the WHOQOL-BREF.[1],[2] It had two parts; the first part evaluated the patients' subjective assessment of her QoL and satisfaction with her state of health while the second part assessed the four domains: physical health, mental health, social health, and the environment. Both parts of the questionnaire present some questions with a five option Likert rating scale for the respondent to score. Open data kit (ODK) software was used to create the survey tool; the ODK was installed (via Google play store) on the smartphones/tablets of all the data collectors and used to collect data on the field in Hausa and English Languages.

Data cleaning involved manually checking for completeness and errors on the ODK, this was followed by data export to IBM (International Business Machines, New York, USA). Exploratory data analysis (using frequency distribution tables) was further conducted to identify errors in data entry. Frequencies were computed for the sociodemographic variables The WHOQOL-Bref protocol for calculating domain scores was used in obtaining the domain scores.[2] After item recoding and handling of missing data, a raw score is computed by a simple algebraic sum of each item in each of the four domains.[2] Once complete, the frequencies of each domain was checked to be sure that the scores are within the correct range. Subsequently, transformation of each raw scale score was done.[2] The possible raw score ranges for each domain are as follows: Physical health = 28, Psychological = 24, Social relationships = 12, and environment = 32.[2] The 4 domains are then scored, labeled, and transformed to a 0–100 scale used to interpret and compare to other validated instrument tools such as the WHOQOL-100.[2] Mean and standard deviations were then calculated for domain scores.

Correlations between a respondent's domain score and socio-demographics were reported. Some socio demographic variables with more than two groups were re-categorized into two groups. Pearson correlation coefficient (r) was computed for correlation between domain scores and age, while point-biserial correlation (rpb) was computed for bivariate correlation between domain scores and other binary categorical sociodemographic variables.


   Results Top


The mean age of respondents was 22.4 ± 4.9, with almost two-third (58 [71.6%]) in the 15–25 years age group. The majority (50 (61.7)) were married. Almost half of the women (39 (48.1)) were primipara [Table 1].
Table 1: Sociodemographic profile of study participants

Click here to view


The environmental domain had the highest mean score of 51.7 ± 11.8 while psychological domain had the least score of 41.3 ± 14.3. The mean overall QoL and general health were 49.5 ± 10.2 [Table 2].
Table 2: Domains and overall quality of life scores of study participants

Click here to view


Those in the 15–25 years of age group had a higher mean score for the social relationship than those in the age group 26–35 years and the difference was statistically significant, t = 2.310, P = 0.023 [Table 3]. Study participants in the 26–35 years of age group had higher mean scores for physical and psychological domains. Younger study participants had higher overall QoL and general health scores than older study participants
Table 3: Comparison of domain scores of study participants

Click here to view


There was a moderate positive correlation between physical domain score and age, this was statistically significant (r = 0.258, P < 0.005). There was also a positive correlation between Psychological domain score and Husband's educational status, i.e., the higher the educational level of the husband the higher the psychological domain score of the wife (rpb = 0.241, P < 0.05). Social relationship domain score positively correlated with being married, i.e., respondents who were currently married had higher social relationship domain scores (rpb = 0.414, P < 0.01). Environment domain positively correlated with Marital status, i.e., those who were married had higher environmental domain scores (rpb = 0.421, P < 0.01). The overall QoL positively correlated with marital status, i.e., those who were married had higher overall QoL scores (rpb = 0.337, P < 0.001) and husband's educational status (rpb = 0.259, P < 0.05) [Table 4].
Table 4: Correlation between domain scores and sociodemographic variables of study participants

Click here to view


Following stratification by age, there was no statistically significantly correlation between the domain scores and sociodemographic variables among respondents 26–35 years. In the 15–25 years age group, there is still positive correlation between marital status and social relationship (rpb = 0.457, P < 0.01), environment (rpb = 0.463, P < 0.01), and overall QoL (rpb = 0.441, P < 0.01) [Table 5].
Table 5: Correlation between domain scores and sociodemograhic variables stratified by age

Click here to view



   Discussion Top


Although VVF has been widely studied in Nigeria, most studies focused mainly on the physical aspects of the condition and there is a paucity of studies on the health related QoL of sufferers despite the well-known fact that the condition predisposes its sufferers to being pariahs and social outcasts in their communities. QoL is an important determinant of health and it is particularly important to determine the QoL in this socially stigmatizing condition.

This research was thus conducted to understand the perceived health-related QoL of VVF patients following repair services. Majority of the study participants were young and without formal education, similar to findings of other studies.[5],[9] Greater than half of the study participants were married, more than a third were divorced. Divorce has been reported as a sequela of VVF in quite a number of studies in Northern Nigeria.[5],[11],[13] This finding contrasts with a similar study conducted in Southern Nigeria which reported that none of the participants studied was divorced.[4] Almost half of the study participants were primipara; this result is in line with findings from similar studies that have reported primiparas as being the highest group affected in some centers in northern Nigeria.[5],[11],[13] This finding, however, contrasts with results from a similar study conducted in Nigeria which reported that the majority of the study population were grand multiparous women.[4]

Although it can be assumed that QoL of patients with VVF improves following a successful surgical correction, however this assessment is mainly a subjective one and can only be objectively assessed with the aim of a tool like the WHOQOL-Bref which was developed by the WHO to serve as a means for objectively measuring the QoL of individuals globally.

Comparing the four domains of the study respondents, the mean score in descending order; the physical, environment, social, and psychological with scores of 58.9 ± 11.9, 51.7 ± 11.8, 44.9 ± 19.0 and 41.3 ± 14.3, respectively, with an overall QoL score of 49.5 ± 10.2.

The mean overall Qol and general health score of study participants were lower than the scores obtained from a previous study in India (93.25).[9] Physical domain (which focuses on activities of daily living, mobility, work capacity, sleep, and rest) had the highest score in this study; this may be associated with successful surgical repair of VVF. Successful repair of VVF may have led to relief from persistent urinary leakage and perineal wetness giving rise to improved hygiene, sleep pattern and work capacity.[4],[9],[14],[15] However, this score was still lower than scores reported from other studies in India[9] and southern Nigeria.[4] Psychological domain (which reflects positive feelings, bodily image and appearance, self-esteem, personal beliefs) was also lower than that observed in a previous study conducted in India,[9] and southern Nigeria.[4] The low score may reflect experiences and or psychological trauma which the study participants suffered from before the repair of the fistula. Such experiences usually lead to feelings of low self-esteem, anxiety and depression, feelings which may not necessarily disappear immediately following the fistula repair.

Social relationship domain score, which assesses personal relationship, social support, sexual activity was also lower than scores reported from previous studies.[4],[9] In the study population, the psychological domain had the lowest QoL score while the physical domain recorded the highest score. This contrasts with the finding during the postoperative assessment by Singh et al., in which the overall QoL domain had the highest score and the environmental domain had the least score.[9] Differences in the research methodology as well as in the backgrounds of both study populations may explain this observation.

Younger women had a statistically significantly higher mean social relationship score compared to the older ones. A social relationship involves other people and women affected with VVF may require sometime to regain the level of activity they engaged in before the occurrence of the fistula.[16] The persistent leakage of urine, pervasive odor, and perineal excoriation disrupts the women's intimate sexual relationship and in extreme cases may lead to marital disharmony and divorce. This may be the reason behind the high rate of divorce observed in this study. The older study participants had higher physical and physiological scores compared with the younger study participants; there was a moderate positive correlation between physical domain score and age, these findings may not be unconnected to resilience to physical and psychological trauma that is associated with age.

The study observed that being married gave rise to higher social relationship score, higher environmental scores; the overall QoL score was also found to be positively correlated with marital status. This finding was also collaborated by a previous study conducted in rural Bangladesh which reported that marital status had a positive effect on the four domain scores.[17] This is not surprising as married individuals report better health, wellbeing and live longer than unmarried individuals.[18],[19],[20] Having a husband who had some formal education gave rise to a higher overall QoL scores, this may not be surprising as it has been reported that spousal education to some extent influence self-rated health measures.[21]


   Conclusion Top


The study adds to existing literature by objectively determining the QoL among patients who had undergone repair of VVF. The findings of this study have significant implications for clinical practice. The occurrence of higher scores in the physical and physiological domains among older respondents underscores the importance of reaching psychological maturity before embarking on pregnancy and child birth as it demonstrates the higher degree of resilience with advancing age. The need for social support for VVF sufferers is also fundamental given the observed higher overall QoL scores among sufferers who are currently married. It thus underscores the need to ensure an improved male involvement in pregnancy and childbirth among the male population in developing countries as this will likely result in an increased support for women both during pregnancy and childbirth as well as in the event of any complications thereafter. Conventionally, in these countries, pregnancy and childbirth is the purview of the female members of the household with the male members only getting involved in the financial aspects of pregnancy and childbirth. Involving the male partners in events throughout pregnancy and child birth will further help to support women as well as enable women to develop stronger coping strategies in the event of a fistula complicating childbirth.

Instead of a one-point assessment of QoL as was performed in this, future research should compare the pre and post-operative QoL of women who undergo repair of obstetric fistula.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
World Health Organization. WHOQOL: Measuring Quality of Life. Geneva: World Health Organization; 2020. Available from: http://www.who.int. [Last accessed on 2020 Jul 17].  Back to cited text no. 1
    
2.
World Health Organization. Whoqol-Bref Introduction, Administration, Scoring and Generic Version of the Assessment Field Trial Version. Geneva: World Health Organization; 1996. Available from: https://www.apps.who.int/iris/handle/10665/63529. [Last accessed on 2020 Jul 17].  Back to cited text no. 2
    
3.
Wong FY, Yang L, Yuen JW, Chang KK, Wong FK. Assessing quality of life using WHOQOL-BREF: A cross-sectional study on the association between quality of life and neighborhood environmental satisfaction, and the mediating effect of health-related behaviors. BMC Public Health 2018;18:1113.  Back to cited text no. 3
    
4.
Umoiyoho A, Inyang-Etoh EC, Abah GM, Abasiattai AM, Akaiso OE. Quality of life following successful repair of vesicovaginal fistula in Nigeria. Rural Remote Health 2011;11:1734.  Back to cited text no. 4
    
5.
Ijaiya MA, Rahman AG, Aboyeji AP, Olatinwo AW, Esuga SA, Ogah OK, et al. Vesicovaginal fistula: A review of Nigerian experience. West Afr J Med 2010;29:293-8.  Back to cited text no. 5
    
6.
Orji EO, Adeloju OP, Orji VO. Correlation and impact of obstetric fistula on motherhood. J Chin Clin Med 2007;2:448-54.  Back to cited text no. 6
    
7.
AbouZahr C. Global burden of maternal death and disability. Br Med Bull 2003;67:1-11.  Back to cited text no. 7
    
8.
Mikah S, Daru P, Karshima J, Nyango D. The burden of vesico-vaginal fistula in North Central Nigeria. J West Afr Coll Surg 2011;1:50-62.  Back to cited text no. 8
    
9.
Singh V, Jhanwar A, Mehrotra S, Paul S, Sinha RJ. A comparison of quality of life before and after successful repair of genitourinary fistula: Is there improvement across all the domains of WHOQOL-BREF questionnaire? Afr J Urol 2015;21:230-4.  Back to cited text no. 9
    
10.
Wall LL. Obstetric vesicovaginal fistula as an international public-health problem. Lancet 2006;368:1201-9.  Back to cited text no. 10
    
11.
Ijaiya MA, Aboyeji AP, Ijaiya ZB. Epidemiology of vesico-vaginal fistula at the university of Ilorin teaching hospital, Ilorin, Nigeria. Trop J Obstet Gynaecol 2002;19:101-3.  Back to cited text no. 11
    
12.
Baba SB. Birth and sorrow: The psycho-social and medical consequences of obstetric fistula. Int J Med Sociol Anthropol 2014;2:55-65.  Back to cited text no. 12
    
13.
Wall LL, Karshima JA, Kirschner C, Arrowsmith SD. The obstetric vesicovaginal fistula: Characteristics of 899 patients from Jos, Nigeria. Am J Obstet Gynecol 2004;190:1011-9.  Back to cited text no. 13
    
14.
Nielsen HS, Lindberg L, Nygaard U, Aytenfisu H, Johnston OL, Sørensen B, et al. A community-based long-term follow up of women undergoing obstetric fistula repair in rural Ethiopia. BJOG 2009;116:1258-64.  Back to cited text no. 14
    
15.
Kopp DM, Tang JH, Bengtson AM, Chi BH, Chipungu E, Moyo M, et al. Continence, quality of life and depression following surgical repair of obstetric vesicovaginal fistula: A cohort study. BJOG 2018;126:926-34.  Back to cited text no. 15
    
16.
Mwangi J, Mutiso S, Puri R, Gatebi J. Quality of life in pre-and posttreatment among obstetric fistula patients at Kisii Hospital, Kenya. Clin Health Promot 2012;2:59-63.  Back to cited text no. 16
    
17.
Imoto A, Matsuyama A, Ambauen-Berger B, Honda S. Health-related quality of life among women in rural Bangladesh after surgical repair of obstetric fistula. Int J Gynaecol Obstet 2015;130:79-83.  Back to cited text no. 17
    
18.
Gardner J, Oswald A. How is mortality affected by money, marriage, and stress? Health Econ 2004;23:1181-207.  Back to cited text no. 18
    
19.
Lorenz FO, Wickrama KA, Conger RD, Elder GH Jr. The short-term and decade-long effects of divorce on women's midlife health. J Health Soc Behav 2006;47:111-25.  Back to cited text no. 19
    
20.
Manzoli L, Villari PM, Pirone G, Boccia A. Marital status and mortality in the elderly: A systematic review and meta-analysis. Soc Sci Med 2007;64:77-94.  Back to cited text no. 20
    
21.
Brown DC, Hummer RA, Hayward MD. The importance of spousal education for the self-rated health of married adults in the United States. Popul Res Policy Rev 2014;33:127-51.  Back to cited text no. 21
    



 
 
    Tables

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



 

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 Tables

 Article Access Statistics
    Viewed459    
    Printed4    
    Emailed0    
    PDF Downloaded7    
    Comments [Add]    

Recommend this journal