• Users Online: 927
  • Print this page
  • Email this page


 
 
Table of Contents
ORIGINAL RESEARCH
Year : 2022  |  Volume : 15  |  Issue : 2  |  Page : 66-70

Financial benefit of antidiabetic drugs available at jan aushadhi (people's drug) stores to geriatric pensioners: A pilot study from India


1 Department of Pharmacology, Amrita Institute of Medical Sciences, Ernakulam, Kerala, India
2 A.J. Institute of Medical Sciences and Research Centre, Mangalore, Karnataka, India
3 Research Unit, Mangalore Institute of Oncology, Mangalore, Karnataka, India

Date of Submission22-Sep-2021
Date of Decision29-Sep-2021
Date of Acceptance05-Oct-2021
Date of Web Publication04-Jul-2022

Correspondence Address:
Manjeshwar Shrinath Baliga
Mangalore Institute of Oncology, Pumpwell, Mangalore, Karnataka
India
Princy Louis Palatty
Department of Pharmacology, Amrita Institute of Medical Sciences, Peeliyadu Road, Ernakulam, Kerala
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/hmj.hmj_64_21

Rights and Permissions
  Abstract 


Background: For the elderly, affected with Type II diabetes the costs for medications can be immense and forms a substantial part of their savings and pensions. Aims and Objectives: Diabetes mellitus is a major health issue in India and the treatment costs severely affect the elderly who are dependent on their family or on their pensions. In this study, we evaluated the economic cost of branded versus Jan Aushadhi drugs for geriatric pensioners. Materials and Methods: This was an observational, cross-sectional study and was conducted at the outpatient department of General medicine and Endocrinology at Amrita Institute of Medical Sciences, Ernakulam, Kerala, India. The prescriptions of patients attending the clinic for the care of type II diabetes and associated co-morbidities were analysed. The age, sex, and the number of medications were noted. The price of the costliest, cheapest, and most prescribed branded drugs were noted from the CIMS index 2020, while that for Jan Aushadhi drug was observed from the price catalogue. The financial cost burden on retired aged citizens was calculated by considering INR 8000 as the pension amount. Results: The average cost of the drugs when bought from the costliest brands amounted to 2592.52, of which 750.31 amounted for antidiabetics, while when purchased from Jan Aushadhi was 542.3 and 350.46, respectively. The percentages of the cost required for monthly treatment for an individual with 8000 INR pension for the branded drug was 32.4% and 6.77% for all medications and antidiabetic drugs, while when bought from Jan Aushadhi was 9.37 and 4.38, respectively. Conclusions: A significant difference between cost for Jan Aushadhi and branded drugs and this can be of benefit to the geriatric pensioners. As far as the authors are aware of this is the first study that addresses the beneficial effect of Jan Aushadhi antidiabetic drugs in the geriatric pensioners and has high relevance and use in public health.

Keywords: Branded, co-morbidities, diabetes mellitus, Indian national rupee, Jan Aushadhi generic drug


How to cite this article:
Mamatha J, Palatty PL, Sachendran D, Vijendra R, Baliga MS. Financial benefit of antidiabetic drugs available at jan aushadhi (people's drug) stores to geriatric pensioners: A pilot study from India. Hamdan Med J 2022;15:66-70

How to cite this URL:
Mamatha J, Palatty PL, Sachendran D, Vijendra R, Baliga MS. Financial benefit of antidiabetic drugs available at jan aushadhi (people's drug) stores to geriatric pensioners: A pilot study from India. Hamdan Med J [serial online] 2022 [cited 2022 Aug 8];15:66-70. Available from: http://www.hamdanjournal.org/text.asp?2022/15/2/66/349782




  Introduction Top


Globally, type II diabetes is a 'public health priority' and irrespective of the gender, ethnic background, financial and domicile status, the incidence of diabetes is exponentially increasing and attaining a high percentage in both developing and developed economies.[1],[2] From an Indian perspective, recent reports suggest that after China, India has the second-largest of diabetic population of approximately 73 million and predictions based on the recent scientific evidence and trend analysis indicate that the numbers may increase to 134 million in the year 2045.[3] From a percentage perspective, conservative estimates are that people affected with diabetes constitute close to 8.9% of the Indian population.[4] Worse, the incidence of diabetes is exponentially increasing and has been highlighted by several investigators in the recent past.[4],[5],[6]

Reports also suggest a large difference in the prevalence and that the regional and socio-economic differences have a role in some population.[7] However, when compared to the recent past decade with the same study population, there is undoubtedly an increase in the prevalence among the urban poor, the middle class and also in the rural population suggesting the ailment will be a major health issue in the coming decades.[8],[9] The major reason attributed for this is that in association to the genetic predisposition; over the last two decades, contributory factors like rural to urban migration of a large population, socio-economic transitions, urbanisation, lifestyle changes, sedentary lifestyle, increase in obesity, physical inactivity coupled with low exercise regimen have contributed for the increase in diabetes in India.[10],[11],[12],[13],[14] To precipitate, managing diabetes and its co-morbidities is major challenge principally because of lack of awareness on the risk and prevention strategies, financial and educational status, knowledge on the pathogenesis of the ailment and non-adherence to medicines contribute to the problem immensely.[15],[16],[17],[18],[19],[20]

What is extremely worrying is that while the incidence of diabetes increases in the elderly (above 65)[21] in the developed countries, in India, the increase in incidence is seen to occur in the individuals in the age group of 45–60 years.[7] Most people in the age group of 45–60 years are in the peak of their productive period of their lives and have immense responsibility for the sustenance of their family. When an earning member of the productive age group gets affected, it has repercussions on the affected individual, their family, the society and country at large.[21],[22] The matter of worry is that a person affected with diabetes in his mid-life can develop macrovascular or microvascular complications that aggravate the disease burden.[23] Further, the significant morbidity associated with diabetes necessitates the need for multitude of drugs with different pharmacological endpoints and this will increase the financial costs to the individual.[22],[23],[24],[25],[26],[27]

Globally, the costs for effective treatment of diabetes are rapidly increasing and factors like duration of diabetes, the severity of the ailment and the co-morbidities have a bearing on both direct and indirect treatment costs.[15] For a developing country like India, which has the world's second-highest number of diabetics, the financial burden on the health-care system and the affected individual is colossal.[15] Reports also indicate that in 2017, India spent 31 billion US dollars on diabetes care and that this was the fourth highest after the USA, China and Germany.[15]

In India, majority of the people do not have insurance schemes and policies and the affected patients have to pay substantial amount of the treatment costs from out-of-pocket.[1] The cost of antidiabetic drugs can be immense[28] and reports from the American Diabetes Association suggest that in the year 2018, the total cost of treating diabetes was $327 million and that it increased to 26% over a period of 5 years.[29] Studies from India have also shown that in 2013, the average cost per diabetic patient with co-morbidities was USD 314.15, while that of an individual without co-morbidities was USD 29.91[25] and that since 1990 the escalation has been high.[4] Of all the population, the elderly are highly affected when they are affected by chronic ailments. The treatment and medication costs can be very high and severely affect the elderly who are dependent on their pension or saved income.[25]

In India, almost 80% of the drugs are branded and their costs are higher than their unbranded counterparts.[23] With the objective of improving the quality of affordable health care, in 2008, the Government of India started Jan Aushadhi Scheme (JAS), a public medicine system to facilitate dispensing generic medicines at affordable prices to the needy through designated stores across the country.[30] The principal objective for initiating this scheme was the observation that although India is the largest supplier of generic drugs to the world, the marginalised populations of the country had limited access to these medicines. This was mainly because the branded medicines had a monopoly in the market and sold drugs at higher prices than the generic equivalents.[30]

From a functioning and administrative perceptiveness, the JAS scheme is strictly monitored and administered by the Department of Pharmaceuticals and the Ministry of Chemicals and Fertilisers, Government of India.[30] The drug procurement dispended through the JAS, the Government of India procures medicines from both private manufacturers and central public sector undertakings through tenders.[30] These drugs are then checked for quality and in a systematic manner in which the medication from every batch are tested in designated empanelled National Accreditation Board for Testing and Calibration Laboratories.[30] On quality certification, these drugs are then sent to every JAS outlet through a distribution system.[30] All these are adhered to principally to provide pharmaceutically graded good quality of medicines at affordable prices to the general population.[30]

In India, most people do not have health insurance cover and this problem is more in the elderly who in most cases are dependent on their savings or on their family members for their medication and health check-up requirements.[23] The burden of out-of-pocket medication expenditure for the elderly can be substantial and this is extremely bothersome for people needing medications to manage their chronic health issues such as diabetes, hypertension and cardiac ailments.[23],[24],[25],[26],[27] The low-income status combined with neglect in the family can aggravate the issue and affect mental and physical health.[23] In lieu of all these observations, a way in which the medication cost can be reduced will be extremely useful. Considering these aspects, an attempt is made at understanding the pharmacoeconomic difference between branded verses Jan Aushadhi drugs used in the care of elderly diabetics.


  Materials and Methods Top


This was a prospective observational chart-based study and was carried out at Amrita Institute of Medical Sciences, Ernakulam, Kerala, India, from 1st December 2020 to 31st January 2021 after obtaining permission from the institutional ethics committee (IEC/Amritha/2019/PHARMA-038). The inclusion criteria consisted of patients suffering from type 2 diabetes mellitus, patients receiving at least one antidiabetic drug and other concomitant medications prescribed by the physician. The sample size was calculated based on the Mean ± standard deviation of the cost of drugs from Jan Aushadhi and the cost of drugs from the pharmacy for geriatric diabetic patients (412.937 ± 115.3230 and 1296.854 ± 327.8397). Considering 80% power and 95% confidence, the minimum sample size came to 16. As the study emphasised also on percent cost burden, a total of 20 samples were included in the study. Exclusion criteria consisted of lactating or pregnant women, nursing a child and paediatric age groups, unwilling patients.

The drug prescriptions of patients who attended the clinic suffering from type 2 diabetes were analysed. Their age, sex, number of drugs and class of drugs prescribed was noted. For comparative cost analysis, the costs of the costliest, cheapest, and most prescribed branded drugs were understood by referring into CIMS index 2020. For the Jan Aushadhi drug, the cost was noted from the price catalogue available. To ascertain the financial cost burden on a common citizen, an average amount of INR 8000/-was considered as the pension amount for most geriatric population based on reports from the community. The percentages of the cost required for monthly treatment for diabetes among the pensioners were determined using standard formula drug cost/monthly income ×100.


  Results Top


The results of the study suggest that 65% were male, while 35% were female. Majority of the participants were in the age group of 60–70 years (80%). The average number of drugs prescribed was 7.45, of which 2.6 were antidiabetics. With regard to the non-antidiabetic drugs, atorvastatin (9/20) and cilnidipine (8/20) were the most prescribed drugs. Among the antidiabetic drugs, metformin (12/20) and mixtard (10/20) were the two most prescribed. The cost analysis showed that there was wide difference between the cost of branded drugs with JAS for metformin and pantoprazole [Table 1]. In addition, the average costs of the drugs when bought from costliest brands amounted to 2592.52, of which 750.31 amounted for antidiabetics. On the contrary, when bought from JAS, it was 542.3 and 350.46, respectively, for total drugs and antidiabetic drugs. Most importantly, the percentages of the cost required for monthly treatment for an individual with 8000 INR pension showed for the branded drug, it was 32.4% and 6.77% for all medications and antidiabetic drugs, while if opted for JAS, it was 9.37 and 4.38 respectively [Figure 1].
Table 1: The details on age, gender and the drugs used in the study population

Click here to view
Figure 1: Percentage of pension spent on total drugs

Click here to view



  Discussions Top


Reports indicate that diabetes attaining an epidemiologic proportion severely affects the financial status and worse the chronic nature and predictions of increase in the number of diabetes will severely affect the individuals and nation's economy.[15],[31] Of worry is the economically compromised geriatric population dependent on their children and family members. Paying a significant part of the household income for diabetic medications and for a prolonged period can be a burden for the earning member.[32],[33],[34],[35] Depending on the number and severity of the co-morbidities the cost of medication can be high and this severely affects their livelihood and family dynamics and this can consequentially affect the mental health of the elderly.[33],[34],[35],[36] In lieu of these, a need for propagating the use of affordable generics drugs was felt and the JAS scheme initiated by the government is an important endeavour.[30]

From an Indian perspective, the majority of the people do not have insurance.[37] Conservative estimates are that 85%–95% of health care and treatment costs are borne by the affected individual from the monthly household income.[37] In this study, it was observed that the average cost incurred when procuring the branded drugs from stores was INR 2592.52/-per month as against INR 542.3/-from the Jan Aushadi, and the difference being almost five times. Further, the average cost of antidiabetic drugs at Jan Aushadhi stores was INR 350, while it was INR 750.31 in the general pharmacy. With regard to the antidiabetic drug metformin and pantoprazole, a proton-pump inhibitor, almost 10 and 20 fold difference in cost was observed between Jan Aushadi and the highest cost variant available in the market [Table 1]. Several studies have shown that generic drugs were as effective as branded drugs and satisfied the Indian Pharmacopoeial standards for quality.[38] Reports also affirm that substitution with generics can result in almost 15% savings on the medication cost.[39]

The most important aspect of the study is that we extrapolated the financial toxicity considering the elderly who are solely dependent on their pensions for their sustenance. Considering an average pension amount to be INR 8000, we calculated the percentage of the amount spent on the medicines every month and our observations suggest that if drugs were procured from JAS, it accounted for 6.77%, as against32.40% with branded drugs. In addition, with antidiabetic medications, it was observed that when the JAS drugs were procured, it accounted for 4.38% of the pension as against 9.37% for branded medicines.

From an individual viewpoint, the medical costs expended by diabetics is estimated to be two to five folds more than that by an age-matched person without diabetes.[37] The direct costs of treatment of diabetes varies from place to place and to substantiate this reports indicate that in the rural and urban poor, direct expenses amount to 27%–34%, while in the middle-to-high income groups, it constitutes 5.0%–12.6% and 4.8%–16.9%, respectively, of the household income.[40] Worse the annual increment in the costs of drugs exerts additional burden especially on the economically marginalized and impoverished groups.[40] Under these circumstances, JAS, which is now available throughout India, is very useful in reducing the direct costs and the incurring financial burden on the household earning of the affected individual.


  Conclusions Top


The incidence of diabetes is high in elderly people who are dependent on their children and or on pension or savings. Our observations indicate that procuring drugs from JAS was cheaper and that this would be beneficial for people from lower financial strata and for elderly pensioners with multiple co-morbidities. As far as the authors are aware of this is the first study that addresses a comparative cost analysis between the branded drugs and generic drugs dispensed through the JAS outlets. Further studies are underway to ascertain the benefit of the JAS in the geriatric population affected with a range of chronic ailments and by considering their financial status and family cohesiveness. The outcome of this study will be very useful from both health economic and societal perspectives.

Ethical clearance

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The study was conducted after obtaining clearance from Institutional Ethics Committee (IEC/Amritha/2019/PHARMA-038).

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgements

The authors are grateful to all the patients who participated in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kumpatla S, Kothandan H, Tharkar S, Viswanathan V. The costs of treating long term diabetic complications in a developing country: A study from India. JAPI 2013;61:1-17.  Back to cited text no. 1
    
2.
International Diabetes Federation (IDF). Diabetes in South-East Asia. Available from: https://www.idf.org/our-network/regions-members/south-east-asia/diabetes-in-sea.html. [Last accessed on 2021 Jul 19].  Back to cited text no. 2
    
3.
International Diabetes Federation: IDF Diabetes Atlas; 2017. Available from: http://www.idf.org/idf-diabetes-atlas-eight-edition. [Last accessed on 2021 Jul 01].  Back to cited text no. 3
    
4.
Guariguata L, Whiting DR, Hambleton I, Beagley J, Linnenkamp U, Shaw JE. Global estimates of diabetes prevalence for 2013 and projections for 2035. Diabetes Res Clin Pract 2014;103:137-49. doi: 10.1016/j.diabres.2013.11.002. Epub 2013 Dec 1. PMID: 24630390.  Back to cited text no. 4
    
5.
Anjana RM, Ali MK, Pradeepa R, Deepa M, Datta M, Unnikrishnan R, et al. The need for obtaining accurate nationwide estimates of diabetes prevalence in India-rationale for a national study on diabetes. Indian J Med Res 2011;133:369.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Shetty P. Public health: India's diabetes time bomb. Nature 2012;485:S14-6.  Back to cited text no. 6
    
7.
Bansode B, Jungari DS. Economic burden of diabetic patients in India: A review. Diabetes Metab Syndr 2019;13:2469-72.  Back to cited text no. 7
    
8.
Chan JC, Malik V, Jia W, Kadowaki T, Yajnik CS, Yoon KH, et al. Diabetes in Asia: Epidemiology, risk factors, and pathophysiology. JAMA 2009;301:2129-40.  Back to cited text no. 8
    
9.
Srinivasa SV, Majety P, Sindhuri K, Venkatarathnamma PN, Raghavendra PB, Gupta U. Study of diabetes care in urban and rural diabetics. J Evol Med Dent Sci 2014;34:9157-68.  Back to cited text no. 9
    
10.
Ramachandran A, Snehalatha C, Shetty AS, Nanditha A. Trends in prevalence of diabetes in Asian countries. World J Diabetes 2012;3:110-7.  Back to cited text no. 10
    
11.
Ng SW, Popkin BM. Time use and physical activity: A shift away from movement across the globe. Obes Rev 2012;13:659-80.  Back to cited text no. 11
    
12.
Misra R, Misra A, Kamalamma N, Vikram NK, Gupta S, Sharma S, et al. Difference in prevalence of diabetes, obesity, metabolic syndromeand associated cardiovascular risk factors in a rural area of Tamil Nadu and an urban area of Delhi. Int J Diabetes Dev Ctries 2011;31:82-90.  Back to cited text no. 12
    
13.
Dhanaraj S. Economic vulnerability to health shocks and coping strategies: Evidence from Andhra Pradesh, India. Health Policy Plan 2016;31:749-58.  Back to cited text no. 13
    
14.
Oommen AM, Abraham VJ, George K, Jose VJ. Prevalence of riskfactors for non-communicable diseases in rural and urban Tamil Nadu. Indian J Med Res 2016;144:460-71.  Back to cited text no. 14
[PUBMED]  [Full text]  
15.
Oberoi S, Kansra P. Economic menace of diabetes in India: A systematic review. Int J Diabetes Dev Ctries 2020;40:1-12.  Back to cited text no. 15
    
16.
Ramachandran A, Snehalatha C. Current scenario of diabetes in India. J Diabetes 2009;1:18-28.  Back to cited text no. 16
    
17.
Tharkar S, Devarajan A, Kumpatla S, Viswanathan V. The socioeconomics of diabetes from a developing country: A population based cost of illness study. Diabetes Res Clin Pract 2010;89:334-40.  Back to cited text no. 17
    
18.
Rao KD, Bhatnagar A, Murphy A. Socio-economic inequalities in the financing of cardiovascular & diabetes inpatient treatment in India. Indian J Med Res 2011;133:57-63.  Back to cited text no. 18
[PUBMED]  [Full text]  
19.
Tripathy JP, Prasad BM. Cost of diabetic care in India: An inequitable picture. Diabetes Metab Syndr 2018;12:251-5.  Back to cited text no. 19
    
20.
Viswanathan V, Rao VN. Problems associated with diabetes care in India. Diabetes Manag 2013;3:31-40.  Back to cited text no. 20
    
21.
Mohan D, Raj D, Shanthirani CS, Datta M, Unwin NC, Kapur A, et al. Awareness and knowledge of diabetes in Chennai – The Chennai Urban Rural Epidemiology Study [CURES-9]. J Assoc Physicians India 2005;53:283-7.  Back to cited text no. 21
    
22.
Shivaprakash G, Nishith RS, Basu A, Shivaprakash P, Adhikari P, Gopalakrishna HN, et al. Dispensing patterns and cost of glucose lowering therapies in diabetes mellitus patients at a tertiary care hospital in Southern India. Drug Invent Today 2012;4:671-3.  Back to cited text no. 22
    
23.
Singla R, Bindra J, Singla A, Gupta Y, Kalra S. Drug prescription patterns and cost analysis of diabetes therapy in India: Audit of an endocrine practice. Indian J Endocrinol Metab 2019;23:40-5.  Back to cited text no. 23
    
24.
Cavanagh P, Attinger C, Abbas Z, Bal A, Rojas N, Xu ZR. Cost of treating diabetic foot ulcers in five different countries. Diabetes Metab Res Rev 2012;28 Suppl 1:107-11.  Back to cited text no. 24
    
25.
Akari S, Mateti UV, Kunduru BR. Health-care cost of diabetes in South India: A cost of illness study. J Res Pharm Pract 2013;2:114-7.  Back to cited text no. 25
[PUBMED]  [Full text]  
26.
Acharya LD, Rau NR, Udupa N, Rajan MS, Vijayanarayana K. Assessment of cost of illness for diabetic patients in South Indian tertiary care hospital. J Pharm Bioallied Sci 2016;8:314-20.  Back to cited text no. 26
    
27.
Eshwari K, Kamath VG, Rao CR, Kamath A. Annual cost incurred for the management of type 2 diabetes mellitus – A community based study from coastal Karnataka. Int J Diabetes Dev Ctries 2019;39:590-5.  Back to cited text no. 27
    
28.
Bansal D, Purohit VK. Accessibility and use of essential medicine in health care: Current progress and challenges in India. J Pharmacol Pharmacother 2013;4:13-8.  Back to cited text no. 28
[PUBMED]  [Full text]  
29.
American Diabetes Association. Economic costs of diabetes in the U.S. in 2017. Diabetes Care 2018;41:917-28.  Back to cited text no. 29
    
30.
Mukherjee K. A cost analysis of the Jan Aushadhi scheme in India. Int J Health Policy Manag 2017;6:253-6.  Back to cited text no. 30
    
31.
Cho NH, Shaw JE, Karuranga S, Huang Y, da Rocha Fernandes JD, Ohlrogge AW, et al. IDF diabetes atlas: global estimates of diabetes prevalence for 2017 and projections for 2045. Diabetes Res Clin Pract 2018;138:271-81.  Back to cited text no. 31
    
32.
Kalra S, Jena BN, Yeravdekar R. Emotional and psychological needs of people with diabetes. Indian J Endocrinol Metab 2018;22:696-704.  Back to cited text no. 32
    
33.
Bansal R, Chatterjee P, Chakrawarty A, Satpathy S, Kumar N, Dwivedi SN, et al. Diabetes: A risk factor for poor mental health in aging population. J Geriatr Ment Health 2018;5:152-8.  Back to cited text no. 33
  [Full text]  
34.
Ganguly BB, Kadam NN. Age-related disease burden in Indian population. J Natl Med Assoc 2020;112:57-73.  Back to cited text no. 34
    
35.
Bhandari P, Paswan B. Lifestyle behaviours and mental health outcomes of elderly: Modification of socio-economic and physical health effects. Ageing Int 2021;46:35-69.  Back to cited text no. 35
    
36.
Beverly EA, Ritholz MD, Shepherd C, Weinger K. The psychosocial challenges and care of older adults with diabetes: “Can't do what I used to do; can't be who I once was”. Curr Diab Rep 2016;16:48.  Back to cited text no. 36
    
37.
Singh J. Economic Burden of Diabetes. In: Muruganathan A, Geetha T, editors. Vol. 23. Medicine Update. Association of Physicians of India, India; 2013. p. 205-8. Available from: http://apiindia.org. [Last accessed on 2021 Jul 01].  Back to cited text no. 37
    
38.
Joshi SS, Shetty YC, Karande S. Generic drugs – The Indian scenario. J Postgrad Med 2019;65:67-9.  Back to cited text no. 38
[PUBMED]  [Full text]  
39.
Cameron A, Mantel-Teeuwisse AK, Leufkens H, Laing R. Switching from originator brand medicines to generic equivalents in selected developing countries: How much could be saved? Value Health 2012;15:664-73.  Back to cited text no. 39
    
40.
Ali MK, Narayan KM. Innovative research for equitable diabetes care in India. Diab Res Clin Pract 2009;86:155-67.  Back to cited text no. 40
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1]



 

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
Discussions
Conclusions
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed585    
    Printed2    
    Emailed0    
    PDF Downloaded82    
    Comments [Add]    

Recommend this journal