• Users Online: 148
  • Print this page
  • Email this page


 
 Table of Contents  
ORIGINAL ARTICLES
Year : 2021  |  Volume : 12  |  Issue : 2  |  Page : 176-181

Utility of an Internet-based short message service in the care of children and adolescents with type 1 diabetes mellitus


1 Department of Pediatrics, Mehta Multispeciality Hospitals India Private Limited, Chennai, Tamil Nadu, India
2 Department of Pediatric Endocrinology and Diabetes, Mehta Multispeciality Hospitals India Private Limited, Chennai, Tamil Nadu, India

Date of Submission19-Jul-2020
Date of Decision13-Aug-2020
Date of Acceptance07-Oct-2020
Date of Web Publication31-Mar-2021

Correspondence Address:
Dr. Hemchand Krishna Prasad
Department of Pediatric Endocrinology, Consultant Pediatrician, No 2, Mc Nichols Road, Chetpet, Mehta Multispeciality Hospitals India Pvt Ltd, Chennai 600031, Tamil Nadu.
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jod.jod_65_20

Rights and Permissions
  Abstract 

Objective: To evaluate the impact of an internet-based intervention system and a short message service (SMS) using cellular phones on the diabetes care and glycemic control in children and adolescents with type 1 diabetes mellitus (DM). Materials and Methods: Observational study in children with type 1 DM on basal bolus regimen. After administering diabetes care education children were divided in 2 groups, group I received timely SMS on diabetes care and group II did not. At the end of 3 months detailed data of diabetes care was recorded. Analysis was done using Statistical Package for the Social Sciences. Results: In a total of 42 children, group I (21) who received the SMS and group II (21), completed the follow-up period of 3 months were included in the study. There was marginal improvement in glycosylated hemoglobin in group I (from 9.2 ± 1.7 to 8.8 ± 1.2); and a minimal increase observed in group II (from 8.8 ± 1.8 to 9.4 ± 1.9) (P > 0.05). The percentage of capillary blood glucose (CBG) values below and above the target range, mean CBG, frequency of self-monitoring blood glucose, significantly improved compared to the control group (P < 0.05). Conclusion: SMS-based education program lead to a significant improvement in self-monitoring blood glucose frequency, diabetes self-care and marginal increase in glycemic control.

Keywords: Intervention, self-monitoring blood glucose, short message service, type 1 diabetes


How to cite this article:
Lohiya N, Prasad HK, White S, Prasanna B, Sangalalingam T, Krishnamoorthy N. Utility of an Internet-based short message service in the care of children and adolescents with type 1 diabetes mellitus. J Diabetol 2021;12:176-81

How to cite this URL:
Lohiya N, Prasad HK, White S, Prasanna B, Sangalalingam T, Krishnamoorthy N. Utility of an Internet-based short message service in the care of children and adolescents with type 1 diabetes mellitus. J Diabetol [serial online] 2021 [cited 2021 Apr 16];12:176-81. Available from: https://www.journalofdiabetology.org/text.asp?2021/12/2/176/312670




  Introduction Top


Type 1 diabetes mellitus (DM) is on the rise in children. Type 1 DM cases in southeast Asia, according to the 6th edition of International Diabetes Federation Diabetes  Atlas More Details, India reported three new cases/1,00,000 children of 0–14 years;[1] In Chennai, incidence is 3.2 cases/1,00,000.[2] Adhering to health-care regimen by these children includes parental motivation, self-monitoring of blood glucose (BG) and therapeutic life-style changes, dietary changes, meticulous care during illnesses, recognition and treating hypoglycemia, and endocrine clinic follow-up visits several times per year. Tight glycemic control reduces the risk of complications of DM.[1],[2] On the basis of this observation, the American Diabetes Association (ADA) has recommended that all individuals with diabetes should attempt to achieve near-normalization of BG levels.[3] The International Society for Pediatric and Adolescent Diabetes (ISPAD) in its recent recommendation suggested a glycosylated hemoglobin (HBA1c) of 7.5 across all ages, including toddlers.[4] It is a challenge in developing countries to achieve this target owing to practical difficulties in monitoring of BG and adhering to diabetes care regimens.

To overcome patient fatigue, researchers all over the world have considered taking the help of technology in the form of telephonic calls as reminders, blue tooth-coupled device, web-based technologies, and mobile apps to control sugars.[5] The ISPAD has come out with the current evidence and practice of applicability of technology in care of children and adolescents with type 1 diabetes.[5]

Mobile phone has become an essential part of everyone’s life and is the easiest mode of communication. Short message service (SMS) is an excellent modality to create awareness in a concise way, providing support and motivating them for adherence to appropriate care of high standards. Utility of SMS services in a country like ours can have multiple benefits. First, it helps patients who face multiple difficulties in reaching doctors owing to logistic difficulties. Second, reinforces the advice given by doctors in clinic visits. Lastly, it primes the family to rationalize discussions with the doctor and save clinician time. Previous evidence on utility of smartphone adjuncts in self-care and glycemic control has yielded conflicting results.[6],[7] Researchers have attempted to optimize diabetes care using web-based programs,[8] mobile applications[9] and SMS based programs.[10],[11],[12] Hence, we decided to perform the current study with an aim of evaluating the impact of an internet-based SMS using cellular phones on the diabetes care and glycemic control in children and adolescents with type 1 DM under the care in our setting.


  Materials and Methods Top


We conducted a prospective observational study for 4 months at the pediatric diabetes and endocrine unit of a tertiary pediatric hospital of South India. Children diagnosed to have type 1 DM as per ISPAD guidelines on basal bolus regimen and on follow-up with parental access to the cell phones and able to read and write English were included in the study. Children with secondary DM, DM type 2, drug-induced DM, on split mix regimen, and neonatal DM were excluded from the study. Baseline assessment of growth and Tanner’s stage of sexual maturity was performed. Pubertal assessment was performed by a single pediatric endocrinologist in the study by physical assessment. Sexual Maturity Rating (SMR) assessments performed on girls with minimal clothing in complete privacy with a female staff nurse and mother, for boys in the presence of father. Basic education about diabetes care was given to all children on follow-up as a regular program of management and care which included counseling about the nature of the disease and insulin therapy,[13] about the necessity of proper diet with matched insulin-carbohydrate ratio,[14] daily BG monitoring and hypoglycemia management, sick day management, and structured diabetes education by the diabetic team including physicians, intensivist, dietician and diabetic educator.[15]

Children and adolescents in the study were divided into two groups using computer-generated random numbers. Group I were sent pre-formulated SMS, reminding the child about the regular checking of glucose, reminding about insulin administration, about sick-day management, checking of ketones, reminding to correct hypoglycemia, regular exercises, and also motivating them by quotes (frequency of SMS––weekdays 5, weekend 5). Also, one SMS each of motivation and exercise in diabetes were sent per week. A total of 150 SMS per child were sent to the parents for 3 months. The time, date, and number on which SMS were sent were noted and stored in an excel sheet from the SMS service provider. Both the groups were on regular follow-up. It was ensured that all messages were reinforcement of what has been taught to them at clinic. The recruitment period was for 1 month and rest of the three months the intervention was done. Group II did not receive any SMS during the study period. At the end of 3 months follow-up data were recorded.

Both the group subjects were managed as per the ISPAD 2018 guidelines.[4] They were in touch with the diabetes team through telephone, as necessary. They were assessed for glycemic control using HBA1c, mean and variability of percentage of capillary BG targets recommended by ISPAD,[4] Self-Monitoring Blood Glucose (SMBG) frequency-cross checked with glucometer, regularity of log book maintenance, correct counting of carbohydrates, correction of basal and bolus dose of insulin, frequency of hypoglycemic episodes, inappropriate correction of hypoglycemia, frequency of forgetting insulin injection, number of illness and sick day management, episodes of breakthrough DKA, frequency of ketone checking and action taken, post-exercise hypoglycemia, frequency of calls to unit, regularity of visit and motivation satisfaction and self-confidence among both the groups were recorded.

Ethical approval was taken from the institutional review board (IRB approval number: IRB-MCH/01/2016). Written consent from parents and assent from children. Anonymity and confidentiality were guaranteed to participants.

Statistical analysis

Sample size estimation

Based on the previous meta-analysis, the mean of HbA1c in the intervention group is reduced by 0.25 (95% confidence interval: 0.41, 0.09) the effect size was estimated to be 0.61. Prior data indicate the standard deviation of 1.7 and 0.775 in the control and experimental groups, respectively. With the power of 0.8 and type I error probability of 0.05 the sample size calculated was 17 subjects in each group.

Analysis was performed using Statistical Package for the Social Sciences 22 version software. Data normalcy was ascertained using the Shapiro–Wilk’s test. Data were presented as mean ± SD or proportions as appropriate. Differences in study participants’ characteristics were compared across subgroups with chi-square test for categorical variables and independent t test for continuous variables as appropriate. Paired t test or were also used to test difference between assessment points. A bar plot was constructed to depict distribution of sugar values in the two groups. A value of P < 0.05 was considered statistically significant.


  Results Top


Of 221 children registered in the diabetes clinic, 124 children had type 1 diabetes and were on regular follow-up in the diabetic clinic. Of these, 50 children satisfied the inclusion criteria, of whom 45 consented to participate in the study. 45 families were randomly divided to either group I (n = 23) to receive educative SMSs or group II (n = 22) not to receive the educative SMSs and underwent the study. The baseline characteristics of the two groups pertaining to: chronological age, duration of diabetes, sex, pubertal status, and insulin requirement are summarized in [Table 1]. At the end of 3 months, 21 children each in groups I and II came for follow-up and had their outcome measures analyzed. One child in each group was lost to follow-up. One child in group 1 was excluded as the family used a “DIASMART app” which is an educative interactive app whose impact on the outcome measures may alter the results [Figure 1].
Table 1: Baseline characteristics of children and adolescents in groups I and II

Click here to view
Figure 1: Recruitment and follow-up of the study sample

Click here to view


Glycemic control

At the end of study period, we observed that there was an improvement in HBA1cin group I (from 9.2 ±1.7 to 8.8 ± 1.2); versus an increase observed in group II (from 8.8 ±1.8 to 9.4 ± 1.9); (P > 0.05), depicted in [Figure 2]A. The percentage of capillary blood glucose (CBG) values below target, in target and above target as per ISPAD 2018 guidelines in two groups were: 10% and 6.8% (P < 0.05); 26.9% and 19.9% (P > 0.05) and 63.1% and 73.2% (P < 0.05), respectively [Figure 2]B. A comparison of the mean CBG during the study period showed a significantly lower mean CBG of 187.6 ± 17.3 in group I compared to 205.4 ± 35.6 in group II (P < 0.05) [Figure 2]C. The change in HBA1c from baseline was compared in groups I and II. The mean change in HBA1c was -0.3 ± 0.2 versus +0.5 ± 0.2 (P < 0.05) in groups I and II, respectively.
Figure 2: (A) Comparison of glycosylated hemoglobin among children in groups I and II. (B) Comparison of CBG values divided as per ISPAD recommended targets among children in groups I and II. (C) Comparison of CBG values in groups I and II. *P < 0.05; CBG = capillary blood glucose

Click here to view


Self-monitoring blood glucose

During the period of intervention, it was observed that the frequency of SMBG was significantly higher in group I that received SMS education versus those in group II who did not receive educational SMS, that is, 0.57 ± 0.19 episodes per patient per day and 0.37 ± 0.20 episodes per patient per day, respectively (P < 0.05) [Figure 3].
Figure 3: Comparison of SMBG frequency in the two groups

Click here to view


Self-care

It was observed that log book maintenance was good, poor, and not maintained in 50.1%, 31.4%, and 9.5%, respectively, in group I; the corresponding values in group II was 38.1%, 47.6%, and 14.3%. A higher percentage of families in group II (66.7%) admitted to grazing (eating in between meals) when compared to families in group I (47.6%). The frequency of missed basal injection was similar in both the groups (0.15 episodes per patient year of follow-up). However, the missed bolus injection was higher in group II compared to group I (0.63 versus 0.47; P > 0.05).

Hypoglycemia

Although the frequency of documented hypoglycemia is higher in group I (4.3% versus 3.3%), the frequency of severe hypoglycemia is higher in group II (0.6% versus 0.2%); (P > 0.05). The frequency of inappropriate presumed symptomatic hypoglycemia and usage of chocolates for hypoglycemia correction is higher in group II [Table 2].
Table 2: Diabetes care aspects in the two study groups

Click here to view


Sick days

All children had access to ketone testing. 100% and 86% of children in group I and II tested for urine ketones and took appropriate action. One child in each group developed breakthrough DKA despite checking ketones (extrapolated to 0.15 episodes per patient year). The child in group I developed DKA, despite taking appropriate measures after testing ketones; whereas the family of child in group II failed to take action based on urine ketone test.

There was no mortality during study period.


  Discussion Top


We have looked into impact of simple SMS technology on health-care of diabetes and glycemic control in children and adolescent with type 1 DM. We observed a significant improvement in SMBG frequency in those who received SMS. A study on Internet-based contingency management in 4 adolescents observed an increase in SMBG frequency.[16] A similar app-based study that linked the glucometer readings to the app via a blue tooth device in 20 adolescents on Canada resulted in an increase in SMBG frequency and 88% satisfaction.[17] We hypothesize that simple automated reminders result in a behavioral change in the family to increase SMBG. Also the content of the messages educating the value and impact of SMBG and dose adjustment and its impact on glycemic control could have added to the same. Previous studies have shown that BG measurement frequency was significantly associated with better metabolic control, with a drop of HBA1c of 0.2% for one additional reading per day.[18]

We observed that there was an improvement in HBA1c in those who received SMS. A South Indian study used an app-based system to observe a similar improvement in HBA1c.[10] Franklin et al.[19] in a study on 126 subjects with type 1 DM similar to ours using sweet talk––an SMS-based education system observed that there is an improved of diabetes self-care management skills, but no improvement in glycemic control. Berndt et al.[20] studied 68 children and adolescents in Germany and did not observe a significant improvement in HBA1c. A study on 123 children with type 1 DM using telephone as an educational tool failed to elicit an impact on HBA1c, knowledge, psychosocial aspects, and compliance to regimen.[21] A study on 12 adolescents in Norway using an app-based technology using picture-based diabetic diary to record physical activity and food eaten resulted in better knowledge, but not improved glycemic control.[22] A study on 10 adults with Type 1 DM on usage of Diabmemory application for 3 months resulted in a significant improvement in HBA1c.[23]

Although we observed a higher percentage of CBG values in target in group I and a higher percentage of CBG values above and below the target in group II; we did not see a significant reduction in HBA1c. Possible explanations for this observation would include: short duration of the study or inability of HBA1c (which is a mathematical average) to reflect the improved glycemic control, which is better reflected in the CBG values. Data from an international study group on childhood diabetes have not shown a correlation between insulin regimen and glycemic control, suggesting that factors such as self-care behaviors and educational models likely have substantial impact.[24] We anticipate that the higher SMBG and better self-care would result in a significant improvement in HBA1c in subsequent follow-up. The increase in HBA1c in group II, despite receiving structured diabetes education by +0.5 has been observed in our study. The lower SMBG frequency and higher frequency of presumed hypoglycemia, frequency of missed injections, taking chocolate for hypoglycemia are probable contributory factors for rise in HbA1C in group II.

We did observe an increase in hypoglycemia in the intervention group, but higher severe hypoglycemia in the non-intervention group. This is in agreement with the study by Berndt et al.[25] who did not find a difference in severe hypoglycemia. More checking of sugar will lead to more detection of abnormal sugar. Although our sample size is not powered to interpret difference in severe hypoglycemia, this is an area for further potential research as severe hypoglycemia is the worst nightmare for any parent of a diabetic child and reduction in severe hypoglycemia would be a boon for the parents.

The lesser frequency of presumed symptomatic hypoglycemia, reduced usage of chocolates for hypoglycemia correction, better log book maintenance and lesser frequency of missed bolus injections reflect better self-care skills in the intervention group and will contribute to the better care of diabetes on a wider perspective.

We wish to clarify certain aspects of methodology. Our center caters to diabetic children from affluent educated families that have good access to technology. All values entered in the logbook were cross-verified in the glucometer to ensure accuracy. A period of 3 months was chosen because HBA1c is likely to reflect the glycemic control for the previous 3 months.

Our study is not without limitations: Certain aspects of self-care like site rotation, frequency of needle change, frequency of lancet change, needle priming, etc could not be ascertained as it was difficult for the subjects to record the same in the logbook. We did not collect the per capita income from the families as that could be a confounder for the SMBG frequency (the diabetes care is funded by the family, no public funding). As we cater to the private sector, this may be a non-decisive factor. Psychological well-being, self-esteem, and self-confidence were not assessed as there are no validated tools (in Indian adolescents) for the same. Utility of continuous glucose monitoring, which has been shown to improve diabetes control,[26] has not been evaluated as a part of this study.

We conclude that the usage of SMS based education program has led to a significant improvement in SMBG frequency and other aspects of diabetes self-care and a marginal improvement in glycemic control. Usage of SMS-based education program should be adopted as a part of care of children with type-1 diabetes.

Acknowledgement

The authors thank Sollu.com for helping in delivering the SMS technical support.

Authors’ contribution

The study was conceived by HKP and NL. NL, HKP, SW, BP, and TS were involved in the care of children and conduct of the study. Data collection was performed by NL and NK. NK was involved in the analysis. All authors contributed to the manuscript and HKP shall act as a guarantor of the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Aguiree F, Brown A, Cho N, Dahlquist G, Dodd S, Dunning T, et al. IDF Diabetes Atlas. 6th ed. Brussels: International Diabetes Federation; 2013.  Back to cited text no. 1
    
2.
Ramachandran A, Snehalatha C, Krishnaswamy CV Incidence of IDDM in children in urban population in southern India. Madras IDDM registry group Madras, south India. Diabetes Res Clin Pract 1996;34:79-82.  Back to cited text no. 2
    
3.
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care 2014;37:S14-80.  Back to cited text no. 3
    
4.
DiMeglio LA, Acerini CL, Codner E, Craig ME, Hofer SE, Pillay K, et al. ISPAD clinical practice consensus guidelines 2018: Glycemic control targets and glucose monitoring for children, adolescents, and young adults with diabetes. Pediatr Diabetes 2018;19:105-14.  Back to cited text no. 4
    
5.
Sherr JL, Tauschmann M, Battelino T, de Bock M, Forlenza G, Roman R, et al. ISPAD clinical practice consensus guidelines 2018: Diabetes technologies. Pediatr Diabetes 2018;19:302-25.  Back to cited text no. 5
    
6.
Knox ECL, Quirk H, Glazebrook C, Randell T, Blake H Impact of technology-based interventions for children and young people with type 1 diabetes on key diabetes self-management behaviours and prerequisites: A systematic review. BMC Endocr Disord 2019;19:7.  Back to cited text no. 6
    
7.
Hou C, Carter B, Hewitt J, Francisa T, Mayor S Do mobile phone applications improve glycemic control (hba1c) in the self-management of diabetes? A systematic review, meta-analysis, and GRADE of 14 randomized trials. Diabetes Care 2016;39:2089-95.  Back to cited text no. 7
    
8.
Stanger C, Ryan SR, Delhey LM, Thrailkill K, Li Z, Li Z, et al. A multicomponent motivational intervention to improve adherence among adolescents with poorly controlled type 1 diabetes: A pilot study. J Pediatr Psychol 2013;38:629-37.  Back to cited text no. 8
    
9.
Pramanik BK, Angelin JJ, Mathai VJ, Mathai S, Korula S, Simon A Smartphone app as motivational intervention to improve glycemic control in adolescents with type 1 diabetes. Indian J Pediatr 2019;86:1118-23.  Back to cited text no. 9
    
10.
Hannon TS, Yazel-Smith LG, Hatton AS, Stanton JL, Moser EAS, Li X, et al. Advancing diabetes management in adolescents: Comparative effectiveness of mobile self-monitoring blood glucose technology and family-centered goal setting. Pediatr Diabetes 2018;19:776-81.  Back to cited text no. 10
    
11.
Herbert L, Owen V, Pascarella L, Streisand R Text message interventions for children and adolescents with type 1 diabetes: A systematic review. Diabetes Technol Ther 2013;15:362-70.  Back to cited text no. 11
    
12.
Wagner DV, Barry SA, Stoeckel M, Teplitsky L, Harris MA NICH at its best for diabetes at its worst: Texting teens and their caregivers for better outcomes. J Diabetes Sci Technol 2017;11:468-75.  Back to cited text no. 12
    
13.
Danne T, Phillip M, Buckingham BA, Jarosz-Chobot P, Saboo B, Urakami T, et al. ISPAD clinical practice consensus guidelines 2018: Insulin treatment in children and adolescents with diabetes. Pediatr Diabetes 2018;19:115-35.  Back to cited text no. 13
    
14.
Smart CE, Annan F, Higgins LA, Jelleryd E, Lopez M, Acerini CL ISPAD clinical practice consensus guidelines 2018: Nutritional management in children and adolescents with diabetes. Pediatr Diabetes 2018;19:136-54.  Back to cited text no. 14
    
15.
Phelan H, Lange K, Cengiz E, Gallego P, Majaliwa E, Pelicand J, et al. ISPAD clinical practice consensus guidelines 2018: Diabetes education in children and adolescents. Pediatr Diabetes 2018;19:75-83.  Back to cited text no. 15
    
16.
Raiff BR, Dallery J Internet-based contingency management to improve adherence with blood glucose testing recommendations for teens with type-1 diabetes. J Appl Behav Anal 2010;43: 487-91.  Back to cited text no. 16
    
17.
Seto E, Istepanian RS, Cafazzo JA, Logan A, Sungoor A UK and Canadian perspectives of the effectiveness of mobile diabetes management systems. Annu Int Conf IEEE Eng Med Biol Soc 2009;2009:6584-7.  Back to cited text no. 17
    
18.
Ziegler R, Heidtmann B, Hilgard D, Hofer S, Rosenbauer J, Holl R; DPV-Wiss-Initiative. Frequency of SMBG correlates with hba1c and acute complications in children and adolescents with type 1 diabetes. Pediatr Diabetes 2011;12:11-7.  Back to cited text no. 18
    
19.
Franklin VL, Waller A, Pagliari C, Greene SA A randomized controlled trial of sweet talk, a text-messaging system to support young people with diabetes. Diabet Med 2006;23: 1332-8.  Back to cited text no. 19
    
20.
Berndt RD, Takenga MC, Kuehn S, Preik P, Sommer G, Berndt S SaaS-platform for mobile health applications. In: Proceedings of the 9th International Multi-Conference on Systems, Signals and Devices (SSD), Chemniz, Germany, 20–23 March 2012; pp. 1-4.  Back to cited text no. 20
    
21.
Nunn E, King B, Smart C, Anderson D A randomized controlled trial of telephone calls to young patients with poorly controlled type 1 diabetes. Pediatr Diabetes 2006;7:254-9.  Back to cited text no. 21
    
22.
Frøisland DH, Arsand E, Skårderud F Improving diabetes care for young people with type 1 diabetes through visual learning on mobile phones: Mixed-methods study. J Med Internet Res 2012;14:e111  Back to cited text no. 22
    
23.
Kollmann A, Riedl M, Kastner P, Schreier G, Ludvik B Feasibility of a mobile phone-based data service for functional insulin treatment of type 1 diabetes mellitus patients. J Med Internet Res 2007;9:e36.  Back to cited text no. 23
    
24.
de Beaufort CE, Swift PG, Skinner CT, Aanstoot HJ, Aman J, Cameron F, et al; Hvidoere Study Group on Childhood Diabetes 2005. Continuing stability of center differences in pediatric diabetes care: Do advances in diabetes treatment improve outcome? The Hvidoere Study Group on childhood diabetes. Diabetes Care 2007;30:2245-50.  Back to cited text no. 24
    
25.
Berndt RD, Takenga C, Preik P, Kuehn S, Berndt L, Mayer H, et al. Impact of information technology on the therapy of type-1 diabetes: A case study of children and adolescents in Germany. J Pers Med 2014;4:200-17.  Back to cited text no. 25
    
26.
Kebede MM, Schuett C, Pischke CR The role of continuous glucose monitoring, diabetes smartphone applications, and self-care behavior in glycemic control: Results of a multi-national online survey. J Clin Med 2019;8:109.  Back to cited text no. 26
    


    Figures

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

  [Table 1], [Table 2]



 

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
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed172    
    Printed8    
    Emailed0    
    PDF Downloaded9    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]