Chronic Kidney Disease (CKD): A Growing Medical Issue
Shahid Kamal
With an annual growth rate of more than 2.08%, the 231 million population of Pakistan is set to surpass 330 million by 2030 [1]. The country’s health system continues to be plagued by a paucity of resources, poor governance, a poor health informa- tion management system, corruption in the healthcare industry, and a dearth of skilled workers. The sector suffers from meager health budget allocations [2]. Kidney diseases, one of the lead- ing causes of death and disability, get further impetus due to an increasingly high prevalence of Diabetes Mellitus that further accentuates CKD [3]. The frequency of DM is set to increase by over 150% between 2000 and 2030 in South Asia [4].
doi.org/10.21089/njhs.93.00142
Proposal to Publication: Experience of a Research Capacity Building Initiative from a Low Middle-Income Country
Faheem Khan, Muhammad Salman Rafique
Abstract:Research is primary to academic acceleration and no intellectual growth can happen without its presence. To pursue the recom- mended path of academic progress, research training and capacity building are essential. In low-middle-income countries, institutes lack skilled human resources and financial stability to plan & implement an outcome-based research training program. This article describes an experience of executing a research capacity-building program with minimum financial and human resource. The article is written from the lens of an orga- nizer and a participant, to share challenges and areas of improvement.
Received:December 12, 2023
Revised:July 30, 2024
Accepted:August 07, 2024
doi.org/10.21089/njhs.93.0144
Comparison of Efficacy and Safety of Thalidomide vs Hydroxyurea in Thalassemia Patients: A Single-Centre Pilot Study
Safia Mehmood Khan, Nuzhat Sultana, Saima Siddiqui and Muhammad Nizammuddin
Abstract: Background: Beta thalassemia is a genetic disorder causing defective beta globin chain formation, leading to ineffective erythro- poiesis and hemolysis. It has three types: thalassemia major, thalassemia intermedia, and thalassemia minor. Treatment options include blood transfusions, iron chelation therapy, and bone marrow transplantation, but new treatments like HbF inducers (e.g., hydroxyurea) and erythro- poiesis modulators are being developed. Thalidomide and hydroxyurea are also being used to manage thalassemia by increasing HbF synthesis and reducing transfusion frequency.
Objective: To compare the efficacy and safety of thalidomide and hydroxyurea in beta-thalassemia patients for a period of six months.
Materials and Methods: A Prospective interventional single-centre study was conducted the tertiary care hospital of southern Pakistan, from 1st September 2021 to 03rd March 2022. A total of 39 patients of beta thalassemia major and intermediate with age ranges of >10 and < 30 years were enrolled in this study. 24 patients were fulfilling the study requirement. Thalidomide was started with a dose of 50 mg / day (in patients >10-13 years) while the adult dose was 100 mg /day (age >13 Years) every night. Hydroxyurea was given at 15 mg/kg /day. Pre and post-treat- ment tests were done. For assessing the safety of thalidomide and hydroxyurea biochemistry test was done along with LDH, Platelets counts, and WBCs count. The efficiency of both drugs was analyzed by hemoglobin, reticulocyte count, nucleated red blood cells, MCV, MCHC, white blood cells, and platelets.
Results: Both groups showed a highly significant increment in Hb. Thalidomide treated group baseline was 6.8 ±1.3 and after 06 months 8 ±13; (p-value < 0.001). Furthermore reticulocyte count was highly significantly augmented in HU treated group (p-value < 0.001) Hydroxy- urea-treated group showed significant decline in NRBC with a difference of -2.3±1.1 (p-value 0.02). Moreover, the transfusion interval was more significantly increased in the thalidomide group. The hemolysis parameter, LDH significantly declined in both groups. The hydroxy- urea-treated group showed difference of -62.4±124.4 (p-value 0.03) while the thalidomide-treated group showed a difference of -64.36±32.9 (p-value 0.05). AST was only significantly decreased in thalidomide treated group. Conclusion: Among both groups, hemoglobin, RBCs and reticulocyte count levels raise in both groups while NRBCs significantly decrease in HU treated group. Moreover, transfusion interval was also significantly increased by thalidomide. It shows safety by significantly decreasing the TBIL and AST, whereas LDH was decreased in the HU-treated group. This clinical trial was registered as # NCT06239389.
Received:August 22, 2023
Revised:March 28, 2024
Accepted:March 29, 2024
doi.org/10.21089/njhs.93.0149
Incidence of Contrast-Associated Acute Kidney Injury and Need for Renal Replacement Therapy in Patients who have Undergone Elective PCI in the Last 3 Years in a Tertiary Care Hospital
Kaneez Zehra, Namirah Iftikhar, Ghulam Hussain Soomro, Muhammad Osama Rehan Khalid, Ashar Ekhlaq Ahmed and Michelle Farooq
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Abstract:Background: With more than 660,000 percutaneous coronary interventions (PCI) carried out each year nationwide, Post-procedure acute kidney damage, sometimes referred to as contrast-associated acute kidney injury (CA-AKI), can complicate up to 14% of all PCIs.
Objective: The aim of this study is to provide an assessment of the frequency of contract-induced acute kidney injury in patients undergoing PCI in a single healthcare center.
Materials and Methods: This is a retrospective, clinical research conducted at Dr. Ziauddin Hospital, Karachi, from 20th June 2023 to 30th August 2023. Diagnosis of ischemic coronary artery disease was made and elective or emergency percutaneous coronary intervention (PCI) was performed. SPSS 22 used to analyze the data. For the continuous variables, mean ± standard deviation (SD) or median with interquartile range (IQR) were performed.
Results: A total of 166 patients were enrolled in the study, Mean age estimation of the study population was 63 ± 9.31 years, acute kidney injury was diagnosed in 11 (6.6%) while 157 (94.5%) had no AKI incident. Serum creatinine of baseline 1.4 ± 1.2 mg/dL and 2.1 ± 21.0 mg/dL, day 03 (after 48 hours) 1.5 ± 0.2 mg/dL and 2.5 ± 1.9 mg/dL, and day 30 1.4 ± 1.1 mg/dL and 2.0 ± 1.9 mg/dL were estimated in AKI and non-Aki patients respectively, and results indicated a mean difference of 0.7 ± 0.6 mg/dL in baseline serum creatinine of AKI patients and non-AKI patients. The remaining laboratory investigations were insignificant.
Conclusion: However, CA-AKI is a concern for subspecialties especially cardiology leading to withholding of clinically indicated intervene tions causing an increased risk of morbidity and mortality. This study identified that patient characteristics such as comorbidities can lead to CA-AKI.
Received:November 23, 2023
Revised: August 24, 2024
Accepted:September 03, 2024
doi.org/10.21089/njhs.93.0156
Weight Regain Following Laparoscopic Sleeve Gastrectomy in Morbid Obesity
Allauddin, Ghulam Siddiq, Muhammad Sohaib khan, Gulalai rehman and Tehreem Zahid
Abstract: Background: Sleeve gastrectomy is the common bariatric procedure done for morbid obesity, but there are limited studies available, specifically from South Asia. In Pakistan, no such study has been done before.
Objective: The main outcome of the study was Excess weight loss (EWL) and Weight Regain (WR) after Laparoscopic sleeve gastrectomy and to see improvement in co-morbid associated with morbid obesity.
Materials and Methods: The patients who underwent Laparoscopic sleeve gastrectomy for morbid obesity were analyzed retrospectively. From June 2017 to June 2019, in a tertiary care hospital in Pakistan. Patients whose BMI exceeds 40 kg/m² or falls between 35-39 kg/m² accom- panied by one or more comorbidities, and have undergone at least three years of follow-up. Redo procedures of LSG were excluded. Data was obtained from patients’ charts and hospital database, and last follow-ups were done by telephonic survey.
Results: In 171 patients 56.72% were female. Mean BMI was 48.5kg/m2. %EWL was 77.90% and total body weight loss was (% TBWL ) 39.48. Weight regain WR was 25.7 %, Regain of > 25%EWL was 14%. Increase in BMI >5/kgm2 was 17.5%. DM remission was 70% (28 pts) while in 30% (12) improved. Hypertension in 54.28% (38) pts improved and in 45.71% (32) hypertension completely resolved. Obstructive sleep apnea was resolved completely by 93.6 % (44). Osteoarthritis improved (by 78.4 %). GERD was developed in vivo in 14% of patients postoperatively. Lap chole for symptomatic gall stones was done in 9.35% of post-lap sleeve gastrectomy patients during follow-up.
Conclusion: Weight regain after sleeve gastrectomy was significant but still the post-operative co-morbid remission was promising.
Received:October 23, 2023
Revised: April 28, 2024
Accepted: May 11, 2024
doi.org/10.21089/njhs.93.0162
Charlson Comorbidity Index can be a Predictor of Post-Operative Complications and Hospital Stay by Using Clavien-Dindo Classification of Patients Undergoing Per-Cutaneous Nephrolithotomy
Anil Kumar Utraadi, Sharjeel Saulat, Jahanzeb Sheikh, Umber Rasheed, Ashba Mushtaque and Muhammad Osama
Abstract: Background: The post-operative complications after PCNL are comparatively higher in patients with comorbidities such as old age, recurrent renal stones, multiple stones, stone location and composition.
Objective: The purpose of this study is to evaluate the efficacy of Charlson comorbidity index to predict the post-operative complications and hospital stay of elderly patients by using Clavien Dindo classification under-going PCNL.
Materials and Methods: This is a prospective follow-up study, conducted at urology department of Tabba Kidney Institute. Patient aged ≥ 50 years, both genders diagnosed with Single or multiple, unilateral or bilateral renal stones and, solitary kidney were included in the study. CCI and Clavien Dindo classifications were documented and analyzed for associated and independent results. SPSS 22 was used to analyze the data.
Results: Total 152 participants were recruited in the study. The mean age of study population was 53.5 ± 14.2 years, with range of 38 years. Stone clearance was reported as 97% with 147(96.7%) complete stone free cases and 5(3.2%) cases with confirmed residual stones requiring METs to achieve complete clearance. Correlation of CCI and Clavien Dindo classification identified that there is a direct association with higher grading of both classification with post-operative complications. Assessment of odds of outcome were higher in Grade III Clavien Dindo with 1.48 indicating positive odds of complications and CCI higher grading.
Conclusion: Charlson Comorbidity Index is a swift, simple, and reproducible scoring system to properly calculate the morbidity and mortality after PCNL.
Received:December 15, 2023
Revised:January 30, 2024
Accepted:January 30, 2024
doi.org/10.21089/njhs.93.0168
The Prevalence of Migraine Headache and the Health-Seeking Behavior of Medical Undergraduates in Punjab
Noreen Maqbool Bokhari, Ayesha Khalid, Fatima Khalid, Ayma Azhar, Muhammad Maaz Arif and Hammad Hassan
Abstract: Background: Neurological headaches have been on the rise recently; among these, migraine is the most common. Younger individuals are more prone to this, and it affects their quality of life to a great extent.
Objective: To identify the prevalence, specific characteristics, and relieving factors of migraine as well as the healthcare-seeking practice among undergraduate medical students of Punjab.
Materials and Methods: This cross-sectional survey was conducted on undergraduate medical students of Punjab from June to September 2021. Convenience sampling was used to select 150 students. A validated questionnaire assessed the prevalence of migraine headaches, symptoms, and relieving factors.
Results: The females reported a higher prevalence, 78.57%, than males. Of all the types observed, 67.74% suffered from migraines, 22% suffered from tension headaches, and 9.8% had cluster and other headaches. The prevalence of headaches was most significant among subjects aged 20 to 2 years (37.93%). The top three symptoms experienced before the start of the migraine were disturbance from lights, disturbance by sound, and mood swings. The top three symptoms experienced during migraine were disturbance from light, difficulty in concentration, and irritation from sound. The top three relieving factors were rest, sleep, quietness, and massage.
Conclusion: Migraine is more prevalent in females than males, especially younger adults. Proper sleep/rest, avoiding stress, noise, regular exercise, and healthy lifestyles can significantly prevent migraine headaches. Disturbance from light was the most common symptom experienced before and during headaches. The most common relievers were rest and sleep.
Received:September 25, 2023
Revised:March 24, 2024
Accepted:March 24, 2024
doi.org/10.21089/njhs.93.0173
Impact of Metallic Brackets on Self-Perception of Orthodontic Patients
Hareem Sultan, Ramal Jawaid, Hana Pervez, Sara Shah, Sadia Shabbir and Ujala Kumari
Abstract: Background: The field of orthodontics has seen a drastic increase in patients demanding esthetic brackets. Metallic brackets have a negative impact on smile esthetics but their effects on orthodontic patients in terms of change in their self-perception, social interaction, confidence, experience of getting bullied have not been studied before.
Objective: This study aims to see the patients’ real social and psychological experiences while undergoing orthodontic treatment with metallic brackets.
Materials and Methods: This was a descriptive, cross-sectional study conducted for eight months at ABC Dental College, utilized 200 printed questionnaires that recorded data related to patients’ demographics, change in confidence, anxiety, experience of getting bullied, self-perception and social interaction after getting metallic brackets. Convenience sampling technique was used and patients who consented and had metallic brackets for at least 6 months were included. Data was analyzed by Statistical Package for the Social Sciences (Version 16.0) and reported in percentages.
Results: The age range of the patients who participated was 12-40 (mean=26) years. The patients who felt shy were 64 (33.7%) while, 57 (30%) had their smile esthetics affected, 37 (19.4%) were bullied and 46 (24.2%) experienced negative impact on their self-perception after getting metallic brackets. However, 103 (54.2%) of the patients would have selected esthetic brackets if had a choice.
Conclusion: Most of the patients felt good after having metallic brackets and their self-perception, confidence, and social standing did not get affected adversely. Though, most of them showed inclination towards esthetic brackets over metallic ones if given a choice.
Received:January 09, 2024
Revised:July 29, 2024
Accepted:July 30, 2024
doi.org/10.21089/njhs.93.0178
Effect of Punctuated Lectures on Undergraduate Nursing Students Classroom Learning: A Mixed Methods Design
Nafisa Iqbal, Bushra Sultan and Bibi Hajira
Abstract: Background: The punctuated lecture is the teaching learning strategy which can promote interactive and student centered learning activities to enhance their learning. Implementing punctuated lecture can enhance student engagement in learning activities. This can positively impact their learning.
Objective: To examine the effectiveness of punctuated lecture strategy on undergraduate nursing students’ tests scores. To explore the perceptions of students regarding the process of punctuated lectures.
Materials and Methods: A mixed methods embedded design was conducted. A quasi-experimental post-test design was used with 102 under- graduate students from the private college of nursing, Islamabad. The study duration was from October, 2020-July, 2021. Punctuated lectures were applied as an intervention in three different nursing courses (Pathophysiology, Mental Health Nursing, Teaching and Learning) by select- ing five topics each. After 20 minutes of session, the experimental group was asked to write reflection and feedback, and control group was involved in group discussion. Reflection and feedback, and post-test scores were used for analysis.
Results: The overall mean learning scores were higher in the experimental group in comparison to the control group (6.42 ± 2.32 versus 4.91±2.73) with a statistically significant p-value =0.001. By analysis of reflection and feedback, two categories and subcategories were identified.
Conclusion: It is concluded that punctuated lecture method is beneficial for improving learning outcomes and helping students to develop an interest in learning, clear their concepts, increase knowledge, and retain information. Nurse educators can implement punctuated lecture strategy to improve classroom learning outcomes.
Received:September 21, 2023
Revised:April 15, 2024
Accepted:April 17, 2024
doi.org/10.21089/njhs.93.0184
Association of Hand Dominance with Mechanism and Type of Hand Trauma in Patients Presenting at Civil Hospital Karachi
Rabeeaa Farrukh, Faisal Akhlaq Ali Khan, Waqas Sami, Erum Naz, Mehak Ali Memon and Sumaira Sattar
Abstract: Background: All of the daily tasks in adults’ life such as eating, use of computers, kicking, throwing, learning, and writing are done with using the dominant hand. There are distinctive differences in hand functioning as an influence of hand dominance.
Objective: To determine the pattern of hand injury, its mechanism and its association with hand dominance in patients presenting at emergency department of Civil Hospital Karachi.
Materials and Methods: This cross-sectional study was performed in Emergency department, Civil Hospital Karachi during February to Octo- ber, 2023. Adults of age 18 years and above of any gender presenting with acute hand injuries were included into the study. Patients committed suicide and amputed upper limbs were excluded from this study. Patients’ data was documented in a pre-designed proforma. Data was analyzed using SPSS version 26.
Results: Total 249 patients were enrolled into the study. Median age of patients was 22 (IQR=18-33) years. Majority of patients were males (n=209, 80.6%). Majority had injury in their right hand (n=175, 70.3%) and dominant hand (n=171, 68.7%). The most common injury mode was road traffic accidents (n=90, 36.1%) followed by assault (n=71, 28.5%), workplace (n=70, 28.1%), burns (n=10, 4%) and knife cut injuries (n=8, 3.2%). Frequency of workplace injury was significantly higher among dominant hand than non-dominant hand. Frequency of RTA and assaults was higher in non-dominant hand (p < 0.001).
Conclusion: The present study analyzed that in most of hand injuries cases dominant hand was affected. Frequency of workplace related hand injuries was significantly higher among dominant hand than non-dominant hand
Received:March 20, 2024
Revised:June 13, 2024
Accepted:June 14, 2024
doi.org/10.21089/njhs.93.0192
Prevalence of Anxiety and Depression in COVID-19 Patients and Frontline Healthcare Workers
Faheem Khan, Zainab Babar, Saira Imtiaz and Abdullah Khalid
Abstract: Background: During global health crises such as the COVID-19 pandemic, understanding the psychological impact on both patients and healthcare workers is crucial for effective public health response and support strategies.
Objective: To assess anxiety and depression prevalence among COVID-19 patients and healthcare workers in Pakistan, utilizing the Aga Khan University Anxiety and Depression Scale.
Materials and Methods: A cross-sectional survey from 20th May 2020 to 25th August 2020, using a 15-item structured questionnaire was conducted on patients diagnosed with COVID-19 and healthcare workers at the Pakistan Kidney and Liver Institute & Research Center, Lahore. The Aga Khan University Anxiety and Depression Scale – Short Form (AKUADS-SF) was employed to assess the levels of anxiety and depres- sion among the participants. Data were analyzed using descriptive statistics, chi-square tests, and logistic regression to identify significant predictors of anxiety and depression.
Results: Of 183 participants, 55% were healthcare workers and 44.8% were patients. Preliminary findings showed 37.6% of healthcare workers had anxiety and depressive symptoms. Significant predictors among healthcare workers included family members with psychiatric disorders, family members affected by COVID-19, and a history of psychiatric disorders. Among patients, 13.4% had positive scores on the AKUADS-SF, with significant predictors being marital status (single), affected family members, smoking, and addiction.
Conclusion: The study identified significant anxiety and depression among healthcare workers and patients during COVID-19. Predictors for healthcare workers included family psychiatric issues and personal history, while patients’ predictors were marital status, affected family members, smoking, and addiction. This underscores the need for targeted psychological support.
Received:January 03, 2024
Revised:July 29, 2024
Accepted:July 30, 2024
doi.org/10.21089/njhs.93.0197
Trend of Infectious Disease Positivity in Exchange and Voluntary Blood Donors at Regional Blood Centre, Karachi.
Samra Waheed, Muhammad Sarwar Khan, Shumaila Qamar, Syeda Madiha Shah and Erum Rafiq
Abstract: Background: Pakistan has a high prevalence of hepatitis and increasing prevalence of HIV, these infections imply a serious risk to the health of those who need blood transfusions. As blood donors are generally considered as the healthy population, assessing the risk of these silent killers in the blood donors can overall help in understanding the potential impact of these infections on the general population.
Objective: As the TTI prevalence is increasing rapidly in our region, it is much needed to take necessary actions for its prevention. The first step should be the actual frequency of these TTI’s in healthy blood donors, so our study aimed to identify the positive ratio of Hep B, Hep C, HIV, malaria and syphilis in exchange and voluntary blood donors, their comparison and need of effective testing.
Materials and Methods: It is a retrospective analysis in which all the data is taken from BBMIS software and analyzed by SPSS version 23. We included 56732 donors from 2020-2022. Screening of Hepatitis B, Hepatitis C and HIV was done by Chemoimmunoliscence (CLIA) whereas ICT based screening was done for Syphilis and Malaria.
Results: Among donors, 50147 (88.4%) were exchange while 6585 (11.6%) were voluntary donors. The frequency of HCV was 3.1% followed by HbsAg (2.3%) and syphilis (1.6%), HIV 0.3% and the least was malaria 0.2%. As 88% of the donors were exchange, TTI positivity was also more in them.
Conclusion: The prevalence of TTI in donors of RBC Karachi is worrysome. It highlights the fact of Nucleic Acid testing significance. Though CLIA is a sensitive technique, 100% safety of blood products requires the implication of Nucleic Acid testing, moreover the implication of voluntary blood donation should also be considered significantly.
Received:February 27, 2024
Revised: July 20, 2024
Accepted: July 22, 2024
doi.org/10.21089/njhs.93.0204
Factors Influencing Students’ Choice of Pursuing Nursing in Central Karachi
Muhammad Hasnain Shaikh, Rizwan Ali, Afsha Bibi, Ismail Khan, Shamsher Ali Khan, Waqar Ahmad and Dar-l- Islam
Abstract: Background: The choice of pursuing nursing education is influenced by various factors that can vary from individual to individual. Determining these factors is crucial for improving the recruitment and retention of nursing professionals in the region.
Objective: This study aimed to determine the factors influencing students’ choice of pursuing nursing education in central Karachi.
Materials and Methods: Cross-sectional survey was employed, and data were collected from 1st-year nursing students of Generic Bachelor of Science in Nursing (GBSN). Convenient sampling was used to select participants from two Private Schools of Nursing in central Karachi from October 2022 to February 2023.
Results: A total of 100 participants were enrolled in the study, comprising 90% males and 10% females. Most of the students 70% strongly agreed that nursing is a profession characterized by caring and helpful attributes, and 50% agreed that it is also distinguished by recognition and respect. However, concerns were raised as 70% of students who disagreed or strongly disagreed that nursing is well-paid, and 52% felt it was too difficult for them.
Conclusion: Majority of nursing students viewed nursing as a caring and altruistic profession, which is considered a positive factor influencing their career choice. However, concerns about low pay and nursing as a difficult profession were highlighted.
Received:July 30, 2023
Revised:July 18, 2024
Accepted:July 22, 2024
doi.org/10.21089/njhs.93.0209
Diagnostic Comparison of Transabdominal and Transvaginal Ultrasound in Determining Endometrial Thickness
Javeria Khan
Abstract: Background: The investigation of the endometrium is essential for any pathology related to the female menstrual cycle. Endometrial thickness serves as a significant biomarker in transvaginal and pelvic ultrasound examinations, closely tied to gynecological function. To enhance the precision of predicting endometrial thickness, we have synthesized various studies and literature to incorporate bleeding patterns and combine transabdominal and transvaginal ultrasounds. These techniques offer accurate and noninvasive means of exploring endometrial thickness (ET).
However, the current body of literature lacks a unanimous agreement on the threshold value for defining normal ET levels, especially when considering women who are symptomatic or asymptomatic during both pre and post menopause stages. This study aims to compare ultrasound findings in endometrial thickness between transabdominal and transvaginal approaches. Several studies suggest that pelvic ultrasound pro- vides a reliable method for diagnosing endometrial conditions and assessing uterine pathologies by observing internal genitalia morphology.
Conversely, transvaginal ultrasound is suggested as a primary approach due to its superior resolution and broader field of view, positioning it potentially as the first-line technique.
Received:August 23, 2023
Revised: July 23, 2024
Accepted: July 24, 2024
doi.org/10.21089/njhs.93.0214
Blockchain Revolutionizing Healthcare Industry: A Survey of Existing Literature
Danish Khilani, Pranitha Shanthi Lobo, Haider Ali
Abstract: Background: Health care is a vast industry that requires huge data storage and sharing and this is where this industry faces multiple challenges and requires an efficient system. This review article aimed to summarize the benefits of the blockchain industry in the healthcare sector. Literature review was conducted through PubMed and Google Scholar. A total of 30 articles were selected for review purposes with keywords health care, blockchain technologies, and benefits of blockchain and blockchain and health care industry with search engines like Google Scholar, Research Gate, and APA journals. A thorough review of existing literature suggests that blockchain technology can be beneficial for many fields and subfields of the healthcare industry including patients, organizations, hospitals, pharmaceuticals, global record-keeping organizations, health professionals, and researchers. Blockchain can be beneficial as it is efficient, reliable, transparent, cost-effective, easily accessible, vast data storage and management enable, and many in many more ways. In a nutshell, the importance of blockchain in the healthcare industry and suggests incorporating this technology in healthcare for efficient working.
Received:August 22, 2023
Revised: May 20, 2024
Accepted: May 23, 2024
doi.org/10.21089/njhs.93.0221
