Home Print this page Email this page Small font sizeDefault font sizeIncrease font size
Users Online: 14661

 

Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Advertise Contacts Login 
     

  Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 55  |  Issue : 1  |  Page : 54-57  

Intravenous paracetamol versus intramuscular pethidine in relief of labour pain in primigravid women


1 Department of Anesthesia, Shahid Sadoghi University of Medical Science, Yazd, Iran
2 Department of Gynecology and Obstetrics, Shahid Sadoghi University of Medical Science, Yazd, Iran
3 Department of Physical Medicine and Rehabilitation Research Center, Tabriz University of Medical Science, Tabriz, Iran
4 Department of Gynecology and Obstetrics, Tabriz University of Medical Science, Tabriz, Iran
5 Department of Psychiatry, Tabriz University of Medical Science, Tabriz, Iran
6 Students' Research Committee, Tabriz University of Medical Science, Tabriz, Iran
7 Students' Research Committee; Medical Philosophy and History Research Center, Tabriz University of Medical Science, Tabriz, Iran

Date of Web Publication4-Mar-2014

Correspondence Address:
Mohammad-Hasan Abdollahi
Medical Philosophy and History Research Center, Tabriz University of Medical Science, Daneshgah Street, Tabriz, Eastern Azerbaijan
Iran
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0300-1652.128167

Clinical trial registration IRCT201207215506N5

Rights and Permissions
   Abstract 

Background: Intramuscular pethidine is one of most common opioids used for labour analgesia. There are a number of concerns in the literature regarding the use of pethidine. The aim of this study is to compare analgesic efficacy of paracetamol with pethidine for labour pain in normal vaginal delivery. Materials and Methods: In this single-blinded, randomised control trial, 80 primigravid singleton women with full-term pregnancy candidate for normal vaginal delivery, were entered the trial and divided in to pethidine (A) and paracetamol (B) groups. At the time of admission, age and body mass index of mother and gestational age based on last day of period were recorded. In both groups, intravenous promethazine and hyoscine were administered to each patient at the first stage of delivery. From beginning of active phase of delivery, patients in group A received 50 mg intramuscular pethidine injection. At the same time patients in group B, received an intravenous solution infusion containing 1000 mg paracetamol and 300 cc of normal saline. After child birth, average labour pain was assessed using Visual Analogue Scale (VAS) by direct questioning from patient in both groups. Results: After patients' selection, 19 individual omitted during study due to exclusion criteria and finally 30 patients in paracetamol group and 31 patients in pethidine group remained to enter the trial. There was no significant difference in age and BMI of mothers between both groups (P > 0.05). Maternal age and labour duration in paracetamol group had no meaningful difference with maternal age and labour duration of patients in pethidine group (P > 0.05). The average VAS pain score was significantly lower in paracetamol comparing to that of pethidine group (8.366 out of 10, 9.612 out of 10, respectively, P < 0.001). Conclusion: It is concluded that intravenous paracetamol is more effective than intramuscular pethidine to relief labour pain in normal vaginal delivery.

Keywords: Labour pain, intramuscular pethidine, intravenous paracetamol, vaginal delivery


How to cite this article:
Abdollahi MH, Mojibian M, Pishgahi A, Mallah F, Dareshiri S, Mohammadi S, Naghavi-Behzad M. Intravenous paracetamol versus intramuscular pethidine in relief of labour pain in primigravid women. Niger Med J 2014;55:54-7

How to cite this URL:
Abdollahi MH, Mojibian M, Pishgahi A, Mallah F, Dareshiri S, Mohammadi S, Naghavi-Behzad M. Intravenous paracetamol versus intramuscular pethidine in relief of labour pain in primigravid women. Niger Med J [serial online] 2014 [cited 2024 Mar 28];55:54-7. Available from: https://www.nigeriamedj.com/text.asp?2014/55/1/54/128167


   Introduction Top


Labour is generally considered to be a painful experience and analgesia is regularly required. In a study comparing different painful medical conditions, the average labour pain scores in primigravid and multigravid women where more than that of sciatic, dental or bone fracture pain scores. [1],[2] Stretch of the cervix during dilatation, ischaemia of the muscle wall of the uterus with buildup of lactate and stretch of the vagina and perineum in the second stage are the probable causes of labour pain. [3],[4],[5]

Labour pain which results in marked increase in minute ventilation and oxygen consumption during contractions, can causes severe respiratory alkalosis and a left shift of the maternal oxyhemoglobin dissociation curve, thus diminishing oxygen transfer to the foetus. Compensatory hypoventilation between contractions may cause transient maternal hypoxemia, and potentially, foetal hypoxaemia. These periods of hypoventilation may be exacerbated by analgesic techniques that result in respiratory depression (e.g., systemic opioid analgesia). [5],[6],[7]]

Intramuscular pethidine is one of most common opioids used for labour analgesia. There are a number of concerns in the literature regarding the use of pethidine. Some studies have suggested that pethidine provides little or no pain relief in labour, its main effect being to cause sedation rather than analgesia. Pethidine also has a number of side effects on both the mother and the neonate which make it a less ideal choice for labour analgesia. It can cause nausea, vomiting and dysphoria in women receiving it during labour. [8],[9] All opioids cross the placenta. In utero, opioid exposure results in a slower foetal heart rate and decreased beat-to-beat variability. The risk of neonatal respiratory depression depends on the dose and timing of maternal opioid administration. The active metabolite of pethidine, normeperidine, has a half-life of 60 hours in neonates. [8],[10]

Although the exact mechanism of action is still a controversial issue, paracetamol (acetaminophen) is a safe and effective agent for pain management. Studies have suggested that paracetamol is an effective treatment for postoperative pain relief. [11],[12] Studies examining analgesic effect of paracetamol in obstetrics surgeries such as abortion, [13] post-operative pain after Caesarean delivery [14],[15] and perineal pain after child birth [16],[17] have proposed that paracetamol has an admirable analgesic effect. Based on our knowledge, there are no significant clinical trials regarding paracetamol analgesic effect on labour pain in primigarvid women.

The aim of this randomised, single-blinded, placebo-controlled clinical study is to compare efficacy and safety of single dose intravenous paracetamol with intramuscular pethidine in treatment of labour pain in primigravid women.


   Materials and Methods Top


This study protocol was approved by the Ethics Committee of Tabriz University of Medical Sciences (TUMS), which was in compliance with Helsinki Declaration. After written informed and verbal consents had been obtained, 80 primigravid singleton women with full-term pregnancy (Gestational Age (GA) more than 37 weeks based on ultrasound findings) candidate for normal vaginal delivery, were entered to the trial. During present single-blind control trial (IRCT201207215506N5), a computer-generated random table was used and a hospital nurse allocated women in to two groups: Pethidine (group A) and Paracetamol (group B). All the patients were blinded to the study group assignment. Exclusion criteria were history of cardiac, liver and renal diseases, anti-convulsive medication consumption, malpresentation of foetus, abnormal foetal monitoring during labour and multiple gestations.

At the time of admission, age and Body Mass Index (BMI) of mother, and GA based on last day of period were recorded. During first stage of delivery, foetus was monitored using a non-stress test (NST) and transvaginal ultrasonography. All NSTs were conducted by a nurse and evaluated by our gynaecologist. Each individual with abnormal finding of NST (late deceleration or variable deceleration) was omitted from the trial. All ultrasound imaging were performed by our gynaecologist in order to evaluate foetus before delivery.

In both groups, intravenous promethazine and hyoscine were administered to each patient at the first stage of delivery. From beginning of active phase of delivery (50 mm of cervical dilatation and 100 % effacement), patients in group A received 50 mg intramuscular pethidine injection. At the same time patients in group B, received an intravenous solution infusion containing 1000mg paracetamol and 300 cc of normal saline. After child birth, average labour pain was assessed using Visual Analogue Scale (VAS) by direct questioning from patient in both groups.

Apgar score of neonate, duration of labour and incidence of complications including dyspnea, elevated liver enzymes, skin rash, thrombocytopenia, and systolic blood pressure less than 90 mmHg in 24 hours after delivery were recorded in each group.


   Results Top


Eighty primigravid full term women candidate for normal vaginal delivery were randomly allocated in to two groups of paracetamol (N = 40) and pethidine (N = 40). Nineteen individual omitted during study due to exclusion criteria and finally 30 patients in paracetamol group and 31 patients in pethidine group remained to enter the trial.

At the time of admission, age and BMI of mother, and GA based on last day of period were recorded. During first stage of delivery, foetus was monitored using (NST) and transvaginal ultrasonography. There was no significant difference in age and BMI of mothers between both groups (P = 0.704 and P = 0.496, respectively) [Table 1].
Table 1: Comparison of paracetamol and pethidine group


Click here to view


Maternal age and labour duration in paracetamol group had no meaningful difference with maternal age and labour duration of patients in pethidine group (P = 0.503 and P = 0.418, respectively).

Only one individual in paracetamol group and two patients in pethidine group had systolic blood pressure less than 90 mmHg, which did not need further intervention. There were no records of other complications in 24 hours after delivery in both groups. Apgar score of neonates in both groups was above 8/10.

The estimated pain score based on verbal questioning from mothers at the end of delivery using VAS of pain, was significantly lower in paracetamol group comparing to that of the pethidine group (8.366 out of 10, 9.612 out of 10, respectively, P < 0.001), [Figure 1].
Figure 1: Visual analog score comparing normal vaginal pain between paracetamol and pethidine groups

Click here to view



   Discussion Top


This study attempted to compare analgesic effect of intravenous paracetamol with intramuscular pethidine in reducing labour pain. Based on findings of this trial, in order to decrease labour pain in singleton primigravid women candidate for normal vaginal delivery, intravenous infusion of paracetamol is more effective than single-dose injection of intramuscular pethidine. There were no significant drug complications, and Apgar scores of neonates were similarly normal in both groups of the study. This may be suggestive of safety of using paracetamol as an analgesic agent in labour pain.

Pain during the first stage of labour originates predominantly in the cervix and the lower uterine segment, rather than the body of the uterus. During the late first stage and second stage of labour, the foetus descends in the birth canal and progressively greater pressure of the foetus on the vagina and perineum form additional sources of pain. [6],[7],[8]

Chou et al., reviewed 10 randomised clinical trials comparing analgesic efficacy of single-dose paracetamol with placebo for perineal pain in early postpartum period. They concluded that more women experienced pain relief and fewer had additional pain relief with paracetamol compared with placebo, although potential adverse effects were not assessed and generally the quality of study was unclear. [16]

Another trial comparing effect of paracetamol with placebo on postoperative pain management in Caesarean operations showed that paracetamol is a safe and effective treatment option in post-Caesarean pain. [15] Although there are numerous studies in favour of our findings which show efficacy of paracetamol for pain management in gynaecological operations, but trials examining normal vaginal delivery pain are not adequate.

Intramuscular opioids are one form of analgesia regularly employed to relief labour pain. There are a number of concerns in the literature regarding the use of pethidine. Some studies have suggested that pethidine provides little or no pain relief in labour, its main effect being to cause sedation rather than analgesia. [18],[19] Pethidine also has a number of side effects on both mother and neonate which make it a less ideal choice for labour analgesia. It can cause nausea, vomiting and dysphoria in women receiving it during labour. [20] It also crosses the placenta and can cause reduced foetal heart rate variability and fewer heart rate accelerations. [21] Effects on the neonate include respiratory depression, impaired feeding and altered crying. [22],[23]

The reason that we selected intravenous paracetamol instead of oral paracetamol is that peak analgesic effect of IV paracetamol occurs in 1 hour, with duration of approximately 4-6 hours. Intravenous administration of propacetamol has been shown to be at least as effective as oral administration of an equivalent dose of paracetamol, and the target concentration achieved more rapidly and with less variability in plasma concentrations compared with enteral formulations. [24],[25],[26]

A number of physical factors may influence the severity and duration of labour pain and suffering which include maternal age, parity, maternal condition, the condition of the cervix at the onset of labour, and the relationship of the size and position of the foetus to the size of the birth canal. [7] Based on such factors, we tried to make the diversity of maternal age, GA, and delivery duration similar in both groups as much as possible.

There is a limitation for this study. Although we assessed pain score just at the end of delivery, but it would have been better if we had evaluated labour pain before and after paracetamol administration, in order to have better understanding of pain relief during labour.

Finally, our study suggested that in order to relief labour pain in primigravid singleton women candidate for normal vaginal delivery, it is better to use intravenous paracetamol instead of intramuscular pethidine, since paracetamol has better analgesic efficacy and at least complications are as same as those of pethidine.

 
   References Top

1.Nezhad HS, Aram S, Monajjemi Z, Jaafar-Zadeh L. Intravenous fentanyl infusion as an analagesic agents for labor pain. J Res Med Sci 2001;6:1-2.  Back to cited text no. 1
    
2.Tournaire M, Theau-Yonneau A. Complementary and alternative approaches to pain relief during labor. Evid Based Complement Alternat Med 2007;4:409-17.  Back to cited text no. 2
    
3.Allameh Z, Rouholamin S, Hekmat R. Comparison of vaginal misoprostol tablet with oxytocin infusion for induction of labor in term pregnancy. J Res Med Sci 2012;17:134-9.  Back to cited text no. 3
    
4.Brennan D. The ABC of child care politics. Aust J Soc Issues 2007;42:213.  Back to cited text no. 4
    
5.Zahiri Soroori Z, Hajar Sharami S, Heidarzadeh A, Shokri L. The comparison between suppository diclofenac and pethidine in post-cesarean section pain relief: A randomized controlled clinical trial. J Res Med Sci 2006;11:292-6.  Back to cited text no. 5
    
6.Shahraki AD, Jabalameli M, Ghaedi S. Pain relief after cesarean section: Oral methadone vs. intramuscular pethidine. J Res Med Sci 2012;17:143-7.  Back to cited text no. 6
[PUBMED]  Medknow Journal  
7.Wong CA. Advances in labor analgesia. Int J Women's Health 2009;1:139.  Back to cited text no. 7
    
8.Elbohoty AE, Abd-Elrazek H, Abd-El-Gawad M, Salama F, El-Shorbagy M, Abd-El-Maeboud KH. Intravenous infusion of paracetamol versus intravenous pethidine as an intrapartum analgesic in the first stage of labor. Int J Gynaecol Obstet 2012;118:7-10.  Back to cited text no. 8
    
9.Wee MY, Tuckey JP, Thomas P, Burnard S. The IDvIP Trial: A two-centre randomised double-blind controlled trial comparing intramuscular diamorphine and intramuscular pethidine for labour analgesia. BMC Pregnancy Childbirth 2011;11:51.  Back to cited text no. 9
    
10.Arslan M, Celep B, Çiçek R, Kalender HÜ, Yýlmaz H. Comparing the efficacy of preemptive intravenous paracetamol on the reducing effect of opioid usage in cholecystectomy. J Res Med Sci 2013;18:172-7.  Back to cited text no. 10
[PUBMED]  Medknow Journal  
11.Moore A, Collins S, Carroll D, McQuay H, Edwards J. Single dose paracetamol (acetaminophen), with and without codeine, for postoperative pain. Cochrane Database Syst Rev 2000;CD001547.  Back to cited text no. 11
    
12.Tzortzopoulou A, McNicol ED, Cepeda MS, Francia M, Farhat T, Schumann R. Single dose intravenous propacetamol or intravenous paracetamol for postoperative pain. Cochrane Database Syst Rev 2011;5CD007126.  Back to cited text no. 12
    
13.Penney G. Treatment of pain during medical abortion. Contraception 2006;74:45-7.  Back to cited text no. 13
    
14.Alhashemi JA, Alotaibi QA, Mashaat MS, Kaid TM, Mujallid RH, Kaki AM. Intravenous acetaminophenvs oral ibuprofen in combination with morphine PCIA after Cesarean delivery. Can J Anaesth 2006;53:1200-6.  Back to cited text no. 14
    
15.Kiliçaslan A, Tuncer S, Yüceaktaº A, Uyar M, Reisli R. The effects of intravenous paracetamol on postoperative analgesia and tramadol consumption in cesarean operations. Agri 2010;22:7-12.  Back to cited text no. 15
    
16.Chou D, Abalos E, Gyte GM, Gülmezoglu AM. Paracetamol/acetaminophen (single administration) for perineal pain in the early postpartum period. Cochrane Database Syst Rev 2010;CD008407.  Back to cited text no. 16
    
17.Azam Foroughipour FF, Ghahiri A, Norbakhsh V, Heidari T. The effect of perineal control with hands-on and hand-poised methods on perineal trauma and delivery outcome. J Res Med Sci 2011;16:1040.  Back to cited text no. 17
    
18.Olofsson C, Ekblom A, Ekman-Ordeberg G, Hjelm A, Irestedt L. Lack of analgesic effect of systemically administered morphine or pethidine on labour pain. BJOG 2005;103:968-72.  Back to cited text no. 18
    
19.Tsui MH, Ngan Kee WD, Ng FF, Lau TK. A double blinded randomised placebo-controlled study of intramuscular pethidine for pain relief in the first stage of labour. BJOG 2004;111:648-55.  Back to cited text no. 19
    
20.Bricker L, Lavender T. Parenteral opioids for labor pain relief: A systematic review. Am J Obstet Gynecol 2002;186:S94-109.  Back to cited text no. 20
    
21.Ido Solt M, Ganadry S, Weiner Z. The effect of meperidine and promethazine on fetal heart rate indices during the active phase of labor. Isr Med Assoc J 2002;4:178-80.  Back to cited text no. 21
    
22.Nissen E, Widström AM, Lilja G, Matthiesen AS, Uvnäs-Moberg K, Jacobsson G, et al. Effects of routinely given pethidine during labour on infants' developing breastfeeding behaviour. Effects of dose-delivery time interval and various concentrations of pethidine/norpethidine in cord plasma. Acta Paediatr 2008;86:201-8.  Back to cited text no. 22
    
23.Ransjö-Arvidson AB, Matthiesen AS, Lilja G, Nissen E, Widström AM, Uvnäs-Moberg K. Maternal analgesia during labor disturbs newborn behavior: Effects on breastfeeding, temperature, and crying. Birth 2001;28:5-12.  Back to cited text no. 23
    
24.Anderson BJ, Pons G, Autret-Leca E, Allegaert K, Boccard E. Pediatric intravenous paracetamol (propacetamol) pharmacokinetics: A population analysis 1. Paediatr Anaesth 2005;15:282-92.  Back to cited text no. 24
    
25.Holmér Pettersson P, Öwall A, Jakobsson J. Early bioavailability of paracetamol after oral or intravenous administration. Acta Anaesthesiol Scand 2004;48:867-70.  Back to cited text no. 25
    
26.Bahadori F, Ayatollahi H, Naghavi-Behzad M, Khalkhali H, Naseri Z. Predicting factors on cervical ripening and response to induction in women pregnant over 37 weeks. Medical ultrasonography. 2013;15:191-8.  Back to cited text no. 26
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1]


This article has been cited by
1 Pharmacological labour pain interventions: South African midwives’ perspective
LE. Parkies, D. Murray, UB. Okafor
BMC Nursing. 2024; 23(1)
[Pubmed] | [DOI]
2 A randomized controlled trial of intravenous paracetamol and intravenous tramadol for labour analgesia
Kavita Mandrelle, Meghna Marwah, Dootika Liddle
Indian Journal of Obstetrics and Gynecology Research. 2023; 10(3): 259
[Pubmed] | [DOI]
3 Pharmacologic and nonpharmacologic options for pain relief during labor: an expert review
Sivan Zuarez-Easton, Offer Erez, Noah Zafran, Julia Carmeli, Gali Garmi, Raed Salim
American Journal of Obstetrics and Gynecology. 2023;
[Pubmed] | [DOI]
4 Comparison of intravenous paracetamol infusion versus intramuscular tramadol as labor analgesia: a randomized control trial
N. Monisha, G. K. Poomalar
Archives of Gynecology and Obstetrics. 2022;
[Pubmed] | [DOI]
5 Pentazocine versus tramadol-paracetamol combination as analgesia in labor: A randomized controlled trial
Rachael Oluwatunmobi Opadiran, Dennis Anthony Isah, Richard Offiong, Felicia Dele Asudo
Annals of Medical Research and Practice. 2022; 3: 4
[Pubmed] | [DOI]
6 Effectiveness of meperidine, nalbuphine, and paracetamol in labor analgesia at Tanta University Hospitals: a randomized clinical study
AmalN.M Nada, AymanS Dawood, AhmedA Aldbaa, SafaaK Marae
Tanta Medical Journal. 2021; 49(4): 257
[Pubmed] | [DOI]
7 Oral acetaminophen as an adjunct to continuous epidural infusion and patient-controlled epidural analgesia in laboring parturients: a randomized controlled trial
Reecha Panghal,Sukanya Mitra,Jasveer Singh,Rashi Sarna,Bharti Goel
Journal of Anesthesia. 2021;
[Pubmed] | [DOI]
8 Efficacy and safety of intravenous paracetamol in management of labour pains in a low resource setting: a randomized clinical trial
Mohamed Elsibai Anter,Said Abdel Attey Saleh,Sara Shawkey Allam,Ahmed Mohamed Nofal
The Journal of Maternal-Fetal & Neonatal Medicine. 2021; : 1
[Pubmed] | [DOI]
9 Pethidine in Low Doses versus Dipyrone for Pain Relief in Labor: A Randomized Controlled Trial
Rogevando Rodrigues Nunes, André Montenegro Primo
Revista Brasileira de Ginecologia e Obstetrícia / RBGO Gynecology and Obstetrics. 2019; 41(02): 084
[Pubmed] | [DOI]
10 INTRAVENOUS PARACETAMOL INFUSION VERSUS INTRAMUSCULAR PETHIDINE AS LABOUR ANALGESICS
Sallama Nasir, Hala Ibrahim
JOURNAL OF SULAIMANI MEDICAL COLLEGE. 2019; 9(4): 347
[Pubmed] | [DOI]
11 Paracetamol vs. Intravenous Morphine Plus Diclofenac in Renal Colic Pain: A Randomized Clinical Trial
Samad Shams-Vahdati,Navideh Robaei,Paria Habibollah,Asghar Jafari-Rouhi,Sahar Mohammadi,Reza Piri
Nephro-Urology Monthly. 2018; In Press(In Press)
[Pubmed] | [DOI]
12 “We know it’s labour pain, so we don’t do anything”: healthcare provider’s knowledge and attitudes regarding the provision of pain relief during labour and after childbirth
Mary McCauley,Valentina Actis Danna,Dorah Mrema,Nynke van den Broek
BMC Pregnancy and Childbirth. 2018; 18(1)
[Pubmed] | [DOI]
13 Parenteral opioids for maternal pain management in labour
Lesley A Smith,Ethel Burns,Anna Cuthbert
Cochrane Database of Systematic Reviews. 2018;
[Pubmed] | [DOI]
14 Comments on: Is Pethidine Safe during Labor? Systematic Review
Tatiana Henriques Leite, Emanuele Souza Marques, Vitor Barreto Paravidino
Revista Brasileira de Ginecologia e Obstetrícia / RBGO Gynecology and Obstetrics. 2018; 40(10): 656
[Pubmed] | [DOI]
15 Pain in labour and the intrapartum use of intramuscular opioids—how effective are they?
Emma Sprawson
British Journal of Midwifery. 2017; 25(7): 418
[Pubmed] | [DOI]
16 A Randomized Controlled Trial Comparing Use of Enthonox With Pethidine for Pain Relief in Primigravid Women During the Active Phase of Labor
Noshin Mobaraki,Mahzad Yousefian,Solmaz Seifi,Mehran Sakaki
Anesthesiology and Pain Medicine. 2016; 6(4)
[Pubmed] | [DOI]
17 I.V. paracetamol as an adjunct to patient-controlled epidural analgesia with levobupivacaine and fentanyl in labour: a randomized controlled study
K. Gupta,S. Mitra,S. Kazal,R. Saroa,V. Ahuja,P. Goel
British Journal of Anaesthesia. 2016; 117(5): 617
[Pubmed] | [DOI]
18 Intravenous Paracetamol Infusion Versus Intramuscular Tramadol as an Intrapartum Labor Analgesic
Meenakshi Lallar,Haq ul Anam,Rajesh Nandal,Sunder Pal Singh,Surabhi Katyal
The Journal of Obstetrics and Gynecology of India. 2014;
[Pubmed] | [DOI]



 

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
    Viewed7595    
    Printed198    
    Emailed1    
    PDF Downloaded249    
    Comments [Add]    
    Cited by others 18    

Recommend this journal