Journal of Manmohan Memorial Institute of Health Sciences 2018-09-25T15:58:54+00:00 Dr Sujan Babu Marahatta Open Journal Systems <p>Official peer-reviewed journal of <a title="MMIHS" href="" target="_blank">Manmohan Memorial Institute of Health Sciences</a>, under <a title="NEHCO-Nepal" href="" target="_blank">NEHCO-Nepal</a><span style="text-decoration: underline;">.</span></p><p>Submit your manuscripts at <a href=""></a></p>Free full text articles are available Experts warn Nepal Government not to reduce local public health spending 2018-09-22T22:27:13+00:00 P. Simkhada E. Teijlingen B. Simkhada P. Regmi N. Aryal S.B. Marahatta <p>No abstract available.</p><p>JMMIHS.2018;4(1):1-3</p> 2018-09-22T22:27:13+00:00 ##submission.copyrightStatement## Biochemical and hematological parameters in chronic kidney disease 2018-09-22T22:27:19+00:00 S. Singh S. Bhatta <p class="Default"><strong>Background: </strong>Chronic kidney disease is a worldwide public health problem. It is associated with various biochemical and hematological abnormalities that leads to morbidity and mortality. The aim of this study was to evaluate the biochemical and hematological parameters in chronic kidney disease patients.</p><p class="Default"><strong>Methods: </strong>This is a prospective cross sectional study conducted over a period of six months on 52 chronic kidney disease patients at Kist Medical College Teaching Hospital, Lalitpur, Nepal. Biochemical parameters such as urea, creatinine, calcium, phosphorous, sodium, potassium and hematological parameters like hemoglobin, hematocrit, red blood cell count, total leukocyte count, platelet count were measured using standard techniques in chronic kidney disease cases and the findings were compared with age and sex matched controls. Results were analyzed using SPSS 21 for Windows.</p><p class="Default"><strong>Results: </strong>Hemoglobin, hematocrit, red blood cell count, total leukocyte count and platelet count were reduced and statistically significant in chronic kidney disease patients compared to controls(p &lt;0.05).In biochemical parameters, serum urea, creatinine, phosphorous were increased and calcium was reduced which was found statistically significant as compared to controls (p &lt;0.05). The combination of diabetes and hypertension was the lead cause of chronic kidney disease found in 38.46% followed by hypertension alone in 30.76%</p><p><strong>Conclusion: </strong>Biochemical and hematological parameters are deranged in patients with chronic kidney disease. Routine evaluation of these parameters is useful in the management of these patients.</p> 2018-09-22T22:27:19+00:00 ##submission.copyrightStatement## Prostatic lesions: Histopathological study in a tertiary care hospital 2018-09-22T22:27:26+00:00 S. Bhatta S. Hirachan <p class="Default"><strong>Background: </strong>Prostatic lesions like Nodular hyperplasia of prostate, inflammation and carcinoma are common causes of morbidity and mortality in males. The incidence of these lesions increases with age. This study was conducted with the objective of evaluating histopathological pattern of prostatic lesions.</p><p class="Default"><strong>Methods: </strong>This was a retrospective study conducted at KIST Medical College from Jan 2014 to Jan 2018. The study included ninety six prostatic specimens received in department of pathology. Hematoxylin and Eosin stained slides were retrieved and reviewed. The specimens and slides were analyzed according to type of specimen, age of patient, histopathological pattern and final diagnosis. Results were analyzed using Statistical Package for Social Science (SPSS, version 21) for Windows. Independent t test was used to correlate the mean age between patients with benign and malignant lesions. P value less than 0.05 was considered as statistically significant.</p><p class="Default"><strong>Results: </strong>The most common benign lesion was nodular hyperplasia of prostate 86(89.58%). Malignant lesions comprised 8 (8.34%) cases of all prostatic lesions. All the cases of prostate carcinoma were adenocarcinoma. The most frequent Gleason score was 9. Mean age for benign and malignant lesions were 69.6 ± 8.1 years and 72.9 ± 5.2 years respectively. There was no significant difference in the mean age between patients with benign and malignant lesions (p value 0.27).</p><p class="Default"><strong>Conclusion: </strong>Benign lesions of prostate are more common than malignant lesions. Histopathological examination of prostate specimens have important role in diagnosing various benign and malignant lesions, especially to rule out incidental carcinoma.</p><p class="Default">JMMIHS.2018;4(1):12-19</p> 2018-09-22T22:27:26+00:00 ##submission.copyrightStatement## Experience of sexual harassment in public transport among female health science students: A cross sectional study of Kathmandu, Nepal 2018-09-22T22:27:32+00:00 D. Mishra J. Lamichhane <p class="Default"><strong>Background: </strong>Sexual harassment on public transport is an everyday occurrence for millions of girls and women around the globe. With the skyrocketing population of Kathmandu valley public transport has been facing enormous pressure. The major victims of these harassments happens to be college going girls and working women as they tend to travel more in public transports. This study sought to determine the prevalence and factors responsible for sexual harassment in public transport among female health science students.</p><p class="Default"><strong>Methods: </strong>A descriptive cross-sectional study was carried out among 396 female health science students studying in Manmohan Memorial Institute of Health Sciences using self-administered structured questionnaire. Participants were selected through stratified random sampling method.</p><p class="Default"><strong>Results: </strong>The prevalence of sexual harassment among female health science students was found to be 79.6%. Physical harassment was the most prominent type of harassment (67.1%) followed by verbal (61.2%) and non verbal 34.6%. After the experience of sexual harassment, 44.6% scolded the harasser, 29.1% kept silent, 17.3% dropped at nearest bus station whereas remaining 9% reacted in other different ways. Overcrowding was considered as main reason for sexual harassment by 69.2% of the participants. 36.8% of female students didn’t use any precautionary methods whereas 32.6% avoided going out alone at night.</p><p class="Default"><strong>Conclusion: </strong>The study reveals that the prevalence of sexual harassment is significantly high. With increasing population and limited vehicles people are left with no option rather than travelling in the overcrowded vehicles where the chances of experiencing various sorts of sexual harassments are very high. In order to address this emerging issue, prompt and appropriate intervention should be taken by government, public and especially the status of women must be raised in society.</p><p class="Default">JMMIHS.2018;4(1):20-32</p> 2018-09-22T22:27:32+00:00 ##submission.copyrightStatement## Generic prescribing, brand and generic substitution, availability and cost effectiveness of the available medicines 2018-09-22T22:27:40+00:00 D.P. Khanal P. Adhikari S. Chapagain S. Rayamajhi S. Nakarmi B. Adhikari <p class="Default"><strong>Background: </strong>Pharmaceuticals play a key role in the prevention and treatment of disease. The worldwide availability of effective, safe and affordable pharmaceuticals is a key challenge for the global public health system. Large economic interests are at stake within the field of pharmaceuticals. Pharmaceutical sales are existed as trade in many part of developing world including Nepal. At the same time, consumers (patients) are at mercy and unable to judge the quality, safety and, in many cases, the efficacy of the medicine, as well as whether the price is reasonable or not. They depend on others for assured quality medicines. Objective of this study was to find out the prescription written in generic name, availability of generic medicine in hospital pharmacy and outside pharmacy and cost effectiveness of brand –generic substitution in Manmohan Memorial Hospital Premises, Shyombu Kathmandu.</p><p class="Default"><strong>Methods: </strong>All relevant information of brand-generic medicines and generic prescribing were recorded from the patient chart stored at medical record department except orthopedic department. In Orthopedic department, OPD prescriptions were recorded. Hospital pharmacy and outside pharmacy have been audited for the availability of generic medicines. Face to face interview with pharmacists in hospital and Drug Retailers were taken regarding the medicine available in generic name and medicine substitution. The recorded data were analyzed.</p><p class="Default"><strong>Results: </strong>Only 298 out of 5120 medicines were found in generic name mostly from medical department, 215 medicines out of 812 medicines. There was no any single generic prescription in orthopedic department. In the hospital pharmacy and outside pharmacy have very few generic medicines. So no question of brand substitution by generic here. Mostly some large volume parental were available in generic names.</p><p class="Default"><strong>Conclusion: </strong>Only 5.82 % of medicines were prescribed in generic name. Concerns over the therapeutic equivalence of branded products and generics are common amongst physicians, pharmacists and industries of course.</p><p class="Default">JMMIHS.2018;4(1):33-42</p> 2018-09-22T22:27:40+00:00 ##submission.copyrightStatement## Cost and generic prescription analysis of psychotropic prescriptions in psychiatric OPD of a rural tertiary care teaching hospital 2018-09-22T22:27:49+00:00 L. Wagle M. Kumaraswamy M. Bajracharya <p class="Default"><strong>Background</strong>: There is increased interest on cost utilisation of psychotropic drugs in recent years. Objective of this study was to perform cost and generic prescription analysis of psychotropics in psychiatric outpatient department at tertiary care teaching hospital.</p><p class="Default"><strong>Methods: </strong>This was cross sectional, observational and uni-centric study of 6 month duration which was performed at Psychiatric Outpatient Department at one of the tertiary care hospital, Karnataka India. Cost analysis of prescriptions containing at least one psychotropic drug was performed based on cost/defined daily dose method from hospital perspective. Direct drug cost of psychiatric illness per day and pattern of generic prescribing were also studied. The data was analysed &amp; summarised as mean, frequency, percentage (%), standard deviation (SD), and chi square test( at 95% confidence level) as appropriate using Microsoft excel and Graph Pad InStat statistical software.</p><p class="Default"><strong>Results: </strong>We observed 15 different types of psychotropics among 101 prescriptions that was reviewed. Most expensive psychotropic was Divalproex whereas Clonazepam was the cheapest one. Most money was spent by hospital on Sertraline (24.19%) and least on Lithium (1.92%). Most expensive therapeutic categories were antidepressants (32.39%) followed by mood stabilisers (27.06%), antipsychotics (24.77%) and sedative/hypnotics (15.76%). Among different antidepressants; Amitriptyline was cheaper option and Mirtazepine was expensive. Likewise Quetiapine was expensive and Risperidone was cheaper among antipsychotics. Zolpidem and Divalproex were expensive sedative/hypnotic and mood stabilisers respectfully. Most expensive psychiatric illness was found to be bipolar disorder (Rs 20.53±12.84). 19 out of 147 were prescribed with generic names.</p><p class="Default"><strong>Conclusion: </strong>The cost burden due to psychiatric drugs is high. Expensive and cheaper psychotropic for psychiatric OPD were Divalproex and Clonazepam respectively. Expensive therapeutic category was found to be antidepressants. From hospital perspective much money was spent on Sertraline and less on Lithium respectively. Similarly high cost of illness was observed in bipolar disorder and less in dissociative disorder. Generic name prescribing is very less.</p><p class="Default">JMMIHS.2018;4(1):43-54</p> 2018-09-22T22:27:49+00:00 ##submission.copyrightStatement## A retrospective study of poisoning cases in Manmohan Memorial Teaching Hospital 2018-09-22T22:27:58+00:00 M. Bajracharya P. Khadka L. Wagle <p class="Default"><strong>Background: </strong>Poisoning is one of the leading causes of morbidity and mortality in Nepal and also a major public health problem worldwide. It needs specific epidemiological surveillance to determine the extent and pattern of poisoning of a place, and to take preventive measures. Hence this study is aimed to explore the demographic, etiological, and clinical characteristics of poisoning cases of MMTH and to assess the effect of variables such as age, sex, and agent of poisoning frequency.</p><p class="Default"><strong>Methods: </strong>A retrospective, descriptive, unicentric and semi-quantitative study was conducted in a year of 2074 at Manmohan memorial teaching hospital after institution review committee approval in customised data collection form. Data from Baishakh 2070 (April 2013) to Kartik 2074 (October 2017) were reviewed. The data was entered in SPSS 16 version for analysis.</p><p class="Default"><strong>Result: </strong>Among 144 patients, poisoning was common among people from the age group of 15-25 years and 26-40 years. The females were more vulnerable than male. The male to female ratio was 1:1.4. Married females (32%) and married males (31%) were more vulnerable than unmarried ones. Poisoning incidence was found more during night (40.3%) and midnight (18.80%). 81.2% of poisoning cases were found with suicidal intention. Organophosphorous poisoning was abundant with 75 cases.</p><p class="Default"><strong>Conclusion: </strong>This study reveals that OP poisoning is most common for self-harm with females and young at more risk. Therefore, awareness among youths is a must.</p><p class="Default">JMMIHS.2018;4(1):55-65</p> 2018-09-22T22:27:58+00:00 ##submission.copyrightStatement## A comparison of outcomes of four ports versus three ports laparoscopic cholecystectomy 2018-09-25T15:58:54+00:00 K. Koirala G. Simkhada N. Adhikari R. Mukhia S. Shakya <p class="Default"><strong>Background: </strong>Conventional laparoscopic cholecystectomy is performed using four ports. With increasing surgeon experience, there is a trend towards performing it using three ports. The aim of this study was to compare the three-port laparoscopic cholecystectomy with the conventional four-port technique in terms of safety, benefits and feasibility in a teaching hospital and private hospital setups.</p><p class="Default"><strong>Materials &amp; Methods: </strong>A retrospective review of medical records was performed on patients who underwent laparoscopic cholecystectomy at KIST Medical College and Teaching Hospital and Om Hospital &amp; Research Center P. Ltd by a single laparoscopic surgeon. The review included demographics, operating time, analgesics requirement, post- operative hospital stay and intra-operative and post-operative complications. The data were tabulated in MS-Excel and statistically analyzed using SPSS statistics software, version 21.</p><p class="Default"><strong>Results: </strong>There were 150 patients included in this study with 75 patients in each three and four-port groups. The demographics were comparable in both groups. 7.3% were diagnosed with acute calculous cholecystitis, 76.7% with chronic calculous cholecystitis and 3.3 % were gall bladder polyps. Four-port technique was generally required for the acute calculous cholecystitis which was statistically significant. The three-port group had a shorter mean operative time than the four-port group. There was no statistically significant difference in the doses of analgesics requirement and mean post-operative hospital stay in both groups. There were no major intra and post-operative complications in both groups. Four-port technique was commonly done in teaching hospital and the three-port in private hospital.</p><p class="Default"><strong>Conclusions: </strong>There is significant number of laparoscopic cases being performed using three ports and we concluded that the three-port laparoscopic cholecystectomy is safe and feasible in experienced hand although there is no significant benefit. The study also showed an increasing use of four-port technique in the teaching institution which is better to clearly visualize the anatomy of the Calot’s triangle. So we recommend using the four-port technique for teaching the beginners and as the experience is gained, we can gradually shift to three-port technique and at the same time we shouldn’t hesitate to convert to four-port in difficult cases.</p><p class="Default">JMMIHS.2018;4(1):66-71</p> 2018-09-22T22:28:04+00:00 ##submission.copyrightStatement## Development and characterization of pomegranate and orange fruit peel extract based silver nanoparticles 2018-09-22T22:28:13+00:00 C.H. Vinay P. Goudanavar A. Acharya <p class="Default"><strong>Background: </strong>Nanoparticles are those whose size ranges 1 nm to 100 nm. They are in different sizes and shape, such as triangular, spherical, irregular, etc. In recent years, nanoparticles synthesis has received considerable attention due to their unique properties and potential applications. Powdered sample (100gm)was extracted with 800ml ethanol by Soxhlet extraction method for 6 hours. The resultant extract was used to prepare nanoparticles.</p><p class="Default"><strong>Methods: </strong>The main objective of the present work was to prepare pomegranate and orange peel extract based nano particles by chemical complexation method. Ethanolic extracts of pomegranate and orange peel were prepared by using Soxhlet apparatus and evaluated for phyto-chemical constituents.</p><p class="Default"><strong>Results</strong>: Qualitative analysis of pomegranate peel showed positive results for Alkaloids, Anthraquinones, Saponins and Terpenoids, where as orange peel showed positive results for Alkaloids, Tannin and Saponins. The percentage moisture content obtained from the 2 fruits (pomegranate and orange) was 72% and 96.12% respectively. The pH was found to be 3.6 and 3.8 for pomegranate and orange respectively. A zeta potential of prepared nanoparticles for pomegranate extract was found in the range of -24.6 mV to -34.5 mV (P20 &amp; P50) and -21.4 mV to 32.0 mV (O20 &amp; O50) for orange extract, respectively. These values of nanoparticles having higher surface charge which indicates there is least chance of aggregation. The particle size for pomegranate extract was found in the range of 118.6 nm to 231.7 nm (P20 &amp; P30) and 178.8 nm to 191.6 nm (O20 &amp; O50) for orange extract, respectively. These range confirms that obtained particles were in nano range, i.e. &lt;500 nm size. SEM results indicated the formation of nanoparticles and were relatively spherical in shape. Energy dispersive spectrometry (EDS) analysis confirms the presence of AgNPs.</p><p class="Default"><strong>Conclusion: </strong>The silver nanoparticles were prepared by using fruit peels extract of pomegranate and orange. Computability study FT-IR showed no any change of functional groups of peel extracts in prepared nanoparticles. Zeta potential showed higher value hence less particle aggregation. Prepared nanoparticles were spherical in shape and having particle size of approximately 200±20nm. Further the study will be extended for anti-microbial and wound healing activities.</p><p class="Default">JMMIHS,2018;4(1):72-85</p> 2018-09-22T22:28:13+00:00 ##submission.copyrightStatement## Various approaches to enhance the dissolution of Lornoxicam fast dissolving tablets prepared by using different categories of superdisintegrants: A comparative study 2018-09-22T22:28:22+00:00 A. Acharya G.B.K. Kumar P. Goudanavar K. Dhakal <p class="Default"><strong>Background: </strong>Recent developments in fast dissolving tablets have brought convenience in dosing to pediatric and elderly patients who have trouble in swallowing tablets.The main objective of the present study is to formulate fast dissolving tablet of Lornoxicam by direct compression method.</p><p class="Default"><strong>Methods: </strong>Guar gum and crospovidone were used as natural and synthetic superdisintegrants respectively. Fast dissolving tablet of Lornoxicam were prepared by direct compression technique using three different approaches; superdisintegrant addition, sublimation, and solid dispersion.</p><p class="Default"><strong>Results</strong>: IR and DSC studies showed no interaction between the drug and the excipients. All formulation showed disintegration time ranging from 16.09-42.54 second. Wetting time and disintegration time decreased by increasing the super disintegrant concentration from 2.5% to 5% w/w. Formulae L16 gave the best <em>in- vitro </em>disintegration and dissolution results, which would be due to swelling effect of Gaur gum and amorphization of the drug during the solid dispersion preparation.The best formulation L16 was subjected to stability testing for 3 month and results showed no significant change in appearance, hardness, drug content and dissolution profile of the tablets, hence tablet is stable throughout its stability studies.</p><p class="Default"><strong>Conclusion: </strong>It was concluded that fast dissolving tablets of Lornoxicam were formulated successfully with desired characteristics which disintegrated rapidly; provided rapid onset of action; and enhanced the patient convenience and compliance.</p><p class="Default">JMMIHS,2018;4(1):86-102</p> 2018-09-22T22:28:22+00:00 ##submission.copyrightStatement## Traditional healing practice in Rajbanshi and Satar Community of Jhapa, Nepal 2018-09-22T22:28:29+00:00 B. Raut D.P. Khanal A. Kharel <p class="Default"><strong>Background: </strong>Jhapa is the easternmost district of Nepal and lies in Terai plains. Traditional healing system in Nepal has strong cultural and religious background. It exists in different ways such as ethnic or tribal group, ritual or ceremonial practices. In Nepal, traditional healers believe that the disease causing factors are not only the germ theory related but also the spiritual belief. As the census of 2011, there are eight densely populated indigenous ethnic communities including Satar and Rajbansi in Jhapa. The traditional healers of these communities with their indigenous knowledge serve the local people since time immemorial. The main objective of this research work was to find the traditional healing practice in Rajbanshi and Satar community of Jhapa, district, Nepal.</p><p class="Default"><strong>Methods: </strong>The areas were visited from June 2017 to September 2017. A cross sectional study was performed to collect the information through semi structured questionnaires and face to face interviews with the traditional healers of Satar and Rajbanshi community. All together 20 locally reputed traditional healers, 10 from each community were selected.</p><p class="Default"><strong>Results: </strong>Spiritual based five healing techniques and/or approaches, Phukphak, Tantrik Puja, Bali, Jantar-mantar and kul bigreko, used by traditional healers were explored. Moreover, 41 plant species belonged to 29 families were found to be used for the treatment of 22 common illnesses. 6 different dosage forms were used to prepare 28 traditional formulations.</p><p class="Default"><strong>Conclusion: </strong>Spiritual based five healing techniques and/or approaches were used by traditional healers on this locality. We also identified different medicinal plant species that were used in different traditional formulation used by such healers.</p><p class="Default">JMMIHS.2018;4(1):103-116</p> 2018-09-22T22:28:29+00:00 ##submission.copyrightStatement## Knowledge and practice of breast self examination among women of reproductive age in Butwal Sub Metropolitan City 2018-09-22T22:28:37+00:00 S.B. Marahatta S. Sharma <p class="Default"><strong>Background</strong>: Majority of breast cancer cases in developing countries are diagnosed in late stage. Breast cancer is the second most common cancer among females in Nepal and can be detected by Breast self-examination (BSE) in early stage of disease. This study aimed to assess the knowledge and practice of breast self-examination among women of reproductive age in Butwal Sub-Metropolitan city.</p><p class="Default"><strong>Methods</strong>: A quantitative descriptive cross-sectional study with 219 women of reproductive age residing in Butwal Sub-Metropolitan city was conducted between March and August 2016. The study samples were enrolled through the cluster random sampling design. Data was collected using an interviewer administered semi-structured questionnaire. Data was analyzed using SPSS ver. 16.Association was checked using the chi-square test.</p><p class="Default"><strong>Results</strong>: Of total, only 31.1% of respondents had ever heard about BSE. Only 19.2% women had ever practiced BSE. The study revealed that marital status, monthly household income and level of education were independent factors influencing the knowledge of BSE while performance of BSE was influenced by monthly household income, level of education and history of breast disease.</p><p class="Default"><strong>Conclusion</strong>: Knowledge and practice of BSE among women of reproductive age in Butwal sub metropolitan city was found poor and inadequate. This shows gap between knowledge and practice of BSE that might be reduced through implementation of community based awareness and skill development programs on BSE targeting the women of reproductive age group.</p><p class="Default">JMMIHS.2018;4(1):117-129</p> 2018-09-22T22:28:36+00:00 ##submission.copyrightStatement## Health consequences of sex trafficking: A systematic review 2018-09-22T23:04:08+00:00 P. Simkhada E. van Teijlingen A. Sharma P. Bissell A. Poobalan S.P. Wasti <p class="Default"><strong>Background: </strong>Sex trafficking is one of the most common forms of human trafficking globally. It is associated with health, emotional, social, moral and legal problems. The victims of sex trafficking when returned home are often ignored. This study aimed to explore the health consequences of sex trafficking among women and children.</p><p class="Default"><strong>Methods: </strong>Medline EMBASE, PsycINFO and CINAHL were systematically searched, from date of inception to July 2016 using a combination of Medical Subject Headings (MeSH) and text words on health risks and consequences of sex trafficking. Electronic searches were supplemented by searching the reference lists of included papers and citation tracking. Both Qualitative and quantitative primary studies published in English and exploring health-related problems among sex trafficked women and children were included in this review. Health outcomes considered were: physical, psychological or social risks and consequences of sex trafficking among women and children. No restrictions were applied to geographical regions as sex trafficking involves victims being trafficked between different countries, and within countries. Data were extracted and study quality independently appraised by two reviewers and narrative synthesis was conducted for this review.</p><p><strong>Results: </strong>A total of fifteen articles were included covering health risks and well-being related to sex trafficking. Sexual and physical violence among victims such as rape and repetitive stress and physical injuries were common. The prevalence of STI (sexually transmitted infections) and HIV (human immunodeficiency virus) was also reported as high. Being trafficked at a young age, having been in brothels for a longer period and sexual violence and forced prostitution were linked with a higher risk for HIV infection. Physical health problems reported included headaches, fatigue, dizziness, back pain, memory problem, stomach pain, pelvic pain, gynaecological infections, weight loss, lesions or warts, unwanted pregnancies and abortions. The studies on mental health reported that depression, anxiety and post-traumatic stress disorder (PTSD) were commonly reported health consequences among sex trafficking victims.</p><p><strong>Conclusion: </strong>there is a compelling need for interventions raising awareness about sex trafficking among young girls and women most at risk of being trafficked. Most studies in this review have focussed on the physical health problems of the trafficked victims although there is also remarkable mental burden amongst those victims. Key policy makers, government officials, public health officials, health care providers, legal authorities and non-governmental organisations (NGOs) should be made aware about the health risks and consequences of trafficking. Trafficking consequences should be recognised as a health issue and all the sectors involved including regulating bodies should collaborate to fight against sex trafficking. Due to the heterogeneity of the articles, no meta-analysis could be conducted.</p><p class="Default">JMMIHS.2018;4(1):130-150</p> 2018-09-22T22:28:43+00:00 ##submission.copyrightStatement##