TRAUMATIC BRAIN INJURY IN ADULTS: AGE, ETIOLOGY, AND TREATMENT OUTCOME
Keywords:
Age, Etiology, Outcome, Traumatic brain injury
Abstract
Traumatic brain injury had been described as silent epidemic. The etiology is said to be changing and older adults have been said to have worse outcome compared to the younger ones. We prospectively studied adults managed for traumatic brain injury in our center over a four and half year period.
Objectives: To determine the effects of age and etiological factors on the outcome of adults managed for traumatic brain injury.
Methods: It was a prospective study on adults managed for traumatic brain injury in our center from August 2010 to January 2015. Patients were resuscitated in accident and emergency using Advanced Trauma Life Support (ATLS) protocols. Biodata, history and physical examinations were done in accident and emergency. Severity of the injury was assessed using Glasgow Coma Scale. Comatose patients were admitted in intensive care unit (ICU), while orders were admitted in the wards. Data were collected using structured Performa which was component of our prospective data bank that was approved by our ethics and research committee. Data were analyzed with Environmental Performance Index (EPI) info 7 software.
Results: Two hundred and eighty seven patients were studied. There were 244 males. Their ages ranged from 20 – 76 years. The most common etiology in all age groups was road traffic accident (RTA).The outcome was worse in older patients.
Conclusion: We found that more males had traumatic brain injury. The most common etiology in all ages was RTA. The outcome was significantly affected by age. Older patients had worse outcome.
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References
1. Murray GD, Teasdale M, Braakman R, Cohadon F, Maas A, Ohman J, et al. The European brain injury consortium survey of head injuries. Acta Neurochir 1999;141:223-6
2. Smits M, Dippel DW, Steyerberg EW, de Haan GG, Dekker HM, Vos PE, et al. Predicting intracranial traumatic findings on computed tomography in patients with minor head injury: the CHIP prediction rule. Ann Intern Med 2007;146:397-405
3. Maas AI, Marmarou A, Murray GD, Teasdale SG, Steyerberg EW. Prognosis and clinical trial design in traumatic brain injury: the IMPACT study. J Neurotrauma 2007;24:232-8
4. Styrke J, Stalnacke BM, Sojka P, Bjornstig U. Traumatic brain injuries in a well defined population: epidemiological aspects and severity. J Neurotrauma 2007;24:1425-36
5. Thompson HJ, McCormick WC, Kagan SH. Traumatic brain injury in older adults: epidemiology, outcomes, and future implications. J Am Geriatr Soc 2006;54:1590-95
6. Tokutomi T, Miyaji T, Ogawa T, Ono J, Kawamata T, Sakamoto T et al. Agerelated increases in poor outcomes after traumatic brain injury: a report from the Japan Neurotrauma Data Bank. J Neurotrauma 2008;25:1407-14
7. Vollmer DG, Torner JC, Jane JA, Sadovnic B, Charlebois D, Eisenberg HM,et al. Age and outcome following traumatic coma: why do older patients fare worse? J Neurosurg 1991;75:S37-S49
8. Signorini DF, Andrews PJ, Jones PA, Wardlaw JM, Miller JD. Predicting survival using simple clinical variables: a case study in traumatic brain injury. J Neurol Neurosurg Psychiatry 1999;66:20-25
9. Ono J, Yamaura A, Kubota M, Okimura Y, Isobe K. Outcome prediction in severe head injury: analysis of clinical prognostic factors. J Clin Neurosci 2001;8:120-21
10. Andrews PJ,Sleeman DH, Stathan PF,McQuatt A, Comuble V, Jones PA, et al. Predicting recovery in patients suffering from traumatic brain injury by using admission variables and physiological data: a comparison between decision tree analysis and logistic regression. J Neurosurg 2002;97:326-36
11. Demetriades D, Murray J, Martin M,Velmahos G, Salim A, Alo K, et al. Pedestrians injured by automobiles: relationship of age to injury type and severity. J Am Coll Surg 2004;199:382-7
12. Ratanalert S, Chompikul J, Hirunpat S. Talked and deteriorated head injury patients: how many poor outcomes can be avoided? J Clin Neurosci 2002;9:640-43
13. Bahloul M, Chelly H, Ben Hmida M, Ben Hmida C, Ksibi H, Kallel H, et al. Prognosis of traumatic head injury in South Tunisia: a multivariate analysis of 437 cases. J Trauma 2004;57:255-61
14. MRC CRASH Trial Collaborators. Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients.
BMJ 2008;336:425-29
15. Choi SC, Muizelaar JP, Bames TY, Marmarou A, Brooks DM, Young HF. Prediction tree for severely head-injured patients. J Neurosurg 1991;75:251-5
16. Maas AI, Stocchetti N, Bullock R. Moderate and severe traumatic brain injury in adults. Lancet Neurology 2008;7:728-41
17. Langlois JA, Rutland-Brown W, Thomas KE. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. National Center for Injury Prevention and Control, Atlanta, GA: 2004
18. Faul M, Xu L, Wald MM, Coronado VG. Traumatic brain injury in the United States: emergency department visits, hospitalizations and deaths 2002-2006.
Center for Disease Control and Prevention, National Center for Injury Prevention and Control, Atlanta, GA: 2010
19. Jennet B, Bond M. Assessment of outcome after severe brain damage. Lancet 1975;1:480-4
20. King JT, Carlier PM, Marion WD. Glasgow outcome scale scores predict long-term functional outcome in patients with severe traumatic brain injury. J Neurotrauma 2005;22:947-54.
21. Nwadiaro HC, Ekwe KK, Akpayak IC, Shitta H. Motorcycle injuries in northcentral Nigeria. Nigerian Journal of Clinical Practice 2011;14:186-9
22. Ekere AU, Ibeanusi S. Pattern of motorcycle associated injuries in PortHarcourt: a hospital based study. Orient Journal of Medicine 2003;16:36-40
23. Badanich KA, Mulholland PJ, Beckley JT, Trantham-Davidson H, Woodward JJ. Ethanol reduces neuronal excitability of lateral orbitofrontal cortex neurons via a glycine receptor dependent mechanism. Neuropsychophamarcology 2013;38:1176-1188
24. Andriessen TMJC, Horn J, Franschman G, van der Naalt J, Haitsma I, Jacobs B, et al. Epidemiology, severity classification, and outcome of moderate and severe traumatic brain injury: a prospective multicenter study. J Neurotrauma 2011;28:2019-31
25. Myburgh JA, Cooper DJ, Finfer SR, Venkatesh B, Jones D, Higgins A, et al. Epidemiology and 12-month outcomes from traumatic brain injury in Australia and New Zealand. J Trauma 2008;64:854-62
26. Majdan M, Mauritz W, Brazinova A, Rusnack M, Leitgeb J, Janciak I, et al. Severity and outcome of traumatic brain injuries with different causes of injury. Brain Injury 2011;25:797-805
27. Younis R, Younis M, Hamidi S, Musmar M, Mawson AR. Causes of traumatic brain injury in patients admitted to Rafida, Al-Ittihad and the specialized Arab hospitals, Palestine. Brain Injury 2011;25:282-91
28. Mcintrye A, Mehta S, Aubut J, Dijkers M, Teasell RW. Mortality among older adults after a traumatic brain injury, a meta-analysis. Brain Injury 2013;27:31-40
29. Murdoch BE, Theodoros DG. Traumatic brain injury: associated speech, language and swallowing disorders. San Diego, CA: Singular Publishing Group; 2001
30. Mosenthal AC, Lavery RF, Addis M, Kaul S, Ross S, Marburger R, et al. Isolated traumatic brain injury. Age is an independent predictor of mortality, and early outcome. J Trauma 2002;52:907-11
31. Rapaport MJ, Feinstein A. Outcome following traumatic brain injury in the elderly: a critical review. Brain Injury 2000;14:749-61
32. Wagner AK. Functional prognosis in traumatic brain injury. Physical Medicine and Rehabilitation: States of the Art Review 2001;15:245-65
33. Hukkelhoven CW, Steyerberg EW, Rampen AJ, et al. Patient age and outcome following severe traumatic brain injury. Analysis of 5,600 patients. J Neurosurg 2003;99:666-73
34. Stocchetti N, Paterno R, Citerio G, Berreta L, Colombo A. Traumatic brain injury in an aging population. J Neurotrauma 2012;29:1119-25
35. Dams-O’Connor K, Cuthbert JP, Whyte J, Corrigan JD, Faul M, Harrison-Felix C. Traumatic brain injury among older adults at level I and II trauma centers. J
Neurotrauma 2013;30:2001-13
36. Richmond TS, Kauder D, Strumpy N, Meredith T. Characteristics and outcomes of serious traumatic brain injury in older adults. J Am Geriatr Soc 2002;50:215-22
37. Gilmer LK, Ansari MA, Roberts KN, Scheff SW. Age-related mitochondrial changes after traumatic brain injury. J Neurotrauma 2010;27:939-50
38. Ferrell RB, Tanev KS. Traumatic brain injury in older adults. Curr Psychiatry Rep 2002;4:354-62
39. Cefalu CA. Theories and mechanisms of aging. Clin Geriartr Med 2011;27:491-506
40. Goodrich JT. Landmarks in the history of Neurosurgery. In: Rengarchary SS, Wilkins HR, editors. Principles of Neurosurgery; 1994 ed. London: Wolfe Publishing; 1994:p1.2-19
41. Miller JD, Pentland B. Head injuries in elderly patients. J Neurosurg Rev 1989:12Suppl1:441-5
42. Wang YC, P’eng FK, Yang DY,Shoung MH, Hung CF, Cheng JT, et al. Epidemiology study of head injuries in Central Taiwan. Zhoughua Yi Xue Za Zhi (Taipei) 1995;55:50-59
43. Hitmana J, Perez M, Kinasha A, Kakande I. Clinical presentation and outcome of neurosurgical conditions in Bature teaching hospital, Rwanda. East and Central African Journal of Surgery 2009;14:50-56
44. Jacobs B, Beems T, Stulemeijer M, van Vugt AB, Van der Vliet TM, Born FG, et al. Outcome prediction in mild traumatic brain injury: age and clinical variables are stronger predictors than CT abnormalities. J Neurotrauma 2010;27:655-68
45. Gomez PA, Lobato RD, Boto GR, De la Lama A, Gonzalez PJ, de la Cruz J. Age and outcome after severe head injury. Acta Neurochir (Wien) 2000;142:373-81
46. Mushkudiani NA, Engel DC, Steyerberg EW, Butcher I, Lu J, Marmarou A, et al. Prognostic value of demographic characteristics in traumatic brain injury: results from the IMPACT study. J Neurotrauma 2007;24:259-69
47. Marquez de la Plata CD, Hart T, Hammond FM, Frol AB, Hudak A, Harper CR, et al. Impact of age on longterm recovery from traumatic brain injury. Arch Phys Med Rehabil 2008;89:896-903
48. Ratcliff G, Colantonio A, Escobar M, Chase S, Vernica L. Long-term survival following traumatic brain injury. DisabilRehabil 2005;27:305-14
49. Engberg AW, Teasdale TW. Traumatic brain injury in Denmark 1979-1996. A National study of incidence and mortality. Eur J Epidemiol 2001;17:437- 42
50. Flaada JT, Leibson CL, Mandrekar JN, Diehl N, Perkins PK, Brown AW, et al. Relative risk of mortality after traumatic brain injury: a population-based study of
the role of age and injury severity. J Neurotrauma 2007;24:435-45
51. Langlois JA, Rutland-Brown W, Thomas KE, Xi YL. Incidence of traumatic brain injury in the United States, 2003. J Head Trauma Rehabil 2006;21:544-8
52. Colantonio A, Saverino C, Zagorski B, Swaine B, Lewko J, Jaglal S, et al. Hospitalizations and emergency department visits for TBI in Ontario. Can J Neurol Sci 2010;37:783-90
53. Craik FL, Salthouse TA. Handbook of aging and cognition. New Jersey: Lawrence Erbaum Associates; 1992
54. Hayflick L. How and why we age. New York, NY. Ballantine Books; 1994
55. Spence A. Biology of human aging. New Jersey. Prentice Hall; 1995.
56. Czosnyka M, Balestreri M, Steiner L, Smielewski P, Hutchinson PJ, Matta B, et al. Age, intracranial pressure, autoregulation, and outcome after brain trauma. J Neurosurg 2005;102:450-4
57. Dijkers M, Cantor J, Hibbard M, Belkonen S, Warshowsky A, Layman D. The consequences of TBI in the elderly: a systemic review. Brain Injury Professional 2008;5:14-18
58. Fjell AM, Walhovd KB. Structural brain changes in aging: courses, causes and cognitive consequences. Rev Neurosci 2010;21:187-221
59. Kovacs EJ. Aging, traumatic brain injury, and estrogen treatment. Exp Gerontol 2005;40:549-55
60. Selassie AW, McCarthy ML, Ferguson PL, Tian J, Langlois JA. Risk of posthospitalization mortality among persons with traumatic brain injury, South Carolina 1999-2001. J Head Trauma Rehabil 2005;20:257-69
2. Smits M, Dippel DW, Steyerberg EW, de Haan GG, Dekker HM, Vos PE, et al. Predicting intracranial traumatic findings on computed tomography in patients with minor head injury: the CHIP prediction rule. Ann Intern Med 2007;146:397-405
3. Maas AI, Marmarou A, Murray GD, Teasdale SG, Steyerberg EW. Prognosis and clinical trial design in traumatic brain injury: the IMPACT study. J Neurotrauma 2007;24:232-8
4. Styrke J, Stalnacke BM, Sojka P, Bjornstig U. Traumatic brain injuries in a well defined population: epidemiological aspects and severity. J Neurotrauma 2007;24:1425-36
5. Thompson HJ, McCormick WC, Kagan SH. Traumatic brain injury in older adults: epidemiology, outcomes, and future implications. J Am Geriatr Soc 2006;54:1590-95
6. Tokutomi T, Miyaji T, Ogawa T, Ono J, Kawamata T, Sakamoto T et al. Agerelated increases in poor outcomes after traumatic brain injury: a report from the Japan Neurotrauma Data Bank. J Neurotrauma 2008;25:1407-14
7. Vollmer DG, Torner JC, Jane JA, Sadovnic B, Charlebois D, Eisenberg HM,et al. Age and outcome following traumatic coma: why do older patients fare worse? J Neurosurg 1991;75:S37-S49
8. Signorini DF, Andrews PJ, Jones PA, Wardlaw JM, Miller JD. Predicting survival using simple clinical variables: a case study in traumatic brain injury. J Neurol Neurosurg Psychiatry 1999;66:20-25
9. Ono J, Yamaura A, Kubota M, Okimura Y, Isobe K. Outcome prediction in severe head injury: analysis of clinical prognostic factors. J Clin Neurosci 2001;8:120-21
10. Andrews PJ,Sleeman DH, Stathan PF,McQuatt A, Comuble V, Jones PA, et al. Predicting recovery in patients suffering from traumatic brain injury by using admission variables and physiological data: a comparison between decision tree analysis and logistic regression. J Neurosurg 2002;97:326-36
11. Demetriades D, Murray J, Martin M,Velmahos G, Salim A, Alo K, et al. Pedestrians injured by automobiles: relationship of age to injury type and severity. J Am Coll Surg 2004;199:382-7
12. Ratanalert S, Chompikul J, Hirunpat S. Talked and deteriorated head injury patients: how many poor outcomes can be avoided? J Clin Neurosci 2002;9:640-43
13. Bahloul M, Chelly H, Ben Hmida M, Ben Hmida C, Ksibi H, Kallel H, et al. Prognosis of traumatic head injury in South Tunisia: a multivariate analysis of 437 cases. J Trauma 2004;57:255-61
14. MRC CRASH Trial Collaborators. Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients.
BMJ 2008;336:425-29
15. Choi SC, Muizelaar JP, Bames TY, Marmarou A, Brooks DM, Young HF. Prediction tree for severely head-injured patients. J Neurosurg 1991;75:251-5
16. Maas AI, Stocchetti N, Bullock R. Moderate and severe traumatic brain injury in adults. Lancet Neurology 2008;7:728-41
17. Langlois JA, Rutland-Brown W, Thomas KE. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. National Center for Injury Prevention and Control, Atlanta, GA: 2004
18. Faul M, Xu L, Wald MM, Coronado VG. Traumatic brain injury in the United States: emergency department visits, hospitalizations and deaths 2002-2006.
Center for Disease Control and Prevention, National Center for Injury Prevention and Control, Atlanta, GA: 2010
19. Jennet B, Bond M. Assessment of outcome after severe brain damage. Lancet 1975;1:480-4
20. King JT, Carlier PM, Marion WD. Glasgow outcome scale scores predict long-term functional outcome in patients with severe traumatic brain injury. J Neurotrauma 2005;22:947-54.
21. Nwadiaro HC, Ekwe KK, Akpayak IC, Shitta H. Motorcycle injuries in northcentral Nigeria. Nigerian Journal of Clinical Practice 2011;14:186-9
22. Ekere AU, Ibeanusi S. Pattern of motorcycle associated injuries in PortHarcourt: a hospital based study. Orient Journal of Medicine 2003;16:36-40
23. Badanich KA, Mulholland PJ, Beckley JT, Trantham-Davidson H, Woodward JJ. Ethanol reduces neuronal excitability of lateral orbitofrontal cortex neurons via a glycine receptor dependent mechanism. Neuropsychophamarcology 2013;38:1176-1188
24. Andriessen TMJC, Horn J, Franschman G, van der Naalt J, Haitsma I, Jacobs B, et al. Epidemiology, severity classification, and outcome of moderate and severe traumatic brain injury: a prospective multicenter study. J Neurotrauma 2011;28:2019-31
25. Myburgh JA, Cooper DJ, Finfer SR, Venkatesh B, Jones D, Higgins A, et al. Epidemiology and 12-month outcomes from traumatic brain injury in Australia and New Zealand. J Trauma 2008;64:854-62
26. Majdan M, Mauritz W, Brazinova A, Rusnack M, Leitgeb J, Janciak I, et al. Severity and outcome of traumatic brain injuries with different causes of injury. Brain Injury 2011;25:797-805
27. Younis R, Younis M, Hamidi S, Musmar M, Mawson AR. Causes of traumatic brain injury in patients admitted to Rafida, Al-Ittihad and the specialized Arab hospitals, Palestine. Brain Injury 2011;25:282-91
28. Mcintrye A, Mehta S, Aubut J, Dijkers M, Teasell RW. Mortality among older adults after a traumatic brain injury, a meta-analysis. Brain Injury 2013;27:31-40
29. Murdoch BE, Theodoros DG. Traumatic brain injury: associated speech, language and swallowing disorders. San Diego, CA: Singular Publishing Group; 2001
30. Mosenthal AC, Lavery RF, Addis M, Kaul S, Ross S, Marburger R, et al. Isolated traumatic brain injury. Age is an independent predictor of mortality, and early outcome. J Trauma 2002;52:907-11
31. Rapaport MJ, Feinstein A. Outcome following traumatic brain injury in the elderly: a critical review. Brain Injury 2000;14:749-61
32. Wagner AK. Functional prognosis in traumatic brain injury. Physical Medicine and Rehabilitation: States of the Art Review 2001;15:245-65
33. Hukkelhoven CW, Steyerberg EW, Rampen AJ, et al. Patient age and outcome following severe traumatic brain injury. Analysis of 5,600 patients. J Neurosurg 2003;99:666-73
34. Stocchetti N, Paterno R, Citerio G, Berreta L, Colombo A. Traumatic brain injury in an aging population. J Neurotrauma 2012;29:1119-25
35. Dams-O’Connor K, Cuthbert JP, Whyte J, Corrigan JD, Faul M, Harrison-Felix C. Traumatic brain injury among older adults at level I and II trauma centers. J
Neurotrauma 2013;30:2001-13
36. Richmond TS, Kauder D, Strumpy N, Meredith T. Characteristics and outcomes of serious traumatic brain injury in older adults. J Am Geriatr Soc 2002;50:215-22
37. Gilmer LK, Ansari MA, Roberts KN, Scheff SW. Age-related mitochondrial changes after traumatic brain injury. J Neurotrauma 2010;27:939-50
38. Ferrell RB, Tanev KS. Traumatic brain injury in older adults. Curr Psychiatry Rep 2002;4:354-62
39. Cefalu CA. Theories and mechanisms of aging. Clin Geriartr Med 2011;27:491-506
40. Goodrich JT. Landmarks in the history of Neurosurgery. In: Rengarchary SS, Wilkins HR, editors. Principles of Neurosurgery; 1994 ed. London: Wolfe Publishing; 1994:p1.2-19
41. Miller JD, Pentland B. Head injuries in elderly patients. J Neurosurg Rev 1989:12Suppl1:441-5
42. Wang YC, P’eng FK, Yang DY,Shoung MH, Hung CF, Cheng JT, et al. Epidemiology study of head injuries in Central Taiwan. Zhoughua Yi Xue Za Zhi (Taipei) 1995;55:50-59
43. Hitmana J, Perez M, Kinasha A, Kakande I. Clinical presentation and outcome of neurosurgical conditions in Bature teaching hospital, Rwanda. East and Central African Journal of Surgery 2009;14:50-56
44. Jacobs B, Beems T, Stulemeijer M, van Vugt AB, Van der Vliet TM, Born FG, et al. Outcome prediction in mild traumatic brain injury: age and clinical variables are stronger predictors than CT abnormalities. J Neurotrauma 2010;27:655-68
45. Gomez PA, Lobato RD, Boto GR, De la Lama A, Gonzalez PJ, de la Cruz J. Age and outcome after severe head injury. Acta Neurochir (Wien) 2000;142:373-81
46. Mushkudiani NA, Engel DC, Steyerberg EW, Butcher I, Lu J, Marmarou A, et al. Prognostic value of demographic characteristics in traumatic brain injury: results from the IMPACT study. J Neurotrauma 2007;24:259-69
47. Marquez de la Plata CD, Hart T, Hammond FM, Frol AB, Hudak A, Harper CR, et al. Impact of age on longterm recovery from traumatic brain injury. Arch Phys Med Rehabil 2008;89:896-903
48. Ratcliff G, Colantonio A, Escobar M, Chase S, Vernica L. Long-term survival following traumatic brain injury. DisabilRehabil 2005;27:305-14
49. Engberg AW, Teasdale TW. Traumatic brain injury in Denmark 1979-1996. A National study of incidence and mortality. Eur J Epidemiol 2001;17:437- 42
50. Flaada JT, Leibson CL, Mandrekar JN, Diehl N, Perkins PK, Brown AW, et al. Relative risk of mortality after traumatic brain injury: a population-based study of
the role of age and injury severity. J Neurotrauma 2007;24:435-45
51. Langlois JA, Rutland-Brown W, Thomas KE, Xi YL. Incidence of traumatic brain injury in the United States, 2003. J Head Trauma Rehabil 2006;21:544-8
52. Colantonio A, Saverino C, Zagorski B, Swaine B, Lewko J, Jaglal S, et al. Hospitalizations and emergency department visits for TBI in Ontario. Can J Neurol Sci 2010;37:783-90
53. Craik FL, Salthouse TA. Handbook of aging and cognition. New Jersey: Lawrence Erbaum Associates; 1992
54. Hayflick L. How and why we age. New York, NY. Ballantine Books; 1994
55. Spence A. Biology of human aging. New Jersey. Prentice Hall; 1995.
56. Czosnyka M, Balestreri M, Steiner L, Smielewski P, Hutchinson PJ, Matta B, et al. Age, intracranial pressure, autoregulation, and outcome after brain trauma. J Neurosurg 2005;102:450-4
57. Dijkers M, Cantor J, Hibbard M, Belkonen S, Warshowsky A, Layman D. The consequences of TBI in the elderly: a systemic review. Brain Injury Professional 2008;5:14-18
58. Fjell AM, Walhovd KB. Structural brain changes in aging: courses, causes and cognitive consequences. Rev Neurosci 2010;21:187-221
59. Kovacs EJ. Aging, traumatic brain injury, and estrogen treatment. Exp Gerontol 2005;40:549-55
60. Selassie AW, McCarthy ML, Ferguson PL, Tian J, Langlois JA. Risk of posthospitalization mortality among persons with traumatic brain injury, South Carolina 1999-2001. J Head Trauma Rehabil 2005;20:257-69
How to Cite
1.
Nnadi, Mathias Ogbonna Nnanna, Bankole, Olufemi Babatola, Fente, Beleudanyo Gbalipre. TRAUMATIC BRAIN INJURY IN ADULTS: AGE, ETIOLOGY, AND TREATMENT OUTCOME. Med. res. chronicles [Internet]. 2020Jul.28 [cited 2024Nov.6];3(1):29-. Available from: https://medrech.com/index.php/medrech/article/view/159
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Original Research Article
