Indian Journal of Radiology Indian Journal of Radiology  

   Login   | Users online: 2827

Home Bookmark this page Print this page Email this page Small font sizeDefault font size Increase font size     

 

 Table of Contents    
ORIGINAL ARTICLE  
Year : 2021  |  Volume : 31  |  Issue : 5  |  Page : 139-147
Perception and practice regarding infection control measures in Radiology department during pre-COVID and COVID times—A survey among radiologists and a review of current concepts and literature


1 Department of Radiodiagnosis, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Karnataka, India
2 Department of Community Medicine, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Karnataka, India
3 Department of Microbiology, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Karnataka, India

Click here for correspondence address and email

Date of Submission09-Jul-2020
Date of Acceptance17-Jul-2020
Date of Web Publication23-Jan-2021
 

   Abstract 


Aim: In this study, we aim to evaluate the perception and practice of IPC measures by Radiologists during pre-COVID and present COVID times, while conducting a thorough review of current concepts and literature, to provide a standard operating procedure (SOP) for radiology operations. Methods: This study was conducted by Department of Radiodiagnosis and Imaging, Kasturba Medical College, MAHE, Mangalore. After obtaining approval from the institutional ethics committee, and other required permissions, the Google form questionnaire was sent to 350 Radiologists via email and text during the period of May 2020. Data was collected by time-based sampling in the period of fifteen days during the end of the total lockdown time. Results: 54% (n = 152) reported never attending a training session on (Infection Prevention & Control) IPC prior to the COVID-19 outbreak. The perception regarding IPC were found to be good among radiologists as majority of the respondents were correctly able to answer questions regarding IPC. 86% (n = 152) of the respondents believed that their knowledge on IPC has improved during the COVID-19 pandemic. However, it was revealed that majority of the respondents only started to practice appropriate contact and droplet / procedural precautions only after the COVID-19 outbreak. Conclusion: The present COVID-19 scenario coupled with the lack of knowledge and training regarding IPC amongst radiologists evident from the results of our survey, highlights the need for proper training and establishing standard operating procedures and best practices in IPC pertinent to modern radiology practice

Keywords: COVID-19; empirical precautions; infection prevention and control; procedural precautions; radiology; source control; standard operating procedure; standard precautions; triage

How to cite this article:
Srivastava S, Rai P V, Jain A, Shenoy S. Perception and practice regarding infection control measures in Radiology department during pre-COVID and COVID times—A survey among radiologists and a review of current concepts and literature. Indian J Radiol Imaging 2021;31, Suppl S1:139-47

How to cite this URL:
Srivastava S, Rai P V, Jain A, Shenoy S. Perception and practice regarding infection control measures in Radiology department during pre-COVID and COVID times—A survey among radiologists and a review of current concepts and literature. Indian J Radiol Imaging [serial online] 2021 [cited 2021 Mar 2];31, Suppl S1:139-47. Available from: https://www.ijri.org/text.asp?2021/31/5/139/307726



   Introduction Top


Knowledge and training regarding infection prevention and control (IPC) is lacking among radiologists, and as modern Radiology practice evolves into its more clinical role, the implementation of standardized IPC measures becomes increasingly relevant.[1] This was evident in a study conducted by Reddy et al.,[2] wherein, an online infection control survey for the members of Society of Interventional Radiologists (SIR) was conducted which revealed that only a small percentage of interventional radiologists practised proper infection control measures in their practice. The recent COVID-19 pandemic has taken the world by storm, being the third severe coronavirus outbreak over the past 20 years.[3],[4] Due to its high transmissibility (R0) and a relatively lower mortality rate (2%),[5] over 6 million people have been infected, with over 370,000 deaths at the time of writing this article.[6] COVID-19 may be transmitted via droplets, contact, and possibly airborne transmission.[5] The potential risks of such disease transmission exist in the radiology department as the diagnosis of COVID-19 often relies heavily upon imaging and should be prevented with the implementation of proper IPC measures.[7] Strategies to reduce the risk of acquiring and transmitting COVID-19 due to close patient contact and invasive patient care in the Radiology department is essential.[8] In a report of 44,672 COVID-19 cases in China, 1,716 (3.8%) were health care workers (HCWs), wherein, 14.8% of confirmed cases among HCWs were classified as critical, observing a total of five deaths.[9] Similarly, there are reports of several radiology staff who were infected as a result of improper isolation protocols for patients suspected or confirmed of COVID-19.[7]

In this study, we aim to evaluate the perception and practice of IPC measures by radiologists during pre-COVID and present COVID times, while conducting a thorough review of current concepts and literature, to provide a standard operating procedure (SOP) for radiology operations in the present context.


   Methodology Top


This descriptive cross-sectional study was conducted by the Department of Radiodiagnosis and Imaging, Kasturba Medical College, MAHE, Mangalore. A structured proforma (questionnaire) was built on “Google Forms” for this purpose based on literature review and inputs from experts in medical radiology, infection control, epidemiology, and medical education. The Google forms questionnaire was pilot tested and modified accordingly, as needed. After obtaining the approval from the institutional ethics committee and also the other required permissions, the Google form questionnaire was sent to the study participants via social media, specialty groups, personal contacts, or email. The study participants comprised of consultant radiologists, residents, and postgraduates working in clinics, diagnostic centers, and hospitals involved in performing ultrasound, reporting cross-sectional imaging, and performing procedures in interventional radiology (IR) suites who consented to participate. Data was collected by time-based sampling in a period of 15 days during the end of the total lockdown time.


   Results Top


During the period of May 2020, a total of 350 radiologists were requested via email and text to participate in our 66-item questionnaire, of which 152 completed the full survey. The survey comprised of three sections – A) Demography, B) Perception of Infection Prevention and Control (IPC) measures among radiologists, and C) Impact of COVID-19 on the practice of IPC measures among radiologists. The questions were aimed at assessing the perception, knowledge, attitude, and practices in infection control measures within the Radiology department.

A. Demography

Of all the respondents, performing ultrasound (70%) and reporting cross-sectional imaging (76%) were the most frequently reported predominant areas of radiology practice. A majority of the respondents (54%) reported never attending a training session on infection prevention and control (IPC) prior to the COVID-19 pandemic. For further details on demographic characteristics, refer to “[Table 1]
Table 1: Demography

Click here to view


B. Perception of infection prevention and control (IPC) measures

The general knowledge and perception regarding IPC were found to be good among the respondents. Majority of the respondents were able to correctly answer the questions regarding disease transmission, standard precautions, and personal protective equipment (PPE). However, majority of the respondents (57.2% (n = 152)) perceived “Use of leak-proof plastic containers” as a part of standard precautions by CDC. Although, considered as an important specimen-handling precaution[1] in IPC, the use of leak-proof plastic containers, is not a part of the “Standard Precautions by CDC”. On average, approximately 31% (n = 152) of the respondents incorrectly identified the sequence of donning and doffing of PPE. Additionally, 86% of all respondents (n = 152) believed that their knowledge of IPC has improved during the phase of COVID-19 pandemic.

The questions and percentile answers aimed at the knowledge of the principles of IPC and PPE are listed in [Table 2] and [Table 3]. Awareness of standard precautions and the Spaulding classification system are listed in [Table 4] and [Table 5], respectively.
Table 2: Perception of Radiologists regarding disease transmission in Radiology Departments

Click here to view
Table 3: True or false statements

Click here to view
Table 4: Are the following part of ‘Standard Precautions’ by CDC (Yes/No/Not Sure) (n=152)

Click here to view
Table 5: “Spaulding Classification” for Disinfection of reusable medical items

Click here to view


(C) Assessing the practice of IPC measures and the impact of covid-19 on the practice of IPC measures among radiologists

This section was broadly divided into the following subsections – “Triage, Early recognition & source control,” “Standard Precautions (CDC),” “Contact and Droplet Precautions,” “Procedure Precautions,” and “Future Plans.” Various practices of IPC were mentioned under each subsection and the participants were asked to indicate whether those practices were practiced since before the COVID-19 outbreak, started practicing after the COVID-19 outbreak or if NOT practiced at all, by checking “Before”, “After,” OR “Neither,” respectively.

Majority of the respondents reported establishing a triage station and practicing source control after the COVID-19 outbreak [Figure 1]. Almost all the respondents reported the practice of “Standard Precautions (CDC)” either since before or after the COVID-19 outbreak. Majority (51%) of the participants reported the practice of “strict hand hygiene” before and after contact with each patient and/or with potentially infectious material. “Prevention of needle stick or sharp injuries” was reported by 92% of the respondents since before the COVID-19 outbreak. However, upon inquiring on “proper handling, cleaning, and disinfection of patient care equipment,” “providing patient education on respiratory hygiene,” and “use of appropriate PPE,” majority of the respondents reported the practice of these standard precautions only after the COVID-19 outbreak (72%, 53%, and 77% respectively) [Figure 2]. On inquiring upon practice of “Contact and Droplet precautions,” it was revealed that majority of the respondents started to practice these precautions only after the COVID-19 outbreak, whereas, some respondents even reported not practicing these precautions at all. A much greater portion of respondents (n = 152) reported practicing contact and droplet preventive protocols related to isolation only after the COVID-19 outbreak such as “placement of patients in properly ventilated single room(s)” (64%), “assigning a designated team of HCWs to provide care for those under isolation” (90%), “appropriate donning and doffing of PPE” (84%), and “using a new set of PPE for a different patient” (59%). Similarly, preventive protocols related to transportation of patients were also reported to be practiced majorly after the COVID-19 outbreak. Only 25% (n = 152) of the respondents reported regular cleaning and disinfection of all surfaces the patients may be in contact with, since before the COVID-19 outbreak. However, the “use of disposable/dedicated equipment,” including the “use of dedicated portable X-ray/diagnostic equipment” were the only preventive measures listed under “contact and droplet precautions” that were reported practiced since before the COVID-19 outbreak by approximately 61% (n = 152) [Figure 3]. Regarding “Procedure Precautions,” it was revealed that only few certain precautions such as using US guidance for vascular access, careful handling of sharps, and steam sterilization of critical reusable medical items were practiced since before the outbreak by majority of the respondents. Whereas, maximum procedural precautions were either reported to be practiced only after the COVID-19 outbreak, or less often, not practiced at all. The practice of performing central venous catheter (CVC) placement in an isolation room with an US unit and a C-arm, along with the “use of single-use sterile US gel” and “double-bagging of US unit and transducer & C-arm” was reported not practiced by majority of the respondents (39%, 64%, and 58%, respectively). Although, reported to be practiced, a major bulk of the procedural precautions related to disinfection were reported to be practiced only after the COVID-19 outbreak, including, disinfection of all workstations and procedural rooms after each use (71%), mandatory cleaning undertaken at least four times per day (70%), etc., (For further details on the practice of procedural precautions among radiologists, please refer to [Figure 4]).
Figure 1: Triage, Early Detection & Source Control (n=152)

Click here to view
Figure 2: Standard precautions (CDC) (n=152)

Click here to view
Figure 3: Contact and droplet precautions (N=152)

Click here to view
Figure 4: Procedure precautions (n=152)

Click here to view



   Discussion Top


Based on the questionnaire on perception and practice, a quick review of the current concepts is presented below.

Broad Guidelines

  1. Establishment of efficient central coordination between hospital infection prevention and control and the radiology department
  2. Screening, Early Detection, and Source Control –


    • From the results of our quick survey, it was revealed that establishment of triage stations and the practice of source control was majorly only done after the outbreak of COVID-19 occurred [Figure 1]
    • Screening of all patients for COVID-19 should be done prior to all examinations by establishing a triage station with a standardized questionnaire at all the hospital entrances. This provides a systemic approach towards assessment of all patients at the time of admission and early detection of any active or subclinical cases of COVID-19[10]


      • The standardized questionnaire should be able to clarify any history of fever and/or signs/symptoms of respiratory illness such as cough, sore throat, breathlessness etc
      • Apart from clinical history, it is also essential to inquire with the patient about any form of contact or travel history.[11]


    • Temperature screening should be implemented at all hospital entrances to identify anyone with symptoms that may be related to COVID-19[11]
    • Source Control is the early detection of any suspected/confirmed COVID-19 cases followed by rapid isolation of such patients in an area distinctly separate from all other patients.


  3. Implementation of Standard Precautions (CDC)[12] for all patients.


    • Standard precautions advocated by The Center for Disease Control and Prevention (CDC) include –


      1. Strict hand hygiene (by either using an alcohol-based hand rub or by washing hands with soap and water for at least 20 seconds),[11],[12]
      2. Use appropriate personal protective equipment (PPE) whenever there is an expectation of possible exposure to infectious material.

        Refer to [Table 6] for a brief summary of appropriate PPE requirements according to the level of protection required based on the evidence-based measures in radiology department to limit transmission by Lahoti et al.[11]
      3. Follow respiratory hygiene/cough etiquette principles,
      4. Proper handling, cleaning, and disinfection of patient care equipment/devices and the environment,
      5. Follow safe injection practices, and
      6. Ensure healthcare worker safety including proper handling of needles and other sharps.


    • The results of our survey clearly indicated that most of the standard precautions mentioned above, except for strict hand hygiene and prevention of needle/sharps injury were practiced by radiologists only after the COVID-19 outbreak. This gives an insight into why implementation of standard precautions for all patient care is essential in radiology departments.
    • Standard precautions should be strictly implemented for ALL patients including suspected/confirmed cases[13] of COVID-19.


  4. Implementation of Additional Empirical Precautions for select patients [Table 7]


    • Contact and Droplet Precautions: From the results of our survey, it was revealed that among the radiologists who completed our survey, majority of them only reported implementing these precautions after the COVID-19 outbreak, whereas some respondents even reported not practicing these precautions at all
    • Procedural Precautions (including airborne precautions): The results of our survey indicated that the knowledge and practice of procedural precautions is lacking among radiologists. This implicates the importance of a proper and relevant set of instructions for implementation of appropriate empirical precautions in the setting of a radiology department
    • [Table 7] represents a summary of the essential contact & droplet and airborne precautions pertaining to radiology departments based on the results of our survey along with a review of current concepts and literature[1],[14],[15],[16],[17],[18]


  5. Development and implementation of Standard Operating Procedures (SOPs) for various imaging modalities and interventional procedures for suspected or confirmed cases of COVID-19.


    • Refer to [Figure 5] for a Standard Operating Procedure (SOP) for performing portable chest X-ray for suspected/confirmed patients of COVID-19. [Figure 5]A – Procedure before entering a patients room, [Figure 5]B – Procedure in the patient's room, [Figure 5]C – Procedure after acquiring patient's X-ray[19],[20]
    • Refer to [Figure 6] for a Standard Operating Procedure (SOP) for performing CT scan for a suspected/confirmed patient of COVID-19.[19],[20],[21]


  6. Imaging should only be performed for a COVID-19 patient when imaging will impact the management and outcome of the patient.[19]
  7. Decontamination of reusable medical items according to the Spaulding Classification System[1]


    • Critical items (contacting normal sterile body surfaces)

      Example – Endovascular/endovaginal US probe, reusable surgical instruments

      DecontaminationHeat-resistant items disinfected by steam sterilization and heat-sensitive items disinfected by ethylene oxide gas/hydrogen peroxide gas/plasma/ozone or a liquid chemical sterilant.
    • Semi-critical items (contacting mucus membranes or broken skin)

      Example – Endoscopes, cystoscopes etc.

      DecontaminationHigh-level decontamination with chemical sterilant after each use.
    • Non-critical items (contacting intact skin)

      Example – CT/MRI gantry, noninvasive US probes, viewing station keyboard/mouse/surfaces

      Decontamination – by low-intermediate level disinfectant after each use.


  8. STAFF RELATED –


    1. Staff should be restricted from travelling to any domestic or international destinations for work-related activities.
    2. Adapting to video-conferences for staff meeting.
    3. Adapting to remote interpretations in situations where staff may need to go into isolation.
Figure 5 (A-C): Standard Operating Procedure (SOP) for performing portable chest X-ray for suspected/confirmed patients of COVID-19. (A) Procedure before entering a patients room, (B) Procedure in the patient's room, (C) Procedure after acquiring patient's X-ray

Click here to view
Figure 6: Standard Operating Procedure (SOP) for performing CT scan for a suspected/confirmed patient of COVID-19

Click here to view
Table 6: PPE requirements as per the level of protection

Click here to view
Table 7: Additional Empirical Precautions

Click here to view


From our quick survey, it was revealed that majority (54%) of the respondents reported not receiving any form of training on IPC prior to this COVID-19 pandemic, and 86% of the respondents believed that their knowledge of IPC has improved during this COVID-19 pandemic. 97% of the respondents believed that best practices in IPC should be continued with same vigilance even after the COVID-19 pandemic, and that IPC should be made a permanent part of the postgraduate curriculum. 93.3% of the respondents believed that a “paperless system” involving wireless transfer and reporting of images can contribute significantly in IPC in radiology departments. Other suggestions provided by the respondents included mandatory training sessions on IPC for everyone, assigning an IPC officer similar to radiation safety officer (who performs checks on regular intervals, making required adjustments and improvements), and automatic doors that limit contact transmission. A limitation of the study was a relatively lower number of responses (n = 152), and varied responses from different states/areas.


   Conclusion Top


In conclusion, although the COVID-19 crisis continues to persist, it presents us with an opportunity to continue with improved vigilance and refine standard operational procedures to achieve optimum IPC. Although, following all the guidelines may not be possible in every setting, the present COVID-19 scenario coupled with the lack of knowledge and training regarding IPC among radiologists evident from the results of our survey, highlights the need for proper training and establishing standard operating procedures and best practices in IPC pertinent to modern radiology practice. Radiology departments should be well prepared to continue their operations, especially urgent procedures, and essential elective imaging/procedures, during this period of COVID-19 pandemic. The disease burden can also be better handled and staff and patients can be better protected by adopting to the current concepts and best practices in IPC by discarding all negative practices, while retaining the good ones. Furthermore, a proper knowledge and training regarding IPC can significantly help in reducing the fear factor often associated with imaging COVID-19 patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate participant consent forms. In the form, the participants have given their consent for their participation in our online Google forms questionnaire. The participants understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Mirza SK, Tragon TR, Fukui MB, Hartman MS, Hartman AL. Microbiology for radiologists: How to minimize infection transmission in the radiology department. Radiographics 2015;35:1231-44.  Back to cited text no. 1
    
2.
Reddy P, Liebovitz D, Chrisman H, Nemcek AA Jr, Noskin GA. Infection control practices among interventional radiologists: Results of an online survey. J Vasc Interv Radiol 2009;20:1070-4.e5.  Back to cited text no. 2
    
3.
Su S, Wong G, Shi W, Liu J, Lai ACK, Zhou J, et al. Epidemiology, genetic recombination, and pathogenesis of coronaviruses. Trends Microbiol 2016;24:490-502.  Back to cited text no. 3
    
4.
Cui J, Li F, Shi ZL. Origin and evolution of pathogenic coronaviruses. Nat Rev Microbiol 2019;17:181-92.  Back to cited text no. 4
    
5.
Li JY, You Z, Wang Q, Zhou ZJ, Qiu Y, Luo R, et al. The epidemic of 2019-novel-coronavirus (2019-nCoV) pneumonia and insights for emerging infectious diseases in the future. Microbes Infect 2020;22:80-5.  Back to cited text no. 5
    
6.
World Health Organization (WHO). Coronavirus disease (COVID-19) pandemic. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019. [Last accessed on 2020 Jun 01].  Back to cited text no. 6
    
7.
Yu J, Ding N, Chen H, Liu XJ, He WJ, Dai WC, et al. Infection control against COVID-19 in Departments of Radiology. Acad Radiol 2020;27:614-7.  Back to cited text no. 7
    
8.
Chandy PE, Nasir MU, Srinivasan S, Klass D, Nicolaou S, B Babu S. Interventional radiology and COVID-19: Evidence-based measures to limit transmission. Diagn Interv Radiol 2020;26:236-40.  Back to cited text no. 8
    
9.
Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: Summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention [published online ahead of print, 2020 Feb 24]. JAMA 2020. doi: 10.1001/jama. 2020.2648.  Back to cited text no. 9
    
10.
Mossa-Basha M, Meltzer CC, Kim DC, Tuite MJ, Kolli KP, Tan BS. Radiology department preparedness for COVID-19: Radiology scientific expert panel [published online ahead of print, 2020]. Radiology 2020;200988. doi: 10.1148/radiol. 2020200988.  Back to cited text no. 10
    
11.
Lahoti A, Lakhotiya A, Ukirde V, Gursale A, Satpute S, Bansal A. Coronavirus and interventional radiology department: Evidence-based measures to limit transmission – Indian scenario. Indian J Vasc Endovasc Surg 2020;7:121-4.  Back to cited text no. 11
  [Full text]  
12.
CDC. Standard Precautions for All Patient Care. Available from: https://www.cdc.gov/infectioncontrol/basics/standardprecautions.html. [Last accessed on 2020 Jun 11].  Back to cited text no. 12
    
13.
Global surveillance for COVID-19 caused by human infection with COVID-19 virus. Available from: https://www.who.int/docs/default-source/coronaviruse/global-surveillance-for-covid-v-19-final200321-rev.pdf. [Last accessed on 2020 Jun 12].  Back to cited text no. 13
    
14.
Huang Z, Zhao S, Li Z, Chen W, Zhao L, Deng L, et al. The battle against Coronavirus disease 2019 (COVID-19): Emergency management and infection control in a radiology department. J Am Coll Radiol 2020;17:710-6.  Back to cited text no. 14
    
15.
RSNA. Mossa-Basha M, Azadi J, Ko J, Klein J, Meltzer C, COVID-19 Task Force. RSNA COVID-19 Task Force: Best Practices for Radiology Departments during COVID-19. Available from: https://www.rsna.org/-/media/Files/RSNA/Covid-19/RSNA-COVID-19-bestpractices.ashx?la=en&hash=58700DDDEDB3E5A9C8EDE80BE534B4ABB10291B7. [Last accessed on 2020 Apr 27].  Back to cited text no. 15
    
16.
WHO. Infection prevention and control during health care when COVID-19 is suspected Interim guidance. Available from: https://www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125. [Last accessed on 2020 Mar 19].  Back to cited text no. 16
    
17.
Society of Interventional Radiology. COVID-19 resources for IR – Aerosol Generating Procedures Performed by Interventional Radiology Clinical Notification from Society of Interventional Radiology. Available from: https://www.sirweb.org/practice-resources/covid-19-resources/covid-19-clinical-notification-3-26-20/#Judson. [Last accessed on 2020 Mar 27].  Back to cited text no. 17
    
18.
Atkinson J, Chartier Y, Pessoa-Silva CL, Jensen P, Li Y, Seto WH, editors. Natural Ventilation for Infection Control in Health-Care Settings. Geneva: World Health Organization; 2009.  Back to cited text no. 18
    
19.
Mossa-Basha M, Medverd J, Linnau K, Lynch JB, Wener MH, Kicska G, et al. Policies and guidelines for COVID-19 preparedness: Experiences from the University of Washington. Radiology 2020;8:201326.  Back to cited text no. 19
    
20.
Sctimst.ac.in [Internet]. COVID STANDARD OPERATING PROCEDURE FOR RADIOLOGICAL PROCEDURES, Department of IS&IR, SCTIMST, Trivandrum. Available from: https://www.sctimst.ac.in/COVID-19/RESOURCES/Covid%2019%20Standard%20Operating%20Procedure%20Imaging%20&%20Interventional%20Radiology.pdf. [Last accessed on 2020 Mar 31].  Back to cited text no. 20
    
21.
Zanardo M, Martini C, Monti CB, Cattaneo F, Ciaralli C, Cornacchione P, et al. Management of patients with suspected or confirmed COVID-19, in the radiology department. Radiography (Lond) 2020;26:264-8.  Back to cited text no. 21
    

Top
Correspondence Address:
Dr. Saubhagya Srivastava
Department of Radiodiagnosis, KMC Mangalore, Manipal Academy of Higher Education, Karnataka
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijri.IJRI_567_20

Rights and Permissions


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

Top
 
 
  Search
 
   Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
   Introduction
   Methodology
   Results
   Discussion
   Conclusion
    References
    Article Figures
    Article Tables

 Article Access Statistics
    Viewed986    
    Printed6    
    Emailed0    
    PDF Downloaded43    
    Comments [Add]    

Recommend this journal