Publications by authors named "Sagun Narayan Joshi"

14 Publications

  • Page 1 of 1

Branch Retinal Vein Occlusion in a Case of Sarcoidosis.

Nepal J Ophthalmol 2021 Jan;13(25):146-151

Reiyukai Eiko Masunaga Eye Hospital, Banepa, Kavre, Nepal.

Background: Sarcoidosis is a chronic inflammatory disorder characterized by non-caseation granuloma. It is an inflammatory disorder of unknown etiology. Sarcoidosis has variable ocular presentations from anterior uveitis to rare venous occlusions.

Case: We present a rare case of sarcoidosis with bilateral hilar lymphadenopathy and a compatible uveitis. Positive findings of mutton fat keratic precipitates, Koeppes nodule, posterior synechiae, trabecular meshwork nodules, Candle wax dripping sign, Branch retinal vein occlusion and choroidal granuloma in one eye supported the diagnosis of sarcoidosis. Elevated serum acetylcholine esterase and bilateral hilar lymphadenopathy also confirmed the diagnosis of sarcoidosis.

Observation: The patient responded well to oral steroids and laser photocoagulation of the vein occlusion area. The patient developed complications of steroid like Herpes Zooster of abdomen and avascular necrosis of femur.

Conclusion: Branch Retinal Vein Occlusion is a rare vascular complication in ocular sarcoidosis. Systemic steroids and laser for vein occlusion is mainstay of treatment. Physician must be aware of serious complications of steroid therapy, as seen in this case. Keyword: Sarcoidosis, Branch retinal vein occlusion, Steroids.
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January 2021

Profile of Ophthalmic Tumors in Adult Nepalese Population in Central Nepal.

Nepal J Ophthalmol 2020 Jul;12(24):270-280

Geta Eye Hospital, Dhangadhi, Nepal.

Introduction: Ophthalmic tumors cover benign and malignant tumors of eyelids, conjunctiva, globe, and orbit. There is limited literature on ophthalmic tumors in Nepal. The objective of the study was to find the relative frequency of various ophthalmic tumors in the adult Nepalese population in Central Nepal.

Material And Methods: This is an observational descriptive study. A total of 100 consecutive patients, presenting with ophthalmic tumors to tertiary referral eye hospital were enrolled for the study. Demographic profile, detailed history, clinical features and diagnosis of the ophthalmic tumors were recorded. The tissue from incisional or excisional biopsy was then subjected to histopathological examination for confirmatory diagnosis.

Results: Mean age of subjects with ophthalmic tumors was 51.5 ± 18.2 years with a female to male ratio of 1.2:1. Benign tumors (64%) were the most common tumors followed by malignant (26%) and premalignant tumors (10%). Most common benign tumor was naevus (26.5%); most common premalignant tumor was conjunctival intraepithelial neoplasia (60%), and most common malignant tumor was sebaceous gland carcinoma (30.8%). Eyelid was most frequently involved with ophthalmic tumors (59%) followed by conjunctiva (21%). Clinical diagnosis correlated with histopathological diagnosis in 77% of cases.

Conclusion: As different ophthalmic tumors present in a myriad of ways and a significant proportion of these cases presenting to hospital settings are malignant, it is prudent to confirm with a histopathological diagnosis for optimum management of such cases.
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July 2020

The Risk Factors of Seasonal Hyperacute Panuveitis.

Ophthalmic Epidemiol 2021 Jun 27;28(3):250-257. Epub 2020 Sep 27.

Uveitis Specialist, Department of Ophthalmology, Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, B. P. Koirala Lions Centre for Ophthalmic Studies, Maharajgunj, Kathmandu, Nepal.

Background: Seasonal Hyperacute Panuveitis (SHAPU) is an eye disease of unclear aetiology occurring cyclically during the autumn in odd years in Nepal causing blindness within a week. This study is the first of its type to investigate the risk factors of SHAPU.

Methods: A multicentric national level case-control study was performed during the 2017 SHAPU outbreak. Cases were matched to controls in a 1:3 ratio based on age, sex and geographic area.Questionnaire-based personal interview was used and risk factors were categorized as biological and behavioral. For univariate analysis, frequency, median and interquartile range was calculated. Chi-squared test with/without continuity correction and Fisher's exact test were used. Multivariate conditional logistic regressions were used for all the independent variables for <0.1 in the univariate analyses.

Results: We identified 35 cases and 105 controls; 71.4% were children≤16 years (38-day infant to 50-year-old). All were immunocompetent individuals, males were 57.1% and females 42.9%. Potential risks such as visible moths/butterfly activity, contact with livestock, and attending mass gatherings of people were not reported more frequently in cases vs controls in univariate analyses. Differences in possibly protective factors such as self-reported mosquito net use, light off at night while sleeping, and habit of hands/face washing after physical contact/touch with any insects/butterflies/birds were not statistically significant between both groups. In multivariate model, SHAPU cases were significantly more likely than controls to report physical contact with butterflies/white moths (Adjusted OR:6.89; CI:2.79-17.01, < .001).

Conclusions: Direct physical contact with butterflies/moths was associated with significantly increased odds of SHAPU cases.
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June 2021

HbA1c as a predictor for response of bevacizumab in diabetic macular oedema.

BMJ Open Ophthalmol 2020 12;5(1):e000449. Epub 2020 May 12.

Department of Retina, B.P. Koirala Lions Center for Ophthalmic Studies, Institute of Medicine, Kathmandu, Nepal.

Objective: To study the influence of glycosylated haemoglobin (HbA1c) on response of bevacizumab in patients with diabetic macular oedema.

Methods And Analysis: A total of 37 eyes of 37 patients with vision loss due to diabetic macular oedema treated with bevacizumab were included in this study. Participants received monthly intravitreal bevacizumab (0.05 mL/1.25 mg) for 3 months.

Results: There were 17 patients with baseline HbA1c ≤7% (<53mmol/mol) and 20 patients with baseline HbA1c >7% (>53mmol/mol) treated with bevacizumab included in the study. The mean improvement in visual acuity at 3 months was 0.50 logMAR in HbA1c ≤7%(<53mmol/mol) group and 0.33 logMAR in HbA1c >7%(>53mmol/mol) group (95% CI,-0.05-0.38; p=0.13). The mean central macular thickness (CMT) reduction was -229.76 µm in patients with a baseline HbA1c ≤7% (<53 mmol/mol) and -145.20 µm in patients with HbA1c of >7% (>53mmol/mol) (95% CI,12.98-156.14; p=0.022).

Conclusion: Our study suggests that baseline glycaemic control can affect the treatment outcome of intravitreal bevacizumab in the management of diabetic macular oedema and the response was found to be better in patients with good glycaemic control (low HbA1c).
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May 2020

Outcome of intravitreal bevacizumab injection without pre and postoperative antibiotics.

BMC Ophthalmol 2020 Apr 15;20(1):145. Epub 2020 Apr 15.

Department of Retina, B.PKoirala Lions Centre for Ophthalmic Studies (BPKLCOS), Maharajgunj, Kathmandu, Nepal.

Backgound: Intravitreal injections are the most common treatment modality for several retinal pathologies. Despite endophthalmitis being the most feared complication, antibioprophylaxis remains controversial in intravitreal injections.

Methods: This was a retrospective study done for a period of 2 years from 1st January 2017 to 31st December 2018 in B. P Koirala Lions Centre for Ophthalmic Studies (BPKLCOS) among patients receiving intravitreal bevacizumab. The intravitreal injection was given by a single surgeon. It included 503 eyes which received intravitreal bevacizumab over a period of 2 years without pre and postoperative antibiotics.

Results: Out of 503 eyes studied over a period of 2 years without antibiotic prophylaxis the rate of endophthalmitis was 0.0019% which is very low compared to the other studies with rate of endophthalmitis between 0.019-0.09%.

Conclusion: The risk of endophthalmitis was low even without pre/post-operative antibiotics. Intravitreal injection can be given safely without pre-operative and post-operative antibiotics. Trial Registration not applicable as it is a retrospective study.
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April 2020

Sub-Foveal Choroidal Thickness In Healthy Nepalese Population.

Clin Optom (Auckl) 2019 15;11:145-149. Epub 2019 Nov 15.

BP Koirala Lions Centre for Ophthalmic Studies, Maharajgunj Medical Campus, Institute of Medicine, Kathmandu, Nepal.

Purpose: This study was conducted primarily to measure sub-foveal choroidal thickness (SFCT) in healthy Nepalese population. Also, the correlation of SFCT with age, inter-eye difference of SFCT, inter-gender variation and inter-ethnic variation of SFCT was observed.

Materials And Methods: A cross-sectional, hospital based study in 162 participants (324 eyes) of six ethnic groups (Brahmin, Chhetri, Newar, Tamang, Muslim, and Gurung) was conducted. The mean age of participants was 37.37 ± 15.02 years. All the participants underwent SFCT measurement using Spectral Domain Optical Coherence Tomography (Spectralis HRA+OCT, Heidelberg Engineering, Germany) with the help of in-built caliber. Age, inter-gender, inter-eye and inter-ethnic differences in SFCT were recorded and analyzed.

Results: The average SFCT of right eye (RE) and left eye (LE) was 307.98 ± 74.64 µm and 312.63 ± 76.90 µm respectively, with average SFCT of 310.31 ± 75.70 µm for both eyes. SFCT of only the RE was selected for further calculation due to insignificant inter-eye difference of SFCT (p = 0.128). There was a significant negative correlation of SFCT with age (r = -0.705, p = 0.01). A regression analysis showed thinning of SFCT by 3.50 ± 0.278 µm per year. In another context, SFCT of male and female was 305.49 ± 79.72 µm and 313.55 ± 70.76 µm respectively. However, there was no significant inter-gender difference (p = 0.51). Similarly, inter-ethnic variations of SFCT was also statistically non -significant (p = 0.74).

Conclusion: SFCT was negatively correlated with the age of participants, implying a decrease in choroidal thickness (CT) with an increase in age. Age can be considered as an important factor in the measurement of SFCT. Gender and ethnic groups did not have a significant role in the measurement and comparison of SFCT.
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November 2019

Combined Intravitreal Bevacizumab And Dexamethasone In Bilateral Lupus Retinopathy.

Int Med Case Rep J 2019 30;12:329-333. Epub 2019 Oct 30.

Department of Gynaecology and Obstreitics, Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal.

This paper reports and discusses a case of bilateral lupus retinopathy with macular edema in a patient diagnosed with systemic lupus retinopathy and treated with combined intravitreal bevacizumab (0.025 mL/0.625 mg) and intravitreal dexamethasone (0.05 mL/0.2 mg). The patient was a 25-year-old female with a history of diminution of vision in both eyes. Best corrected visual acuity (BCVA) of the right eye was 2/60 and of the left eye was 1/60. Fundus examination revealed bilateral swelling of the optic disc nasally, cotton wool spots, and multiple flame shaped, dot and blot hemorrhages in the disc and macula. Optical coherence tomography (OCT) revealed macular edema in both eyes. Despite being treated with immunosuppressive the visual acuity did not improve. Two doses of combined intravitreal bevacizumab (0.025 mL/0.625 mg) and dexamethasone (0.05 mL/0.2 mg) were given to the patient in both eyes at an interval of one week. Two weeks after the last intravitreal injection the BCVA was 6/24 and N8 in both eyes. Fundus examination revealed a decrease in the number and size of hemorrhages, and resolution of the blurred disc margin, cotton wool spots, and hard exudates. OCT of the macula 2 weeks after the last intravitreal injection showed a significant decrease in macular edema. The intraocular pressure was not elevated for a period of 6 months. This case would be a unique case of lupus retinopathy with macular edema receiving a combined half dose of intravitreal injection bevacizumab and dexamethasone with promising results. This could be beneficial in a set up where the patients cannot afford intraocular steroid implants.
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October 2019

Effect of High Myopia on Optic Nerve Head by Confocal Scanning Laser Ophthalmoscopy in Nepalese Eyes.

Korean J Ophthalmol 2019 Apr;33(2):181-188

BP Koirala Lions Centre for Ophthalmic Studies, Institute of Medicine, Maharajgunj Medical Campus, Kathmandu, Nepal.

Purpose: To compare parameters of confocal scanning laser ophthalmoscopy (Heidelberg Retinal Tomograph [HRT] II) in high myopia with age- and sex-matched emmetropes.

Methods: A hospital-based cross-sectional study was conducted among Nepalese subjects aged 18 to 35 years at BP Koirala Lions Centre for Ophthalmic Studies, Institute of Medicine, Maharajgunj, Kathmandu from November 2015 to October 2016. Fifty consecutive subjects with high myopia (spherical equivalent ranging from -6.00 to -12.00 diopters) and age- and sex-matched emmetropic subjects were enrolled for comparison. Correlations between disc area and other HRT parameters, asymmetry between the right and left eyes, and comparisons between male and female subjects in both high myopic and emmetropic groups were evaluated.

Results: Disc area was not significantly ( = 0.11) larger in high myopic eyes than in emmetropic eyes. HRT parameters in highly myopic eyes involved smaller cup parameters and greater rim parameters compared with emmetropic eyes. Disc area was found to be significantly positively correlated with inter disc parameters and significantly negatively correlated with rim to disc area ratio in the high myopia group. Disc area and other intra-disc parameters showed significant correlations between right and left eyes in both high myopia and emmetropia, and no significant differences between males and females from a Nepalese population.

Conclusions: Characteristics of HRT parameters in high myopic eyes involved smaller cup parameters and greater rim parameters compared with emmetropic eyes in a Nepalese population. The effect of disc area on HRT parameters differed significantly only in height variation contour by emmetropic eyes.
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April 2019

Awareness of Eye Health and Diseases among the Population of the Hilly Region of Nepal.

J Ophthalmic Vis Res 2018 Oct-Dec;13(4):461-469

B.P. Koirala Lions Centre for Ophthalmic Studies, Institute of Medicine, Maharajgunj Medical Campus, Tribhuvan University, Maharajgunj, Kathmandu, Nepal.

Purpose: To collect information regarding awareness and knowledge of eye health and diseases among the population of the hilly region of Nepal.

Methods: In a population-based survey, 1834 participants were enrolled in to the study. Field procedures included the development of a survey questionnaire, field orientation, pretesting, and household data collection. Association between knowledge of eye diseases was derived using the Chi-square test and odds ratios with a 95% confidence interval. A value of ≤0.05 was considered significant.

Results: Most participants were 31-40 years old (33.4%), female (51.1%), of upper caste (43.4%), Hindus (83.3%), received secondary level of education (34.4%), and involved in agriculture (48.6%). Awareness of cataract, night blindness, glaucoma, strabismus, and systemic diseases was 74.6%, 53.4%, 17.4%, 70.8%, and 46.5%, respectively. Knowledge regarding these diseases among those aware was 39.1%, 72.2%, 50.9%, and 92.3%, respectively. Awareness of cataract was significantly higher (88.4%) among higher caste groups ( < 0.001; OR, 4.29; 95% CI, 3.34-5.54), followed by business as an occupation (88.2%; = 0.001; OR, 2.65; 95% CI, 1.44-4.9). Awareness of night blindness was significantly higher among students (72.6%; < 0.001; OR, 2.46; 95% CI, 1.65-3.67).

Conclusion: There was a general lack of awareness and knowledge of common eye diseases. Improved awareness and knowledge are required for the prevention, early treatment, and access to eye care.
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November 2018

Toxoplasma gondii bradyzoites and tachyzoites isolation from vitreous of atypical necrotizing retinitis.

J Ophthalmic Inflamm Infect 2018 Jun 15;8(1). Epub 2018 Jun 15.

Department of Microbiology, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal.

Background: Detection of Toxoplasma gondii cysts in vitreous of immunocompetent patient with necrotizing retinitis is extremely rare. We herein report the isolation of Toxoplasma bradyzoites and tachyzoites from the vitreous of healthy person.

Results: A 19-year-old immunocompetent female presented with sudden loss of vision in left eye since 1 week. The BCVA was 6/6 and HM in right and left eye. The left eye finding was suggestive of diffuse necrotizing retinitis with retinal detachment. The IgM and IgG for TORCH infection were negative and HIV, HCV and HBsAg tests were also non reactive. The patient underwent diagnostic and therapeutic vitrectomy with silicon oil installation. The vitreous toxoplasma IgG titre was found to be significantly raised to 1:16. Bradyzoites of toxoplasma were identified in H&E staining and tachyzoites of Toxoplasma were identified in Giemsa staining of vitreous sample. She received oral clindamycin and oral corticosteroid but the vision could not be restored in left eye.

Conclusion: Hence, atypical toxoplasmosis with necrotizing retinitis is a fulminant condition with the diagnostic and therapeutic challenge.
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June 2018

Evaluation of effect of bevacizumab on central subfield macular thickness in the injected and contralateral (untreated) eye of patients with bilateral diabetic macular oedema.

BMJ Open Ophthalmol 2017 10;2(1):e000102. Epub 2017 Dec 10.

Department of Ophthalmology, B P Koirala Lions Centre for Ophthalmic Studies, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal.

Purpose: Antivascular endothelial growth factor (anti-VEGFs)-bevacizumab is routinely utilised for the treatment of diabetic macular oedema (DME). We plan to evaluate the impact of bevacizumab on the central subfield macular thickness (CSMT) of the treated and untreated eye.

Methods: A sequential group of patients with bilateral DME who were treated with unilateral bevacizumab injection were assessed preinjection and postinjection by Spectral Domain-Optical Coherence Tomography (SD-OCT) by CSMT.

Results: Thirty-one patients, 20 male and 11 female, were evaluated. Seven patients had type 1 diabetes mellitus and 24 had type 2 diabetes mellitus. In regard to the duration of disease, 23 patients had diabetes for more than 10 years, seven patients had the condition for 5-10 years and one patient for more than 5 years. Mean age of the patients was 60.48 years (SD±7.13) with the range of 46-72 years. Mean follow-up was 28 days (range 26-35 days). The eyes which received intravitreal injection had median CSMT of 473.2 µm(range 321-566 µm). The CSMT of the contralateral eye had median of 347.6 µm (range 357-437 µm). A median reduction of -132 µm (range 93-156 µm) could be observed in the treated eye and -18 µm (range 15-22) in the untreated eye after treatment. Our study also found that eyes with greater CSMT, when injected with bevacizumab, produced higher responses in the contralateral eye (R 0.538, P<0.05).

Conclusions: Patients with bilateral DME treated with bevacizumab in one eye produced a bilateral response. Eyes with greater CSMT due to DME elicited higher levels of response in the untreated eye.
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December 2017

Patterns of Macular Edema in Uveitis as Diagnosed by Optical Coherence Tomography in Tertiary Eye Center.

Nepal J Ophthalmol 2018 Jan;10(19):39-46

Sagarmatha Choudhary Eye Hospital, Siraha, Lahan.

Aim: The aim of the study is to classify the patterns of uveitic macular edema using Optical Coherence Tomography as a diagnostic tool.

Methodology: It is the Descriptive, cross-sectional study. All patients fulfilling the diagnostic criteria with Optical coherence tomography diagnosed macular edema were enrolled from 1 January 2012 to 30 June 2013. Patterns of uveitic macular edema were classified.

Results: A total of 65 eyes of 47 patients were included. Twenty eight (59.57%) were male. The male to female ratio was 1.5:1. The mean age was 38 years (SD 14.68). Twenty nine patients (61.71%) had unilateral involvement and 18 (38.29%) had bilateral involvement. Forty five eyes of 33 cases (69.23%, 70.21%) had intermediate uveitis, followed by 10 eyes of 7 cases (15.38, 14.9%) of posterior uveitis, 6 eyes of 5 cases (9.23%, 10.63 %) of anterior uveitis and 4 eyes of 2 cases (6.16%,4.2%) of pan-uveitis. Patterns of macular edema were classified: diff use macular edema (DME), cystoid macular edema (CME) and serous retinal detachment (SRD) of which 35 (53.84%) eyes had CME. The etiological diagnosis was found in 7(14.90 %) out of 47 patients.

Conclusion: A significant percentage of cases were idiopathic. Macular edema may go unnoticed unless OCT is performed. Macular detachment is an important feature of macular edema that affects visual acuity and is not readily detected by Fundus Fluorescein Angiography (FFA). Optical coherence tomography (OCT) is safe and non-invasive technique and has the potential for measuring changes in retinal thickness and axial extent of edema.
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January 2018

Diabetic retinopathy with or without clinically significant macular edema: The influencing factors.

Nepal J Ophthalmol 2015 Jul;7(14):142-7

Introduction: Diabetic retinopathy is the commonest micro vascular complication in patients with diabetes and remains a leading cause of blindness in people of working age group.

Objective: to determine the prevalence of clinically significant macular edema (CSME) and the influence of systemic risk factors Materials and methods: It is a hospital based comparative study conducted in 220 eyes of 110 diabetic patients. DR was graded according to International Clinical Diabetic Retinopathy Severity Scale and CSME was defined according to Early Treatment Diabetic Retinopathy Study (ETDRS) system. The patients were grouped as 1) CSME group (DR and CSME in one or both eyes) and 2) Non- CSME group(CSME in none of the eyes but with any grade of DR).Level of glycosylated hemoglobin (HbA1C), serum total cholesterol, triglyceride (TG), low density lipoprotein (LDL), high density lipoprotein (HDL) and urine for albumin were studied in both groups.

Results: CSME was present in 36% of 110 patients. Poor glycemic control and high total cholesterol level showed positive association with CSME (p LESS THAN 0.05). LDL and TG levels were higher and HDL lower in CSME group. However, no statistical significance was found.

Conclusion: The CSME is significantly associated with poorer glycemic control and elevated total cholesterol level.
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July 2015

Multifocal electroretinogram responses in Nepalese diabetic patients without retinopathy.

Doc Ophthalmol 2014 Aug 5;129(1):39-46. Epub 2014 Jun 5.

Visual Science and Medical Retina Laboratories, Institute of Health and Biomedical Innovation, School of Optometry and Vision Science, Queensland University of Technology, 60 Musk Avenue, Kelvin Grove, Brisbane, QLD, 4059, Australia,

Purpose: To determine neuroretinal function with multifocal electroretinogram (mfERG) in diabetic subjects without retinopathy.

Methods: Multifocal electroretinogram (mfERG) was performed in 18 eyes of 18 diabetic subjects without retinopathy and 17 eyes of 17 age and gender-matched healthy control participants. Among 18 diabetic subjects, two had type 1 and 16 had type 2 diabetes. MfERG responses were averaged by the retinal areas of six concentric rings and four quadrants, and 103 retinal locations; N1-P1 amplitude and P1-implicit time were analysed.

Results: Average mfERG N1-P1 amplitude (in nv/deg(2)) of 103 retinal locations was 56.3 ± 17.2 (mean ± SD) in type 1 diabetic subjects, 47.2 ± 9.3 in type 2 diabetic subjects and 71.5 ± 12.7 in controls. Average P1-implicit time (in ms) was 43.0 ± 1.3 in type 1 diabetic subjects, 43.9 ± 2.3 in type 2 diabetic subjects and 41.9 ± 2.1 in controls. There was significant reduction in average N1-P1 amplitude and delay in P1-implicit time in type 2 diabetic subjects in comparison to controls. mfERG amplitude did not show any significant correlation with diabetes duration and blood sugar level. However, implicit time showed a positive correlation with diabetes duration in type 2 diabetic subjects with diabetes duration ≥5 years.

Conclusions: This is the first study in a Nepalese population with diabetes using multifocal electroretinography. We present novel findings that mfERG N1-P1 amplitude is markedly reduced along with delay in P1-implicit time in type 2 diabetic subjects without retinopathy. These findings indicate that there might be significant dysfunction of inner retina before the development of diabetic retinopathy in the study population, which have higher prevalence of diabetes than the global estimate and uncontrolled blood sugar level.
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August 2014