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==Treatment==
==Treatment==


'''See most recent CDC guidelines for all STD's'''
'<span style="font-size:85%">'''Abbreviations:''' '''QHS''' : Every bedtime , '''BID''': 2 times daily, '''TID''': Three times a day, '''QID''': Four times a day, '''IM''' :Intramuscular
 
<br />
 
{| style="border: 2px solid #4479BA; align=" left"
! style="width: Organism; background: #4479BA;" |{{fontcolor|#FFF|[[Organisms]]}}
! style="width: Recommended Drugs; background: #4479BA;" |{{fontcolor|#FFF|Recommended [[Drugs]]}}
! style="width: Alternative drugs; background: #4479BA;" |{{fontcolor|#FFF|Alternative [[drugs]]}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[Candidiasis]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
'''Over-the-Counter Intravaginal Agents'''<ref name="urlVulvovaginal Candidiasis - 2015 STD Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/tg2015/candidiasis.htm |title=Vulvovaginal Candidiasis - 2015 STD Treatment Guidelines |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>
 
*[[Clotrimazole]] 1% cream 5 g intravaginally daily for 7–14 days
 
OR
 
*[[Clotrimazole]] 2% cream 5 g intravaginally daily for 3 days
 
OR
 
*[[Miconazole]] 2% cream 5 g intravaginally daily for 7 days
 
OR
 
*[[Miconazole]] 4% cream 5 g intravaginally daily for 3 days
 
OR
 
*[[Miconazole]] 100 mg vaginal suppository, one [[suppository]] daily for 7 days
 
OR
 
*[[Miconazole]] 200 mg vaginal suppository, one [[suppository]] for 3 days
 
OR
 
*[[Miconazole]] 1,200 mg vaginal [[suppository]], one [[suppository]] for 1 day
 
OR
 
*[[Tioconazole]] 6.5% [[ointment]] 5 g intravaginally in a single application
 
 
 
'''Prescription Intravaginal Agents:'''
 
 
*[[Butoconazole]] 2% cream (single dose bioadhesive product), 5 g intravaginally in a single application
 
OR
 
*[[Terconazole]] 0.4% cream 5 g intravaginally daily for 7 days
 
OR
 
*[[Terconazole]] 0.8% cream 5 g intravaginally daily for 3 days
 
OR
 
*[[Terconazole]] 80 mg [[Vagina|vaginal]] [[suppository]], one [[suppository]] daily for 3 days
 
 
 
'''Oral Agent:'''
 
*[[Fluconazole]] 150 mg orally in a single dose
 
 
<br />
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
[[Nystatin]] 1,00,000 unit tab [[Vagina|vaginally]] QHS for 2 weeks<ref name="pmid21263805">{{cite journal |vauthors=Watson WJ, Demarchi G |title=Vaginal discharge: an approach to diagnosis and management |journal=Can Fam Physician |volume=33 |issue= |pages=1847–52 |date=August 1987 |pmid=21263805 |pmc=2218224 |doi= |url= |issn=}}</ref>
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[Trichomoniasis]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
 
*[[Metronidazole]] 2 g orally in a single dose<ref name="urlTrichomoniasis - 2015 STD Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/tg2015/trichomoniasis.htm |title=Trichomoniasis - 2015 STD Treatment Guidelines |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>
 
OR
 
*[[Tinidazole]] 2 g orally in a single dose<ref name="urlTrichomoniasis - 2015 STD Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/tg2015/trichomoniasis.htm |title=Trichomoniasis - 2015 STD Treatment Guidelines |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>
 
<br />
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
 
*[[Metronidazole]] 500 mg orally twice a day for 7 days<ref name="urlTrichomoniasis - 2015 STD Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/tg2015/trichomoniasis.htm |title=Trichomoniasis - 2015 STD Treatment Guidelines |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>
 
OR
 
*[[Clotrimazole]] 2 X 100 mg [[Vagina|vaginal]] tabs QHS for 7days<ref name="urlTrichomoniasis - 2015 STD Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/tg2015/trichomoniasis.htm |title=Trichomoniasis - 2015 STD Treatment Guidelines |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>
*
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[Bacterial Vaginosis]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
 
*[[Metronidazole]] 500 mg orally twice a day for 7 days<ref name="urlBacterial Vaginosis - 2015 STD Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/tg2015/bv.htm |title=Bacterial Vaginosis - 2015 STD Treatment Guidelines |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>
 
OR
 
*[[Metronidazole]] gel 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days<ref name="urlBacterial Vaginosis - 2015 STD Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/tg2015/bv.htm |title=Bacterial Vaginosis - 2015 STD Treatment Guidelines |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>
 
OR
 
*[[Clindamycin]] cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days<ref name="urlBacterial Vaginosis - 2015 STD Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/tg2015/bv.htm |title=Bacterial Vaginosis - 2015 STD Treatment Guidelines |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
 
*[[Tinidazole]] 2 g orally once daily for 2 days <ref name="urlBacterial Vaginosis - 2015 STD Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/tg2015/bv.htm |title=Bacterial Vaginosis - 2015 STD Treatment Guidelines |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>
 
OR
 
*[[Tinidazole]] 1 g orally once daily for 5 days <ref name="urlBacterial Vaginosis - 2015 STD Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/tg2015/bv.htm |title=Bacterial Vaginosis - 2015 STD Treatment Guidelines |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>
 
OR
 
*[[Clindamycin]] 300 mg orally twice daily for 7 days <ref name="urlBacterial Vaginosis - 2015 STD Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/tg2015/bv.htm |title=Bacterial Vaginosis - 2015 STD Treatment Guidelines |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>
 
OR
 
*[[Clindamycin]] ovules 100 mg intravaginally once at bedtime for 3 days<ref name="urlBacterial Vaginosis - 2015 STD Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/tg2015/bv.htm |title=Bacterial Vaginosis - 2015 STD Treatment Guidelines |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>
 
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[Neisseria gonorrheae|Neisseria gonorrhoea]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
 
 
 
[[Amoxicillin]] orally 3 gm single [[dose]] <br> or <br>[[Ampicillin]] [[Oral|orally]] 3.5 gm single dose <br> or <br>[[Procaine]] PCN G 4.8 million IM single [[dose]] <ref name="pmid21263805">{{cite journal |vauthors=Watson WJ, Demarchi G |title=Vaginal discharge: an approach to diagnosis and management |journal=Can Fam Physician |volume=33 |issue= |pages=1847–52 |date=August 1987 |pmid=21263805 |pmc=2218224 |doi= |url= |issn=}}</ref>
 
<br> '''PLUS'''  
 
<br> [[Probenecid]] 1 gm orally single [[dose]] <ref name="pmid21263805">{{cite journal |vauthors=Watson WJ, Demarchi G |title=Vaginal discharge: an approach to diagnosis and management |journal=Can Fam Physician |volume=33 |issue= |pages=1847–52 |date=August 1987 |pmid=21263805 |pmc=2218224 |doi= |url= |issn=}}</ref>
 
<br> '''AND'''
 
<br> [[Tetracycline]] 500 mg orally QID for 7 days <br> or<br> [[Doxycycline]] 100 mg [[Oral|orally]] BID for 7 days <br> or<br> [[Ceftriaxone]] 250 mg IM single dose<ref name="pmid21263805">{{cite journal |vauthors=Watson WJ, Demarchi G |title=Vaginal discharge: an approach to diagnosis and management |journal=Can Fam Physician |volume=33 |issue= |pages=1847–52 |date=August 1987 |pmid=21263805 |pmc=2218224 |doi= |url= |issn=}}</ref>
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
[[Erythromycin]] 500 mg orally QID for 7 days<ref name="pmid21263805">{{cite journal |vauthors=Watson WJ, Demarchi G |title=Vaginal discharge: an approach to diagnosis and management |journal=Can Fam Physician |volume=33 |issue= |pages=1847–52 |date=August 1987 |pmid=21263805 |pmc=2218224 |doi= |url= |issn=}}</ref> <br> or<br>[[Tetracycline]] 500 mg orally QID for 7 days<ref name="pmid21263805">{{cite journal |vauthors=Watson WJ, Demarchi G |title=Vaginal discharge: an approach to diagnosis and management |journal=Can Fam Physician |volume=33 |issue= |pages=1847–52 |date=August 1987 |pmid=21263805 |pmc=2218224 |doi= |url= |issn=}}</ref> <br> or<br> [[Doxycycline]] 100 mg orally BID for 7 days<ref name="pmid21263805">{{cite journal |vauthors=Watson WJ, Demarchi G |title=Vaginal discharge: an approach to diagnosis and management |journal=Can Fam Physician |volume=33 |issue= |pages=1847–52 |date=August 1987 |pmid=21263805 |pmc=2218224 |doi= |url= |issn=}}</ref> <br> or <br>[[Spectinomycin]] 2 gm IM single [[dose]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[Chlamydia trachomatis]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
[[Tetracycline]] 500 mg orally QID for 7 days<ref name="pmid21263805">{{cite journal |vauthors=Watson WJ, Demarchi G |title=Vaginal discharge: an approach to diagnosis and management |journal=Can Fam Physician |volume=33 |issue= |pages=1847–52 |date=August 1987 |pmid=21263805 |pmc=2218224 |doi= |url= |issn=}}</ref> <br>or<br> [[Doxycycline]] 100 mg [[Oral|orally]] BID for 7 days<ref name="pmid21263805">{{cite journal |vauthors=Watson WJ, Demarchi G |title=Vaginal discharge: an approach to diagnosis and management |journal=Can Fam Physician |volume=33 |issue= |pages=1847–52 |date=August 1987 |pmid=21263805 |pmc=2218224 |doi= |url= |issn=}}</ref>
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
[[Erythromycin]] base 500 mg orally QID for 7 days<ref name="pmid21263805">{{cite journal |vauthors=Watson WJ, Demarchi G |title=Vaginal discharge: an approach to diagnosis and management |journal=Can Fam Physician |volume=33 |issue= |pages=1847–52 |date=August 1987 |pmid=21263805 |pmc=2218224 |doi= |url= |issn=}}</ref> <br> or<br> [[Erythromycin]] ethylsuccinate 800 mg orally QID for 7 days<ref name="pmid21263805">{{cite journal |vauthors=Watson WJ, Demarchi G |title=Vaginal discharge: an approach to diagnosis and management |journal=Can Fam Physician |volume=33 |issue= |pages=1847–52 |date=August 1987 |pmid=21263805 |pmc=2218224 |doi= |url= |issn=}}</ref> <br> or<br> [[Sulfamethoxazole]] 1gm [[Oral|orally]] BID for 10 days
<br />
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[Herpes simplex|Herpes Simplex]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
 
 
[[Acyclovir]]<ref name="pmid21263805">{{cite journal |vauthors=Watson WJ, Demarchi G |title=Vaginal discharge: an approach to diagnosis and management |journal=Can Fam Physician |volume=33 |issue= |pages=1847–52 |date=August 1987 |pmid=21263805 |pmc=2218224 |doi= |url= |issn=}}</ref>
 
<br />
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
|-
|}
 
Patient should be referred to a [[gynecologist]] if following are present. <ref name="SimLogan2020">{{cite journal|last1=Sim|first1=M|last2=Logan|first2=S|last3=Goh|first3=LH|title=Vaginal discharge: evaluation and management in primary care|journal=Singapore Medical Journal|year=2020|pages=297–301|issn=00375675|doi=10.11622/smedj.2020088}}</ref>
 
*Retained [[foreign bodies]].
*Recent instrumentation or [[surgery]] of the [[Genital area|genital tract]] such as [[hysterosalpingography]], [[Dilation and curettage (patient information)|dilation and curettage]], [[hysteroscopy]], termination of [[pregnancy]]/evacuation of retained products of [[conception]], [[laparoscopy]] and major [[Gynaecology|gynaecological]] [[surgical procedure]].
*Suspected [[tumor]] of the [[Genital area|genital tract]].
*[[Cervical]] ectopy or [[Polyp|polyps]].
*Recurrent [[Vulvovaginal Candidosis|vulvovaginal]] [[Candidiasis|candida infections]].
*[[Pregnancy|Pregnant]] woman with abnormal [[vaginal discharge]]
*Symptoms of upper [[Genital|genital tract]] [[Infection|infections]] as [[fever]], [[lower abdominal pain]]
 
'''Treatment in pregnancy:'''
 
*[[Vulvovaginal Candidosis|Vulvovaginal]] [[Candidiasis]]: It frequently occurs during [[pregnancy]]. Only topical [[azole]] therapies for 7 days are recommended for use among pregnant women.<ref name="urlVulvovaginal Candidiasis - 2015 STD Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/tg2015/candidiasis.htm |title=Vulvovaginal Candidiasis - 2015 STD Treatment Guidelines |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>
 
*[[Trichomoniasis]]: [[Metronidazole]] 2 g orally  single dose is recommended. Symptomatic [[Pregnancy|pregnant]] women, regardless of [[pregnancy]] stage, should be tested and considered for treatment.<ref name="urlTrichomoniasis - 2015 STD Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/tg2015/trichomoniasis.htm |title=Trichomoniasis - 2015 STD Treatment Guidelines |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>
 
*[[Bacterial vaginosis]]: Treatment is recommended for all symptomatic [[Pregnancy|pregnant]] women. [[Metronidazole]]  250-mg regimen is effective. But, [[Metronidazole]] 500 mg twice daily can be used.<ref name="urlBacterial Vaginosis - 2015 STD Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/tg2015/bv.htm |title=Bacterial Vaginosis - 2015 STD Treatment Guidelines |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>


==Acute pharmacotherapies==
==Acute pharmacotherapies==

Revision as of 08:35, 22 May 2021


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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Shankar Kumar, M.B.B.S. [2] Samah ObaiahRinky Agnes Botleroo, M.B.B.S.

Synonyms and keywords: Discharge from the vagina

Overview

Vaginal discharge is a common patient complaint that is paired with anxiety regarding sexually transmitted diseases. If a STD is detected, a search for all other STDs should be done. Advise the infected patient to inform all sexual partners of their diagnosis.Also there is normal vaginal discharge depends on periodic hormonal change[1]

Causes

Common Causes

Classification

Normal vaginal discharge as in Neonatal, Pediatric, Puberty, Menstrual cycle[7], Pregnancy, and Menopause. -Abnormal vaginal discharge as

Laboratory findings

Initial tests include:

Other Diagnostic Studies

Type pH Discharge Odor Wet Mount
Trich >4.5 yellow-green, copious present motile, flagellated
BV >4.5 white-grey fishy clue cells
Candida <4.5 white, curd-like none pseudo-hyphae
GC mucopurulent varies PMNs
A.V. thin, gray, watery none few epithelial cells

Treatment

'Abbreviations: QHS : Every bedtime , BID: 2 times daily, TID: Three times a day, QID: Four times a day, IM :Intramuscular


Organisms Recommended Drugs Alternative drugs
Candidiasis

Over-the-Counter Intravaginal Agents[8]

  • Clotrimazole 1% cream 5 g intravaginally daily for 7–14 days

OR

OR

  • Miconazole 2% cream 5 g intravaginally daily for 7 days

OR

  • Miconazole 4% cream 5 g intravaginally daily for 3 days

OR

OR

OR

OR


Prescription Intravaginal Agents:


  • Butoconazole 2% cream (single dose bioadhesive product), 5 g intravaginally in a single application

OR

  • Terconazole 0.4% cream 5 g intravaginally daily for 7 days

OR

  • Terconazole 0.8% cream 5 g intravaginally daily for 3 days

OR


Oral Agent:



Nystatin 1,00,000 unit tab vaginally QHS for 2 weeks[9]

Trichomoniasis

OR


OR

Bacterial Vaginosis

OR

  • Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days[11]

OR

  • Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days[11]

OR

OR

OR

Neisseria gonorrhoea


Amoxicillin orally 3 gm single dose
or
Ampicillin orally 3.5 gm single dose
or
Procaine PCN G 4.8 million IM single dose [9]


PLUS


Probenecid 1 gm orally single dose [9]


AND


Tetracycline 500 mg orally QID for 7 days
or
Doxycycline 100 mg orally BID for 7 days
or
Ceftriaxone 250 mg IM single dose[9]

Erythromycin 500 mg orally QID for 7 days[9]
or
Tetracycline 500 mg orally QID for 7 days[9]
or
Doxycycline 100 mg orally BID for 7 days[9]
or
Spectinomycin 2 gm IM single dose

Chlamydia trachomatis

Tetracycline 500 mg orally QID for 7 days[9]
or
Doxycycline 100 mg orally BID for 7 days[9]

Erythromycin base 500 mg orally QID for 7 days[9]
or
Erythromycin ethylsuccinate 800 mg orally QID for 7 days[9]
or
Sulfamethoxazole 1gm orally BID for 10 days

Herpes Simplex


Acyclovir[9]


Patient should be referred to a gynecologist if following are present. [12]

Treatment in pregnancy:

Acute pharmacotherapies

Bacterial Vaginosis

Candida and Chlamydia

Gonorrhea

Trichomonas

References

  1. ↑ Spence D, Melville C (2007). "Vaginal discharge". BMJ. 335 (7630): 1147–51. doi:10.1136/bmj.39378.633287.80. PMC 2099568. PMID https://www.ncbi.nlm.nih.gov/pubmed/18048541 Check |pmid= value (help).
  2. ↑ Hainer BL, Gibson MV (2011). "Vaginitis". Am Fam Physician. 83 (7): 807–15. PMID 21524046.
  3. ↑ Cettl L, Dvorak J, Felkel H, Feuereisl R (1979). "Results of simulation of non-homogeneous ventilatory mechanics for a patient-computer arrangement". Int J Biomed Comput. 10 (1): 67–74. doi:10.1016/0020-7101(79)90042-4. PMID http://www.ncbi.nlm.nih.gov/pmc/articles/pmc478688 Check |pmid= value (help).
  4. ↑ 4.0 4.1 4.2 Schmoldt A, Benthe HF, Haberland G (1975). "Digitoxin metabolism by rat liver microsomes". Biochem Pharmacol. 24 (17): 1639–41. PMID https://doi.org/10.1016/j.ogrm.2016.08.002 Check |pmid= value (help).
  5. ↑ Wathne B, Holst E, Hovelius B, Mårdh PA (1994). "Vaginal discharge--comparison of clinical, laboratory and microbiological findings". Acta Obstet Gynecol Scand. 73 (10): 802–8. doi:10.3109/00016349409072509. PMID https://pubmed.ncbi.nlm.nih.gov/7817733 Check |pmid= value (help).
  6. ↑ Spence D, Melville C (2007). "Vaginal discharge". BMJ. 335 (7630): 1147–51. doi:10.1136/bmj.39378.633287.80. PMC 2099568. PMID https://pubmed.ncbi.nlm.nih.gov/18048541 Check |pmid= value (help).
  7. ↑ Feingold KR, Anawalt B, Boyce A, Chrousos G, Dungan K, Grossman A; et al. (2000). "Endotext". PMID https://pubmed.ncbi.nlm.nih.gov/25905282 Check |pmid= value (help).
  8. ↑ 8.0 8.1 "Vulvovaginal Candidiasis - 2015 STD Treatment Guidelines".
  9. ↑ 9.00 9.01 9.02 9.03 9.04 9.05 9.06 9.07 9.08 9.09 9.10 9.11 Watson WJ, Demarchi G (August 1987). "Vaginal discharge: an approach to diagnosis and management". Can Fam Physician. 33: 1847–52. PMC 2218224. PMID 21263805.
  10. ↑ 10.0 10.1 10.2 10.3 10.4 "Trichomoniasis - 2015 STD Treatment Guidelines".
  11. ↑ 11.0 11.1 11.2 11.3 11.4 11.5 11.6 11.7 "Bacterial Vaginosis - 2015 STD Treatment Guidelines".
  12. ↑ Sim, M; Logan, S; Goh, LH (2020). "Vaginal discharge: evaluation and management in primary care". Singapore Medical Journal: 297–301. doi:10.11622/smedj.2020088. ISSN 0037-5675.

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