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ORIGINAL ARTICLE
Year : 2020  |  Volume : 21  |  Issue : 1  |  Page : 22-30

Pattern of pathological cutaneous lesions of neonates in neonatal care unit of a peripheral tertiary institution in West Bengal


Department of Pediatrics and Dermatology, Malda Medical College and Hospital, Malda, West Bengal, India

Date of Submission21-Jan-2019
Date of Decision14-Apr-2019
Date of Acceptance26-Sep-2019
Date of Web Publication24-Dec-2019

Correspondence Address:
Dr Syamal Kumar Sardar
C/o- Dr. Supriya Banerjee, 6/2 Kali Charanghosh Road, 4th Floor, Flat No - 8 and 9, Sinthee, Kolkata - 700 050, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.IJPD_7_19

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  Abstract 


Background: A variety of cutaneous disorders have been found in neonatal period. These disorders may be physiological or pathological, temporary or permanent, congenital or acquired. Most of the skin lesions are benign, transient and physiological. Aims and Objectives: To study the incidence of pathological cutaneous disorders of neonates in the neonatal care unit and compare these with other studies in India and also the world. Materials and Methods: It was a hospital based observational, descriptive study. Study duration was one year. Study population was the all admitted neonates in neonatal care unit in peripheral tertiary institution. The study sample size was 108 neonates. We used Chi-square test to evaluate the P value. P value of less than 0.05 was accepted as statistically significant. Results: We found 47 neonates (43.52%) as infective skin disorders, 21 cases (19.44%) as naevi and other developmental disorders, 10 cases each (9.26%) as keratinization disorder and eczematous conditions. 19 neonates (17.59%) were put into miscellaneous group. Among the infective disorders, we found 21 cases of bacterial infections, 18 cases of fungal infections, 6 cases of viral infections. Other important findings were of six aplasia cutis congenita cases, five cases of collodion babies, one harlequin baby, two cases of unilateral digital gangrene of upper limb etc. None of the neonatal dermatosis had shown significance (P > 0.05). Inadequate sample size was the possible cause for these results. Conclusion: The pattern of pathological dermatoses was evaluated. An effective knowledge about these dermatoses will be helpful to the Dermatologists and also Pediatricians for proper treatment and to assure the worried parents.

Keywords: Neonatal care unit, neonatal dermatoses, pathological cutaneous lesions


How to cite this article:
Kar C, Sardar SK. Pattern of pathological cutaneous lesions of neonates in neonatal care unit of a peripheral tertiary institution in West Bengal. Indian J Paediatr Dermatol 2020;21:22-30

How to cite this URL:
Kar C, Sardar SK. Pattern of pathological cutaneous lesions of neonates in neonatal care unit of a peripheral tertiary institution in West Bengal. Indian J Paediatr Dermatol [serial online] 2020 [cited 2020 Jan 25];21:22-30. Available from: http://www.ijpd.in/text.asp?2020/21/1/22/273837




  Introduction Top


The neonatal period is considered as first 28 days of life following delivery. The neonatal skin is thinner, less hairy than the adult skin, and it has weaker attachment between the dermis and the epidermis and also between cells of the epidermis. The pH of the skin surface of a neonate is higher, and the free fatty acid content is lesser than adult skin.[1],[2] The newborn has an extra protective layer called vernix caseosa which has antibacterial, antifungal, and antioxidant properties. This extra layer offers physiological protection in the early neonatal period. However, this delicate neonatal skin is often prone to infections, injuries, and abnormal percutaneous absorption. It has been found that the neonatal skin, its appendages, and oral mucosa have been affected nearly globally, up to 99.3% of neonates.[3] Neonatal skin disorders may be physiological or pathological, temporary or permanent, and congenital or acquired. The pattern of neonatal dermatoses depends on many factors, and those include climate, race, heredity, socioeconomic status, nutrition, hygiene, maturity, customs, somatic makeup, and so on. Most of neonatal skin conditions are physiological, transient, and benign. These disorders need not require any treatment or may need very minimal treatment. However, there are some developmental defects, genodermatoses, autoimmune disorders, and acquired or congenital infective disorders which may need aggressive specialized treatment, monitoring, and counseling. We considered these cases as pathological skin disorders. Most of these neonatal disorders usually need hospitalization with special care facilities. Hence, we, the medical personnel, must have adequate knowledge to understand the disease severity because some minor skin infections may become fatal following septicemia or encephalopathy. Parents are also very much worried in any kind of skin lesions. We have to explain the normal physiological and unwanted pathological skin lesions to the anxious parents. Our study is based on the pattern of pathological skin conditions of the neonates, admitted in neonatal care unit in the peripheral tertiary institution.


  Materials and Methods Top


The study was conducted in the Department of Pediatrics in collaboration with the Department of Dermatology of Malda Medical College, Malda, West Bengal. It was a hospital-based observational, descriptive study. The duration of the study was 1 year from August 2017 to July 2018. The study was approved by the Institutional Ethics Committee and Review Board. All the admitted neonates of neonatal care units were the study population and were examined thoroughly by the pediatrician or on-duty medical officer daily for any skin-related disorders. The dermatologists were called for those screened neonates with skin problems to diagnose the cases. Most of the cases were diagnosed clinically. All physiological skin disorders were excluded from our study. We included only the pathological skin lesions. Some basic investigations such as Gram stain, Tzanck smear, and KOH smear were done to diagnose some confusing skin diseases. The skin biopsy was not performed because none of the parents gave written consent for that. The economic condition of parents restrained us to do any sophisticated investigations. By applying the above exclusion and inclusion criteria, we selected the study sample. After selecting the study patients, we requested the parents or guardians for written consent to enroll their babies in our study where we may use the patients' data and/or photographs. After taking proper consent, a thorough history regarding age of mother, consanguinity, gravida and parity of mother, mode and place of delivery, and maternal illness during pregnancy were filled in the structured pro forma. The gender, gestational age at birth, birth weight, and age of patients were also put in the pro forma. The general conditions of neonates and the morphology of particular skin condition were examined carefully and written accordingly. We diagnosed the cases from detailed history and morphology of the skin lesions with some basic investigations. All the diagnosed cases were tabulated according to groups and subgroups. In our study, we showed the pattern of pathological skin disorders of neonates in our tertiary neonatal care unit.

Statistical analysis

The data were entered in a pivot table functionality of Microsoft Excel software. The statistical analysis was performed in different variables to show the relationship between the occurrence of skin lesions with various maternal and neonatal factors. We used Chi-square test and Fisher's exact test (sample <5 in a cell) by 2 × 2 table to evaluate the P value. P < 0.05 was accepted as statistically significant.


  Results Top


There are four specialized neonatal care units under the pediatric department in this peripheral teaching institution. These are namely special newborn care unit 1 and 2, newborn intensive care unit, and step-down unit. These units cater only ninety beds. Sick or special neonates are admitted in these units as per se verity of the disease from our obstetrics department and also from outside, after sorting them at triage room.

We examined all neonates admitted in our neonatal care units for the specified period of 1 year. The study population was 3698 as per hospital census. Among these, 1510 patients were from in-house obstetrics department and 2188 patients were from outside. Of 1510 in-house delivery, 680 neonates were from cesarean delivery and rest 830 neonates were from vaginal delivery. Of 2188 outborn patients, 946 neonates were from institutional vaginal delivery, 32 patients were from cesarean delivery, and rest 1210 neonates were from home delivery. There were 2283 male and 1415 female patients. The body weights at admission of the neonates were more than or equal to 2.5 kg in 1625 patients. The fetal gestational age of more than 37th week was recorded only in 1153 patients. Among the study population, 406 patients had physiological skin disorders and the parents of those patients were reassured. There was no need to treat them aggressively. We enrolled only pathological skin disorders as a study sample. These patients were treated accordingly and/or referred to specific super specialty centers. The sample size of our study was 108 neonates. Most of the cases were diagnosed clinically though a few cases were diagnosed by Gram stain or KOH smear for confirmation. We classified the diseases into several groups and subgroups [Table 1]. Of our selected neonates, the most common skin disorder was infective skin diseases (47 cases, 43.52%), followed by nevi and other developmental disorders (21 neonates, 19.44%), keratinization disorders (10 cases, 9.26%), and eczematous conditions (10 cases, 9.26%). Only one neonate had a congenital bullous disorder. Nineteen neonates (17.59% of sample size) were included into miscellaneous group. Seven cases were undiagnosed and put into separate undiagnosed subgroup under miscellaneous group.
Table 1: Pattern and frequency of neonatal skin lesions (n=108)

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Among the infective etiology, bacterial infections ranked the first (21 cases, 19.44%) followed by fungal infections (18 cases, 16.67%). We also found six cases of viral infections (5.56%) of which two cases had varicella (1.85%) [Figure 1] and four had herpes simplex infections (3.70%) [Figure 2]. Two neonates were suffering from parasitic infestations, namely scabies. Among bacterial infections, 13 cases were suffering from bullous impetigo, 4 patients had purpura fulminans [Figure 3], and one case each had cellulitis, staphylococcal scalded skin syndrome (SSSS) [Figure 4], and omphalitis. Among fungal infections, 13 cases were suffering from dermatophyte infection and 5 cases had oral candidiasis.
Figure 1: Neonatal varicella

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Figure 2: Herpes simplex infection

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Figure 3: Purpura fulminans

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Figure 4: Staphylococcal scalded skin syndrome

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In the second common group, nine neonates had nevi of which three cases had vascular malformations, four cases had pigmentary nevi, and one case each of verrucous epidermal nevus and nevus sebaceous. Among other developmental anomalies (12 cases), we found six cases of aplasia cutis congenita (ACC) [Figure 5] and [Figure 6], four cases of cleft lip and palate, and one case each of encephalocele [Figure 7] and spina bifida.
Figure 5: Aplasia cutis congenita type IV

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Figure 6: (a) Adams-Oliver syndrome showing aplasia cutis at scalp with dilated surrounding veins. (b) Cutis marmorata telangiectatica congenital with shortness of the right third and fourth toes

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Figure 7: Encephalocele

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Among keratinization disorders, we found five cases (4.63%) of collodion baby [Figure 8], four cases (3.70%) of autosomal recessive form of ichthyosis [Figure 9], and one case of X-linked recessive ichthyosis.
Figure 8: Collodion baby

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Figure 9: Harlequin baby

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In eczema group, seborrhoeic dermatitis was found in five cases, diaper dermatitis was in three cases (2.78%), and contact dermatitis and insect dermatitis were in 1 case each.

Among the miscellaneous group, we found burn, scald, mutilation of genitalia due to dog bite [Figure 10], bilateral pigmentation of legs, acrodermatitis enteropathica (AE), traumatic ulcer, and Ehlers–Danlos syndrome (EDS) [Figure 11] (1 case each). We also found two cases of unilateral digital gangrene of the upper limb [Figure 12] and three cases of skin necrosis due to extravasation at intravenous cannulation sites. We were unable to diagnose seven cases (6.48%) and incorporated them into the miscellaneous group as undiagnosed cases.
Figure 10: Mutilation of genitalia due to dog bite

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Figure 11: Ehlers–Danlos syndrome

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Figure 12: Digital gangrene of the right upper limb

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We found >59% (64 in number) male neonates of our sample size. In this pattern analysis, 62.96% of neonates were admitted with low birth weight (<2.5 kg) and 61.11% of neonates were born within 37th week of gestation. We established 79 neonates (73.15%) born of vaginal delivery. It was also found that the infective etiology was very common in vaginal delivery and found in >80% of neonates (38 of 47 neonates).

Maternal age group was recorded as 17–35 years with an average of 23 years. We observed 48% primipara mother and 35% primigravida mother. We also found a history of consanguinity in nine mothers (8.33%). There was a 100% positivity of similar maternal illness of the said neonatal viral infections and parasitic infestations. We recorded a history of maternal diabetes with insulin therapy in a single case and two cases of maternal urinary tract infection (UTI).

We tried to observe any significant relationship between the said neonatal dermatoses and different neonatal parameters. We tabulated the association of neonatal gender, neonatal birth weight, mode of delivery, and gestational age of baby with different dermatoses in neonates separately [Table 2], [Table 3], [Table 4], [Table 5]. We fixed the P < 0.05 to know the significance between two variables. None of the variables had shown significance. P >0.05 expressed that the variables were statistically nonsignificant. Inadequate sample size was the possible cause for these results. We enrolled only the pathological, neonatal dermatoses in neonatal care unit within 1 year. This highly specific data collection was the reason for inadequate sample size. We did not perform the P value in the miscellaneous group because various subgroups of different arenas including undiagnosed cases were incorporated in this group. We also did not calculate the P value where one of the observed values was 0.
Table 2: Pattern of skin lesions in association with gender

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Table 3: Pattern of skin lesions in association with birth weight

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Table 4: Pattern of skin lesions in association with gestational age

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Table 5: Pattern of infective and infestation disorders in association with mode of delivery

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  Discussion Top


Neonatal dermatoses are very tricky to diagnose because the diagnosis is based on clinical features mainly. The dermatological investigations are rarely done, and the parents are also unwilling to give consent for invasive investigations. Hence, we need very good clinical acumen to diagnose the neonatal dermatoses and to differentiate the benign, transient, physiological conditions from the pathological skin lesions. We diagnosed many physiological skin lesions such as erythema toxicum neonatorum, transient neonatal pustular melanosis, Mongolian spots, and miliaria and assured the parents about its transient, benign nature.[4],[5],[6],[7],[8],[9],[10],[11] We enrolled only the pathological skin lesions for which the pediatricians, dermatologists, and undoubtedly the parents were very much worried.

In our study, infective group was in top (43.52%), and it was quite high from other studies. Behera et al. have found it as 6.3%, Nobby and Chakraborty as 7.2%, and Nanda et al. as 11% in all cutaneous manifestations of the neonates.[7],[12],[13] Bacterial infections ranked the first among infective etiology group in our study and were similar to Behera et al.'s study but not in Nobby and Chakraborty's study. Two cases of bacterial infections were associated with maternal UTI. In bacterial infections, bullous impetigo positioned first and it constituted 12.04% of sample size. We performed Gram staining of pus in a few confused cases for confirmation. We found four cases (3.70%) of purpura fulminans which was higher than the study of Jain et al.[11] The age of the patients was between the 5th and 8th days. All cases were due to septicemia because they had positive sepsis screen. Three patients presented with angry red looking large macules those progressed into purpura and ecchymoses mostly over limbs and buttocks. One patient presented with generalized petechiae and purpura with unconsciousness. There were thrombocytopenias, prolonged prothrombin time, and partial thromboplastin time with increased fibrin degradation product in all cases. Only one patient was survived in spite of aggressive management. We reported one case each of cellulitis, SSSS, and omphalitis. SSSS was not reported in other similar studies.[7],[8],[9],[14] Nobby and Chakraborty have reported a good number of omphalitis (8 cases, 1.6%).

In fungal infections, we found a fair number of dermatophytosis cases (13 cases, 12.04%) which was higher than Behera et al.'s study.[7] None of the literature of neonatal cutaneous findings in intensive care unit have been mentioned any dermatophyte infection.[8],[9],[14] The high incidence of dermatophytoses in our study was due to high incidence of dermatophytosis in India ranging from 36.6% to 78.4% with recurrent dermatophytosis rate of 9.3%.[15],[16] The rising trend of childhood dermatophytosis has been found in India.[17] We found five cases (4.63%) of oral candidiasis which was very close to Gudurpenu et al.'s study.[18]

We reported four cases of herpes simplex infections involving around the mouth, and one of them was complicated with central nervous system involvement. Nobby and Chakraborty have reported a much lesser incidence of herpes simplex infection. Among the two cases of neonatal varicella of our study, one was very severe and disseminated form in contrast to the mild form of others. In the severe case, the mother was suffered from varicella 2 days before delivery, whereas in the mild case, it was happened 8 days before the delivery. Only Jain et al. have reported a single case of neonatal varicella among other similar studies.[11] We also found two cases of scabies which was not mentioned in other articles on neonatal skin disorders in intensive care units.

Among nevi and other developmental disorders, we found 21 neonates (19.44%) having these disorders. There has been a great variation of incidences in different literature because some have included Mongolian spots and salmon patch and some have not.[7],[8],[9],[12] Of vascular nevi, two cases had infantile hemangioma and one patient had port-wine stain. Surprisingly, we had no case of salmon patch, but it usually occurs in 30%–40% of all neonates.[19] In pigmentary disorder group, we diagnosed three cases of nevus depigmentosus and one case of congenital melanocytic nevus. The incidence of these pigmentary disorders was similar to other studies.[7],[18],[20] We also found one case each of nevus sebaceous and verrucous epidermal nevus. The incidences of these two entities were similar to Nobby and Chakraborty's study.

We established the diagnosis of ACC in six neonatal cases (5.56%) of which three were type I ACC, two were type VI ACC, and another one was of Adams–Oliver syndrome (AOS), i.e., ACC type II. Gudurpenu et al. have reported a good number of ACC (13 cases, 5.9%). The type I is the scalp ACC without multiple anomalies, i.e., nonsyndromic ACC of the scalp.[21] The type VI ACC is diagnosed clinically by the absence of skin or scarred areas mostly over lower extremities or large areas of the trunk and extremities associated with congenital epidermolysis bullosa (EB). Our cases fulfilled the above criteria. In our case, we diagnosed AOS clinically by ACC at the midline of the scalp, shortness of the right third and fourth toes, and cutis marmorata telangiectatica congenita all over the body. There were dilated veins around the scalp defect and also over the trunk. As per proposed criteria of AOS by Algaze et al., our patient fulfilled two major and one minor criterion.[22] The patient was referred to higher center for cardiological workup. The type II and VI ACC cases have not been reported from other similar studies.

We also recorded four cases (3.70%) of cleft lip and palate which was a higher percentage than other studies.[12],[18]

In developmental disorders of the nervous system, we found one case each of encephalocele and spina bifida. Most of the literature have reported faun tail nevus or tuft of hair on lumbar spine or sacral hypertrichosis, but none of these have pointed out the spina bifida of any type or encephalocele.[8],[12],[14],[23]

Among keratinization disorders, we found five cases of collodion baby within the 1st–3rd day of their age. We also found four cases of autosomal recessive congenital ichthyosis at the age of 8th–12th day of life, and those will be converted into either lamellar ichthyosis or nonbullous ichthyosiform erythroderma later on. Those cases were born with collodion membrane, ectropion, and eclabium and ultimately transformed into profuse thick scales on their own after 7–10 days. Among these four cases, we included a rare case of harlequin baby having an incidence rate of nearly 1 in 300,000 live births.[24] There was one male neonate of 20 days old having generalized ichthyosis with sparing of flexures, palms, and soles. These points were in favor of X-linked recessive ichthyosis. Our ichthyosis cases were quite high than other similar studies.[7.23] We found nine cases of maternal consanguinity of which two were first cousins and related to congenital ichthyosis. Pandit and Udaya have been reported a much higher incidence than our study.[25]

We found ten cases (9.26%) of eczematous disorders of which five cases (4.63%) were seborrhoeic dermatitis, three cases were diaper dermatitis, and one case each of contact dermatitis and insect dermatitis. Different studies have shown different results and varied from 2% to 40%.[7],[8],[9],[11],[26] These discrepancies were due to environmental, economic conditions and hygienic knowledge of parents.

We diagnosed only one case of EB. At first, the erosions were found in limbs and formed during intravenous cannulation. Later on, a few bullae and erosions were found. It was too early to classify the type of EB.

In the miscellaneous group, we found one case each of accidental scald and burn. The unfortunate accidental burn of both legs happened during incineration of the placenta following delivery at home. The scald was occurred due to accidental fall of hot milk over the face. There was a case of traumatic mutilation of genitalia due to dog bite. By noticing these three accidental cases, we clearly understood the education level and economic condition of the family and society. We also found two cases of unilateral digital gangrene of the upper limb. There was a history of maternal diabetes in the first case, and the mother was on insulin therapy. No specific history was found in another case. Babies' weights were 3.4 kg and 2.8 kg, respectively. The first case was delivered at term by cesarean section at nursing home without any complication. There were no history of maternal complication during pregnancy and no history of any arterial or venous cannulation to a baby. Sepsis screen was negative, and the pulsation of the radial artery of affected limb was palpable. The second case was delivered vaginally at home in full term. No specific history or investigation was positive to evaluate the etiology. Various possible etiologies of digital gangrene are prematurity, polycythemia, hypernatremia, hyperglycemia, hypothermia, septicemia, congenital heart disease, umbilical artery or brachial artery catheterization, congenital thrombophilia, amniotic constriction band, constriction by umbilical cord of neonates or maternal diabetes, oligohydramnios, and finally, retroplacental hematoma following abruptio placentae.[27],[28],[29],[30],[31],[32],[33],[34],[35] The documented autopsy finding was that 37.5% of fetuses with placental thrombi had associated with somatic thrombi.[36] Hence, our first case might be due to diabetic mother and the second one was probably idiopathic. Both the cases were referred to higher center. Previous studies on pattern of cutaneous disorders of neonates have not been reported any digital gangrene.

We also found one case each of bilateral pigmentation of legs, iatrogenic traumatic ulcer, AE, and EDS. AE was due to partial parenteral nutrition of neonate of our study. The diagnosis of AE was confirmed by marked recovery of dermatitis within 3 days following elemental zinc supplementation. Our EDS case was diagnosed clinically by hyperelasticity of the skin and hyperflexible joints. We also found three cases of skin necrosis at intravenous cannulation sites, and one of those necrosis cases was very large due to extravasated calcium gluconate. We were unable to pick up any diagnosis in seven cases and stamped those as undiagnosed cases. They were placed in the miscellaneous group.

We tried to focus on pathological neonatal dermatoses to enrich our knowledge and able to diagnose some rare diseases easily.


  Conclusion Top


Neonatal dermatoses are mostly transient, benign, or physiological, but these innocent dermatoses need to be differentiated from serious, aggressive pathological dermatoses. Every dermatologist should have an adequate knowledge about neonatal dermatoses for appropriate treatment. Pediatricians and nursing personnel should be trained, mostly about contagious infective diseases to isolate the infected neonates early. We should research about the increased incidence of developmental and keratinization disorders and its causal association with environmental and social factors apart from genetic factors.

Limitations

  1. Inadequate sample size was the main limitation of our study
  2. We were unable to diagnose some cases due to lack of consent for skin biopsy
  3. We diagnosed the cases mainly on clinical ground due to unavailability of sophisticated investigations for some selected patients.


Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients 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.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]
 
 
    Tables

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



 

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