4.3 Results and Discussions
4.3.2 Text Generation
The enzymatic glucose oxidase method of plasma glucose measurement is a colorimetric method without deproteinisation. Glucose oxidase catalases the oxidation of Beta D-glucose present in the plasma to D glucono -1,5 –lactone with the formation of hydrogen peroxide; the lactone is then slowly hydrolyzed to D-gluconic acid. The hydrogen peroxide produced reacts, under catalysis by peroxidase, with phenol and 4-aminophenazone to form a red - violet
quinoneimine dye. The intensity of the final color is directly proportional to the glucose concentration and is measured at 500nm wavelength.
Procedure:
10µl of blank (distilled water), sample and standard are pipetted into different test tubes and 1000ul of a mixture of phenol and phosphate buffer with GOD-PAP reagent (Glucose oxidase, 4-aminophenazone and Peroxidase) reagent added to each test tube. The mixture was incubated for 10minutes at 370C. The absorbance of the standard (Astandard) and the sample (Asample) were measured against the reagent blank within 60minutes using a Spectrophotometer at 500nm wavelength. The concentration of Glucose in millimol per litre (mmol/l) was calculated using this formula:
Glucose Concentration (mmol/l) = As / Astd X Cstd Where;
As is the absorbance for the samples or controls, Astd is the absorbance for the standard and Cstd is the concentration for the standard.
4 .12 DATA ANALYSIS
The data was processed and analysed using the statistical package for social sciences version 22 (SPSS Inc., Chicago, Illinois,USA).
Descriptive statistics was used for demographic and baseline data and summarized as mean, standard deviation, and percentages as appropriate.
Comparism between categorical variables was evaluated using the chi-square test with yates correction or the fisher test as appropriate and continuous variables using the student t-test.
P-values less than 0.05 was considered to be statistically significant. (Confidence level =95%)
Sensitivity was calculated as true positive/true positive + false negative Specificity was calculated as true negative/false positive +true negative Positive predictive value was true positive/ true positive +false positive Negative predictive value as true negative/false negative +true negative
The sensitivity denotes the proportion of women with hyperglycemia who was diagnosed as positive while the specificity denotes women without hyperglycemia who have a negative result.
The sensitivity, specificity, positive predictive value (PPV), and negative
predictive value (NPV) with their associated 95 % CI will be determined for the FPG and 75g OGTT done before 24 weeks using the 75g OGTT done between 24-28 weeks as Reference Standard.
4. 13 ETHICAL CONSIDERATIONS
The study was carried out after obtaining approval from the Ethics Committee of the Federal Teaching Hospital Ido-Ekiti and the Ekiti State University Teaching Hospital Ado-Ekiti. In designing this study, the following ethical issues were put into consideration;
INFORMED CONSENT TO PARTICIPATE AND WITHDRAW FROM THE STUDY
The purpose, protocol and details of this study were explained to all eligible participants. The participants were assured that no harm would result from enrolling them irrespective of the outcome of the investigation. The willing participants were asked to sign an informed consent form. They were intimated of their freedom to refuse or withdraw from the study at any point in time, without bias or compromise to our units’ commitment to offer standard care.
CONFIDENTIALITY OF THE DATA
All the information obtained from the participants was kept strictly confidential. The patients were assured that their identity would not be disclosed.
BENEFICENCE
The outcome of this study will help to ascertain the prevalence of hyperglycemia in early pregnancy, the risk factors and the sensitivity of the FPG component of the OGTT in screening and diagnosis of hyperglycemia in early pregnancy and make recommendations concerning the screening of hyperglycemia before 24 weeks of pregnancy.
JUSTICE
Fairness and equity were considered in Medicare to all persons irrespective of their participation or non-participation in the study.
NON-MALEFICENCE TO THE PARTICIPANTS
Information provided by the participants were treated with confidentiality and was not be used as evidence against them during the course of their care or thereafter.
DISSEMINATION OF RESULTS FROM THIS STUDY
The results of this study will be submitted to the National Postgraduate Medical College of Nigeria as part of the fulfillment for the Part II Fellowship examination of the Faculty of Obstetrics and Gynecology
CHAPTER 5:
RESULTS
This was a cross-sectional study carried out between 1st December 2016 to 31st of May 2017 in Federal Teaching Hospital Ido-Ekiti and Ekiti State University Teaching Hospital Ado-Ekiti. A total of 280 women who fulfilled the inclusion criteria were involved in the study. They had 75gOGTT done between 16-22 weeks and respondents who were negative for hyperglycemia were rescreened between 24-28 weeks using the 75gOGTT. Ten women were lost to follow up.
A total of 5 participants were diagnosed with hyperglycemia before 24weeks while 16 were diagnosed between 24-28weeks, making a total of 21 cases of
hyperglycemia in pregnancy in the study population.
Table1 shows the socio-demographic variables of the study participants. All the subjects were within the reproductive age group between 16-45. More than 90%
of the study participants were more than 26yrs .The mean age is 30.20+3.72 More than 98% of the respondents were married with only 3 participants single.
The women were predominantly Christians (73.3%), and of the Yoruba stock (88.9% ) with most belonging to the middle socio-economic class, (65.6%)
Table 1: Socio-demographic variables of study participants
Variables Frequency (N = 270) Percent
Mean age ± SD (years) 30.20 ± 3.72
Range (years) 22 – 45
Age group (years)
21 – 25 20 7.4
26 – 30 130 48.1
31 – 35 79 29.3
> 35 41 15.2
Religion
Christianity 198 73.3
Islam 72 26.7
Marital status
Single 3 1.1
Married 267 98.9
Ethnicity
Hausa/Fulani 2 0.7
Igbo 24 8.9
Yoruba 240 88.9
Others 4 1.5
Social class
Upper 30 11.1
Middle 177 65.6
Lower 63 23.3
Table 2: Gestational age at recruitment and Gravidity of study participants
Variables Frequency (N = 270) Percent
Gestational age at recruitment
Mean age ± SD 19.46 ± 1.94
Range 16 – 22
Gravidity
1 77 28.5
2 – 4 183 67.8
> 4 10 3.7
Median (IQR) 2 (1 – 3)
IQR: Interquartile range
Table 2 shows that the mean gestational age at recruitment was 19.46+1.94, and ranges from 16-22weeks.
Most respondents were multigravidas (67.8%). This is shown in table 2 below
Table 3 shows the demographic characteristics of women with hyperglycemia detected before 24 weeks and while Table 4 shows these for those women detected between 24-28weeks.
Unlike the study population all of these women were older than 25years, all were Christians, married with more than 98% of them belonging to the Yoruba race. A sizeable number of them also belong to the middle economic class.
Table 3: Demographic characteristics of women with hyperglycemia in pregnancy before 24 weeks
OGTT before 24weeks
Socio-demographic variables
Normal Hyperglycemia Total χ2 p value n = 265 (%) n = 5 (%) N = 270
(%) Age group
21 – 25 20 (7.5) 0 (0.0) 20 (7.4) 7.839Y 0.049*
26 - 30 129(48.7) 1 (20.0) 130(48.1)
31- 35 78 (29.4) 1 (20.0) 79 (29.3)
> 35 38(14.3) 3 (60.0) 41 (15.2)
Religion
Christianity 193 (72.8) 5 (100.0) 198 (73.3) 0.724Y 0.395
Islam 72 (27.2) 0 (0.0) 72 (26.7)
Marital status
Single 3 (1.1) 0 (0.0) 3 (1.1) 3.663Y 0.056
Married 262 (98.9) 5 (100.0) 267 (98.9) Ethnicity
Hausa/Fulani 2 (0.8) 0 (0.0) 2 (0.7) 8.399Y 0.038*
Igbo 24 (9.1) 0 (0.0) 24 (8.9)
Yoruba 235 (88.7) 5 (100.0) 240 (88.9)
Others 4 (1.5) 0 (0.0) 4 (1.5)
Social class
Upper 26 (9.8) 0 (0.0) 26 (9.6) 0.094Y 0.954
Middle 157 (59.2) 4 (80.0) 161 (59.6)
Lower 82 (30.9) 1 (20.0) 83 (30.7)
χ2= Chi square; Y= Yates corrected chi square; *= Statistically significant p value <0.05
Table 4: Demographic characteristics of women with hyperglycemia in pregnancy (OGTT done between 24 -28 weeks)
Hyperglycemia pregnancy
Socio-demographic variables
Normal Hyperglycemia Total χ2 p value n = 249 (%) n = 21 (%) N = 270
(100%) Age group
21 – 25 20 (8.0) 0 (0.0) 20 (7.4) 1.561Y 0.668
26 - 30 128 (51.4) 14 (66.7) 142 (52.6)
31- 35 76 (30.5) 5 (23.8) 81 (30.0)
> 35 25 (10.0) 2 (9.5) 27 (10.0) Religion
Christianity 180 (72.3) 18 (85.7) 198 (73.3) 1.785 0.182
Islam 69 (27.7) 3 (14.3) 72 (26.7)
Marital status
Single 3 (1.2) 0 (0.0) 3 (1.1) 0.334Y 0.563
Married 246 (98.8) 21 (100.0) 267 (98.9) Ethnicity
Hausa/Fulani 2 (0.8) 0 (0.0) 2 (0.7) 1.031Y 0.793
Igbo 22 (8.8) 2 (9.5) 24 (8.9)
Yoruba 221 (88.8) 19 (90.5) 240 (88.9)
Others 4 (1.6) 0 (0.0) 4 (1.5)
Social class
Upper 26 (10.4) 0 (0.0) 26 (9.6) 12.034 0.002*
Middle 141 (56.6) 20 (95.2) 161 (59.6)
Lower 82 (32.9) 21 (4.8) 83 (30.7)
χ2= Chi square; Y= Yates corrected chi square; *= Statistically significant p value <0.05
Figure 1: Prevalence of hyperglycemia using FPG (Fasting Plasma Glucose) component of OGTT done before 24 weeks
Figure 1 shows the prevalence of hyperglycemia using the FPG component of the 75gOGTT to be 1.5% when done before 24weeks.
0 50 100 150 200 250 300
Normal Hyperglycemia
265(98.1%)
4(1.5%)
Normal Hyperglycemia
Frequency
FPG component
Figure 2: Prevalence of hyperglycemia using 75g OGTT done before 24 weeks
Figure 1 shows the prevalence of hyperglycemia using the FPG component of the 75gOGTT to be 1.5% when done before 24weeks.
265 (98.1%)
5 (1.9%) Normal
Hyperglycemia
Figure 3: Prevalence of hyperglycemia using OGTT done between 24 - 28 weeks (NB: N = 265 because study participants who had been diagnosed before 24 weeks (5) were not included)
Figure 3 show the prevalence of hyperglycemia when the OGTT is done between 24-28weeks excluding the cases detected in early pregnancy to be 6%.
0 50 100 150 200 250
Normal Hyperglycemia
249(94.0%)
16(6.0%)
Normal Hyperglycemia
Frequency
OGTT done between 24 - 28 weeks
Table 5: Overall prevalence of hyperglycemia in pregnancy
Hyperglycemia Frequency (N = 270) % (95% Confidence Interval)
Yes 21 7.8 (5.2 – 11.5)
No 249 92.2 (88.5 – 94.5)
Table 5 shows the overall prevalence of hyperglycemia in pregnancy using the 75gOGTT to be 7.8%.
Table 6: Comparing the prevalence of hyperglycemia in pregnancy using 75g OGTT done before 24 weeks and 75g OGTT done between 24 – 28 weeks
Variable N Frequency % (95% CI) χ2 p value Before 24 weeks 270 5 1.9 (0.4 – 3.7) 4.917 0.027*
Between 24 – 28 weeks
265 16 6.0 (3.9 – 9.1)
χ2= Chi square; *= Statistically significant p value <0.05
Table 6 shows a comparison of the prevalence of hyperglycemia in early pregnancy and late pregnancy using the 75gOGTT. There was a statistically significant difference between prevalence of hyperglycemia before 24weeks and between 24-28weeks of pregnancy.
Table 7: Risk factors of women with hyperglycemia in pregnancy before 24 weeks OGTT before 24weeks
Variables Hyperglycemia Normal Total χ2 p value
n = 5 (%) n = 265 (%) N= 270(%) Age (years)
> 35 3 (60.0) 38 (14.3) 41 (15.2) 4.794Y 0.029
≤ 35 2 (40.0) 227 (85.7) 229 (84.8)
BMI
Obese 4 (80.0) 36 (13.6) 40 (14.8) 12.293Y 0.001*
Not obese 1 (20.0) 229 (86.4) 230 (85.2)
Hypertensive
Yes 0 (0.0) 6 (2.3) 6 (2.2) 1.418Y 0.234
No 5 (100.0) 259 (97.7) 264 (97.8)
Previous GDM
Yes 1 (20.0) 2 (0.8) 3 (1.1) 3.663Y 0.056
No 4 (80.0) 263 (99.2) 267 (98.9)
Previous macrosomia
Yes 3 (60.0) 29 (10.9) 32 (11.9) 7.096Y 0.008*
No 2 (40.0) 236 (89.1) 238 (88.1)
Unexplained IUFD
Yes 0 (0.0) 4 (1.5) 4 (1.5) 2.533Y 0.111
No 5 (100.0) 261 (98.5) 266 (98.5)
Previous fetal congenital anomaly
Yes 1 (20.0) 3 (1.1) 4 (1.5) 2.533Y 0.111
No 4 (80.0) 262 (98.9) 266 (98.5)
History of spontaneous miscarriage
Yes 1 (20.0) 36 (13.6) 37 (13.7) 0.059Y 0.808
No 4 (80.0) 229 (86.4) 233 (86.3)
History of DM in first degree relative
Yes 4 (80.0) 23 (8.7) 27 (10.0) 20.377Y <0.001*
No 1 (20.0) 242 (91.3) 243 (90.0)
Glycosuria
Yes 2 (40.0) 46 (17.4) 48 (17.8) 0.724Y 0.394
No 3 (60.0) 219 (82.6) 222 (82.2)
χ2= Chi square; Y= Yates corrected chi square; *=statistically significant, p value <0.05
Table 7 shows the risk factors of participants with hyperglycemia in early
pregnancy.Only BMI ≥25kg/m2, previous fetal macrosomia and a history of DM in a 1st degree relative achieved statistical significance with a p value of < than 0.05
Table 8: Risk factors of women with hyperglycemia in pregnancy before 24 weeks and between 24-28weeks.
Risk factors
Before 24 weeks Between 24 – 28 weeks
n = 5 (%) n=21 (%)
Age (years) 3 (60.0) 17 (81.0)
BMI 4 (80.0) 14 (66.7)
Hypertensive 0 (0.0) 2 (9.5)
Previous GDM 1 (20.0) 10 (47.6)
Previous macrosomia 3 (60.0) 13 (61.9)
Unexplained IUFD 0 (0.0) 2 (9.5)
Previous fetal congenital anomaly
1 (20.0) 2 (9.5)
History of spontaneous miscarriage
1 (20.0) 3 (14.3)
History of DM in first degree relative
4 (80.0) 17 (81.0)
Glycosuria 2 (40.0) 3 (14.3)
Table 8 compares the risk factors for hyperglycemia in pregnancy before 24weeks and between 24-28weeks. This shows age, BMI≥25kg/m2, previous GDM,
previous macrosomia, history of DM in a first degree relative and glycosuria assuming statistical significance.
Table 9: Evaluation of the diagnosis of hyperglycemia in pregnancy using FPG with the 75g OGTT before 24 weeks as reference standard.
Evaluation FPG component of 75g OGTT before 24 weeks
Sensitivity 80.0%
Specificity 100.0%
Positive Predictive Value 100.0%
Negative Predictive Value 99.6%
False Positive rate 0.0%
False Negative rate 20.0%
Accuracy 99.6%
Table 9 shows the diagnostic performance of the FPG component of the 75gOGTT before 24weeks using the full 75gOGTT done before 24weeks as a reference standard. This shows the FPG component performing well against the full 75gOGTT with sensitivity and specificity of 80% and 100% respectively.
Table 10: Evaluation of Diagnostic performance of the 75gOGTT before 24weeks of pregnancy (using 75g OGTT done between 24 – 28 weeks as reference standard
Evaluation 75g OGTT before 24 weeks
Sensitivity 23.8%
Specificity 100.0%
Positive Predictive Value 100.0%
Negative Predictive Value 94.0%
False Positive rate 0.0%
False Negative rate 76.2%
Accuracy 94.1%
Table 10 shows the diagnostic performance of the 75gOGTT when done before 24weeks using the 75gOGTT done between 24-28weeks as a reference standard.
The sensitivity of the 75g OGTT before 24weeks was 23.8% with a false negative rate of 76.2%
Figure 4: Proportion of hyperglycemia in pregnancy detected before 24 weeks and between 24 – 28 weeks
Figure 4 compares the proportion of cases of hyperglycemia detected before 24weeks of pregnancy and between 24-28 weeks. This shows the proportion of hyperglycemia in pregnancy that will lose opportunity for early intervention.
CHAPTER 6
0 50 100 150 200 250 300
75g OGTT before 24 weeks Hyperglycemia in pregnancy 265(98.1%)
249(92.2%)
5(1.9%) 21(7.8%)
Normal Hyperglycemia
DISCUSSION
The prevalence of hyperglycemia in early pregnancy in this study was 1.9% and lies within the range of 1-14% quoted worldwide .7-10,21 There have been an
increase in the prevalence of hyperglycemia in pregnancy in the last few decades;
this is not unrelated to the overall increase in the prevalence of diabetes mellitus worldwide.22-24 The mean age of women in this study is 30.20 ±3.72, with a range of 22-45yrs, which lies within the normal age of women in the reproductive age group of 16-45.More than 70% of the study participants are Christians and 88.9%
of them belong to the Yoruba tribe of western Nigeria. This is a reflection of the study location of Ekiti, a Yoruba speaking state of Nigeria. The average gestational age at recruitment for the study was 19.46 ±1.96. with 67.8% of the women being multigravidas.
The prevalence of hyperglycemia in pregnancy in this study using the gold
standard for universal screening and diagnosis of 75g OGTT done between 24-28 weeks was 7.8%, this was lower than the prevalence of 8.6% reported in an earlier study done by Olagbuji et al at the same Centre in 2013. 9 This difference may be due to the higher number of participants in the earlier study. The present study was unable to find significant association between sociodemographic parameters like religion, marital status and ethnicity. This is in keeping with findings from
different studies across Nigeria, which was unable to find any significant association between hyperglycemia in pregnancy and theses parameters.37,39
The study however was able to demonstrate significant association between
hyperglycemia in pregnancy and maternal age above 25yrs as evidenced by all the cases of hyperglycemia in pregnancy detected in the study being above 25years of
age. This was also highlighted by a study by Eweninghi et al89, which shows
increase prevalence of hyperglycemia in pregnancy as maternal age advances. This is also in agreement with a study conducted in India by Seshaiah et al32 which also suggests maternal age more than 25yrs as a major risk factor for hyperglycemia in pregnancy.
A statistically significant number of women in this study who had hyperglycemia in pregnancy had a BMI ≥ 25kg/m2. This reflects a strong correlation between hyperglycemia in pregnancy and obesity. A study by Imoh et al90 found strong association between maternal obesity and risk of hyperglycemia in pregnancy.
Other studies supporting this findings include a study by Shin et al91 in which he observed that BMI ≥ 25kg/m2 as a strong predictor of hyperglycemia in pregnancy and another study in China by Chu et al92 which found maternal obesity as a strong predictor of maternal hyperglycemia in pregnancy.
The present study also suggests a strong association between hyperglycemia in pregnancy and a previous history of fetal macrosomia, previous GDM and history of DM in first-degree relatives. The strong correlation between hyperglycemia in pregnancy and previous GDM was shown in various studies across Nigeria. A study by Kuti et al shows a positive family history and previous GDM as the most consistent risk factors for hyperglycemia in pregnancy.37 It also highlights the strong association between hyperglycemia in pregnancy and a previous history of fetal macrososmia. This is similar to the study findings in Abalaliki by Anzaku et al, which shows a previous history of fetal macrosomia as a major risk factor for development of hyperglycemia in pregnancies.39
This study however, was not able to prove any significant association between hyperglycemia in pregnancy and hypertension, unexplained IUFD, previous fetal congenital anomaly or spontaneous miscarriage or glycosuria. This was supported by Anzaku et al39 in Jos who also did not find any significant association between these risk factors and the development of hyperglycemia in early or late pregnancy.
This may be explained by findings in other studies that more than half of women diagnosed with hyperglycemia are without risk factors.93 While glycosuria was a significant risk factor in the study conducted by Anzaku, and also the one
conducted by Olagbuji et al9, a strong association was only detected in late pregnancy in our own study.
Our study shows that the FPG component of the 75gOGTT before 24 weeks
performed well as a one step screening and diagnostic modality in early pregnancy with a sensitivity of 80% and specificity of 100% when compared to the full
75gOGTT done before 24weeks of gestation. While different studies have assessed the usefulness of the FPG as a screening and diagnostic modality in pregnancy, with mixed results, most studies agree that the FPG can predict risk of GDM and possibly the need for intervention in pregnancy.93,94 This was also corroborated by findings from this study. A multicenter study in Brazil found out that the FPG could be used to diagnose hyperglycemia in pregnancy and also the need for the full 75gOGTT. It was confirmed as a valid strategy for the diagnosis of
hyperglycemia in pregnancy with benefits of reducing cost and improving patient satisfaction.81
Looking at its parameters of sensitivity, specificity, positive predictive value, negative predictive value, false positive rate, false negative rate and accuracy assessed the diagnostic performance of the 75gOGTT done before 24weeks.
The specificity and PPV of the 75gOGTT were 100% with a false positive rate of 0.0%. This was because there were no false positives in this study as any case of hyperglycemia detected is promptly treated and not exposed to any rescreening between 24-28weeks of pregnancy. The sensitivity for the 75gOGTT was 23.8%
while false negative rates was 76.2%. These may not be as a result of an inherent weakness of the test since validity was above 90% but may reflect the increasing insulin resistance as pregnancy progresses.96
While we cannot justify universal screening of all women in pregnancy before the 24th of gestation using the 75gOGTT from this study because of its low sensitivity and high false negative rates, it is of note that 5 out of the 21 cases of
hyperglycemia in pregnancy were detected before the 24th week of pregnancy and would have lost the opportunity for early detection and intervention. Since the FPG performs creditably well before 24weeks against the 75g OGTT, women may benefit from using the FPG as a universal screening and diagnostic modality in early pregnancy for early detection and prompt intervention in cases of
hyperglycemia in pregnancy before 24weeks.The result of this study further corroborates the findings of the IADPSG.16
LIMITATIONS OF THE STUDY
A major limitation of this study is the relative small number of women that was studied. A larger randomized multicenter study will be necessary to confirm the findings of this study.
It was also difficult to convince eligible respondents to participate in the study, this was especially when they discovered that the test will be done twice in pregnancy and that at least 3 samples of blood will be required at each time. A few of them defaulted after doing 75g OGTT before 24 weeks.
There were few studies on universal screening and diagnosis of hyperglycemia in early pregnancy using 75gOGTT to compare this study with.
STRENGHT AND LIMITATION OF THE STUDY
A multi-centered test with a large sample size will be more powered to determine the aim of the study. A number of participants in the study were lost to follow up due to the fact that they have to be screened twice in pregnancy. A major strength of the study is that it is one of the very few studies aimed at screening and diagnosis of hyperglycemia in early pregnancy and findings from this study has confirmed importance of early screening and diagnosis of hyperglycemia in pregnancy.
CHAPTER 7
CONCLUSION/RECOMMENDATION
CONCLUSION:
Findings from this study emphasized the need for screening and diagnosis of women for hyperglycemia in early pregnancy.
It also shows the 75g OGTT when done before 24weeks of pregnancy performed poorly as a screening and diagnostic test for hyperglycemia in early pregnancy and should be replaced with the FPG in the early pregnancy.
The study also validates the current practice of universal screening and diagnosis of hyperglycemia in women between 24-28weeks of pregnancy using the
75gOGTT.
This study shows statistically significant difference between the diagnostic performances of the 75gOGTT when done before 24weeks and when it is done between 24-28weeks, the null hypothesis of the study is therefore rejected.
RECOMMENDATIONS:
Since this study has shown the poor performance of the 75gOGTT when done before 24weeks as a universal screening and diagnostic test for hyperglycemia in pregnancy, the followings are recommended:
1. Screening and diagnosis of hyperglycemia in early pregnancy is justified 2. The FPG should replace the 75gOGTT in the screening and diagnosis of
hyperglycemia in early pregnancy
3. All women who were screened negative for hyperglycemia in early
pregnancy should have a repeat screening with the 75gOGTT between 24-28weeks of pregnancy.
4. Larger randomized multicenter studies are needed to confirm the findings from this study.
WORK PLAN
S/N ACTIVITY TIME 1. Resubmit corrected research proposal
and approval from college.
10 weeks (1st week of September to 2nd week of November, 2016) 2. Patients’ Recruitment and
performance of study
6 months (1st week of December 2016 to 4th week of May, 2017)
3. Data analysis and report writing 4 weeks (1st and 4th week of June, 2017)
4. Vetting by supervisors 2 weeks (1st and 2nd week of July, 2017)
5. Binding and submission of
completed dissertation to college
One week (3rd week of July, 2017)
REFERENCES: