Histologic subtypes of Meningiomas: Review and variation in an African population
Keywords:
Central nervous system, Meningioma
Abstract
Background
Meningiomas are considered to be the commonest neoplasm of the central nervous system and are also the most studied meningeal tumour. According to the WHO 2020 classification of meningiomas, there are fifteen subtypes that have been grouped into grades 1, 2 and 3. The WHO grade 1 meningiomas are generally grouped as benign while the WHO grade 2 and 3 tumours are grouped as malignant. The aim of this study is to show the variation of these subtypes in relation to the age, gender and location in an African population.
Materials and Methods
A 10-year retrospective review of all histologically diagnosed Meningiomas from 1st January, 2010 to 31st December, 2019 is presented. The distribution of the tumour in relation to the age, sex and location was assessed in this study.
Results
The three WHO grades of meningioma were assessed in this study. The M:F ratio was 1:1.4 and peak age incidence was seen in individuals 41 – 50 years (SD ± 16.54). Majority of the cases were WHO grade 1 (86.1%) while WHO grades 2 and 3 tumours were 8% and 5.9% respectively. A slight variation in the common subtypes in males and females were observed. Fibroblastic variant was the overall commonest subtype (27.1%).
Conclusion
The diversity of the subtypes of meningiomas of meningioma calls for strict classification protocols for standardization of patients’ grouping and potentially, management. Tumour genetics of the subtypes can be explored for potential management of complicated cases.
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References
REFERENCES
1. Idowu O, Akang EEU, Malomo A. Symptomatic primary intracranial in neoplasms in Nigeria, West-Africa. J Neurol Sci 2007 Jan; 24(3): 212 – 8
2. Olasode BJ, Shokunbi MT, Aghadiuno PU. Intracranial neoplasms Ibadan, Nigeria. East Afr Med J 2000 Jan; 7(1): 4 – 8
3. Soyemi SS, Oyewole OO. Spectrum of intracranial tumours in a tertiary health care facility: our findings. Pan Afr Med J 2015 Jan; 20: 24
4. Ndubuisi CA, Ohaegbulam SC, Iroegbu LU, Ekuma ME, Mezue WC, Erechukwu UA. Histologically confirmed intracranial tumours managed at Enugu, Nigeria. J Neurosci Rural Pract 2017 October – December; 8(4): 585 – 90
5. Chikani MC, Messi M, Okwunodulu O, Mezue W, Ohaegbulam S, Nubuisi C Et al. Pattern of Presentation and Surgical Management of Spine Tumor in Southeast Nigeria over a 10-year period. Niger J Clin Pract 2020 Aug; 23(8): 1167 – 71
6. Ekpene U, Ametefe M, Akoto H, Bankah P, Totimeh T, Wepeba G Et al. Pattern of intracranial tumours in a tertiary hospital in Ghana. Ghana Med J 2018; 52(2): 79 - 83
7. Zalata KR, El-Tantawy DA, Abdel-Aziz A, Ibraheim AM, Halaka AH, Gawish HH et al. Frequency of central nervous system tumours in delta region, Egypt. Indian J Pathol Microbiol 2011; 54(2): 299 – 306
8. Jaiswal J, Shastry AH, Ramesh A, Chickabasaviah YT, Arimappamagan A, Sentosh V. Spectrum of primary intracranial tumours at a tertiary care neurological institute: a hospital-based brain tumour registry. Neurol India 2016 May – June; 64(3): 494 – 501
9. Wiemels J, Wrensch M, Claus EB. Epidemiology and etiology of meningiomas. J Neurooncol 2010; 99(3): 307 – 14
10. Salami AA, Okunlola AI, Ajani MA, Adekanmbi AA, Balogun JA. Pediatric Meningiomas in Southwestern Nigeria: A Single Institutional Experience. World Neurosurg 2019; 125: e94 – e97
11. Olasode BJ, Onyia CU. Pediatric Neuropathology in Africa: Local experience in Nigeria and challenges and prospects for the continent. J Neuropathol Exp Neurol 2016; 75(11): 1000 – 4
12. Sadamori N, Shibata S, Mine M, Miyazaki H, Miyake H, Kurihara M Et al. Incidence of Intracranial Meningioma in Nagasaki Atomic-Bomb Survivors. Int J Cancer 1996 67(3): 318 – 22
13. Ostrom QT, Patil N, Cioffi G, Waite K, Kruchko C, Barnholtz-Sloan JS. CBTRUS Statistical Report: Primary Brain and Other Central Nervous System Tumors Diagnosed in the United States in 2013 – 2017. Neurooncol 2020; 22(1): 1- 96
14. Elder T, Ejikeme T, Felton P, Raghavan A, Wright J, Wright CH Et al. Association of Race with Survival in WHO grade II and III Meningioma in USA: Systematic Literature Review. World Neurosurg 2020; 138: 361 – 9
15. Kerr K, Qualmann K, Esquenazi Y, Hagan J, Kim DH. Familial Syndrome Involving Meningiomas Provide Mechanistic Insight into Sporadic Disease. Neurosurg 2018; 83(6): 1107 – 18
16. Moody P, Murtagh K, Piduru S, Brem S, Murtagh R, Rojiani AM. Tumour-to-tumour metastasis: Pathology and Noeuroimaging Considerations. Int. J Clin Exp Pathol 2012; 5(4): 367 – 73
17. Ostrom QT, Gittelman H., Liao P., Rouse C, Chen Y, Dowling J Et al. CBTRUS Statistical Report: Primary Brain and Central Nervous System Tumours Diagnosed in the United States in 2007 – 2011. Neuro Oncol. 2014 October; 16(4): iv1 – 63
18. Gump W. C. Meningiomas of the paediatric skull base: a review. J Neurol Surg B, Skull Base 2015 Feb; 76(1): 66 – 73
19. Fan M, Fang W, Liu K, Wang C, Deng W, Sun P Et al. Paediatric intracranial meningiomas: eight-year experience with 32 cases. Chin Neurosurg J 2017 Jul; 3(1): 1186
20. Kotecha RS, Junckerstorff RC, Lee S, Cole CH, Gottardo NG. Pediatric meningioma: current approaches and future direction. J Neurooncol 2011 Aug; 104(1): 1 – 10
21. Mezue WC, Ohaegbulam SC, Ndubuisi CA, Chikani MC, Achebe DS. Management of Intracranial Meningiomas in Enugu, Nigeria. Surg Neurol Int 2012 Sep; 3:110
22. Shah SA, Gonsai R, Makwana R. Histopathological study of meningioma in Civil Hospital, Ahmedabad. Int J Curr Res Rev 2013; 5(3): 76 – 82
23. Benson VS, Pirie K, Green J, Bull D, Casabonne D, Reeves GK Et al. Hormone replacement therapy and incidence of central nervous system tumours in the million women study. Int J Cancer 2010 Oct; 127(7): 1692 – 8
24. Chourmouzi D, Papadoloulou E, Kontopoulos A, Drevelegas A. Radiation-induced intracranial meningiomas and multiple cavernomas. BMJ Case Rep 2013 Sep: 1 – 3
25. Hosking FJ, Feldman D, Bruchim R, Olver B, Lloyd A, Vijayakrishnan J Et al. Search for inherited susceptibility to radiation-associated meningioma by genome wide SNP linkage disequilibrium mapping. Br J Cancer 2011 Mar; 104(6): 1049 – 54
26. Yen YS, Sun LM, Lin CL, Chang SN, Sung FC, Kao CH. Higher risk of meningioma with uterine myoma: a nation-wide population-based retrospective cohort study. J Neurosurg 2014 Mar; 120(3): 655 – 61
27. Schwartzbaum J, Jonsson F, Ahlbom A, Preston-Martin S, Malmer B, Lonn S Et al. Prior hospitalization for epilepsy, diabetes, and stroke and subsequent glioma and meningioma risk. Cancer Epidemiol Biomarkers Prev 2005 Mar; 14(3): 643 – 50
28. Kuan AS, Chen YT, Teng CJ, Wang SJ, Chen MT. Risk of meningioma in patients with head injury: a nation-wide population-based study. J Chin Med Assoc 2014 Sep; 77(9): 457 – 62
29. Meng Y, Tang C, Yu J, Meng S, Zhang W. Exposure to lead increases the risk of meningioma and brain cancer: A meta-analysis. J Trace Elem Med Biol 2020 Jul; 60: 126474
30. Choy W, Kim W, Nagasawa D, Stramotas S, Yew A, Gopen Q Et al. The molecular genetics and tumour pathogenesis of meningiomas and the future directions of meningioma treatments. Neurosurg Focus 2011 May; 30(5): E6
31. Brastianos PK, Horowitz PM, Santagata S, Jones RT, McKenna A, Getz G Et al. Genomic sequencing of meningiomas identifies oncogenic SMO and AKT 1 mutations. Nat Genet 2013 Mar; 45(3): 285 – 9
32. Clark VE, Erson-Omay EZ, Serin A, Yin J, Cotney J, Ozduman K Et al. Genomic analysis of non-NF2 meningiomas reveals mutations in TRAF7, KLF4, AKT 1 and SMO. Science 2013 Mar; 339(6123): 1077 – 80
33. Battu S, Kumar A, Pathak P, Purkait S, Dhaman L, Sharma MC Et al. Clinicopathological and molecular characteristics of pediatric meningiomas. Neuropathology 2018 Feb; 38(1): 22 – 33
34. Bhat AR, Wani MA, Kirmani AR, Ramzan AU. Histological subtypes and anatomical location correlated in meningeal brain tumours (meningiomas). J Neurosci Rural Pract 2014 Jul-Sep; 5(3): 244 – 9
35. Karim AK, Joarder MA, Islam S, Akhter N, Orin M, Hossain J Et al. Clinical Profile and Outcome of Intracranial Meningioma in Apollo Hospital, Dhaka. Pulse 2016; 9(1): 22 – 6
36. Mezue WC, Ohaegbulam SC, Ndubuisi CC, Chikani MC, Achebe DS. Intracranial meningiomas managed at Memfys Hospital for Neurosurgery in Enugu, Nigeria. J Neurosci Rural Pract 2012 Sep; 3(3): 320 – 3
37. Ikeri NZ, Anunobi CC, Bankole OB. Progesterone receptor expression and Ki-67 labelling index in meningiomas in Lagos University Teaching Hospital. Niger Postgrad Med J 2018; 25(1): 17 – 20
38. Louis D. N, Perry A, Reifenberger G. The 2016 World Health Organization Classification of Tumours of the Central Nervous System: a summary. Acta Neuropathol. 2021; 23(8): 1231 – 1251
39. Samadi N, Ahmadi SA. Meningioma: A Clinicopathological Evaluation. Malays J Med Sci 2007 Jan; 14(1): 46 – 52
40. Shri Lakshmi S. Meningioma: A Clinicopathologic study. Int J Med Res Health Sci 2015 Sep; 4(4): 827 – 31
41. Telugu RB, Chowhan AK, Rukmangadha N, Patnayak R, Phaneendra BV, Prasad BCM Et al. Histopathological and Immunihistochemical Evaluation of Meningiomas with Reference to Proloferative Markers p53 and Ki-67. J Clin Diagn Res 2016 Jan; 10(1): EC15 – EC9
42. Wang D, Xie Q, Gong Y, Ying M, Wang Y, Cheng H Et al. Histopathological Classification and Location of Consecutively Operated Meningiomas at a Single Institution in China from 2001 to 2010. Chin Med J (Engl). 2013 Feb; 126(3): 488 – 93
43. Rai T, Shenoy VS, Varshney P, Bhatt AS. Primary Ectopic Meningioma of Nasal Cavity: A Rare Presentation. Indian J Otolaryngol Head Neck Surg 2020 Nov: 1 – 5
44. Kane AJ, Sughrue ME, Rutkowski MJ, Shangari G, Fang S, McDermott MW Et al. Anatomic location is a risk factor in atypical and malignant meningiomas. Cancer 2011 Mar; 117(6): 1272 – 8
45. Liang RF, Xiu YJ, Wang X, Li M, Yang Y, Mao Q Et al. The Potential Risk Factors for Atypical and Anaplastic Meningiomas: Clinical Series of 1,239 Cases. Int J Clin Exp Med. 2014 Dec; 7(12): 5696 – 700
46. Westwick HJ, Shamji MF. Effects of Sex on the Incidence and Prognosis of Spinal Meningiomas: A Surveillance, Epidemiology and End Results Study. J Neurosurg Spine 2015 Sep; 23(3): 368 – 73
47. Toland A, McNulty SN, Pekmezci M, Evenson M, Huntoon K, Pierson CR Et al. Pediatric Meningioma: A Clinicopathologic and Molecular Study with Potential Grading Implications. Brain pathol 2020 Nov; 30(6): 1134 – 43
48. Greene S, Nair N, Ojemann JG, Ellenbogen RG, Avellino AM. Meningiomas in Children. Pediatr Neurosurg 2008; 44(1): 9 – 13
49. Dutton JJ. Optic Nerve Sheath Meningioma. Surv Ophthalmol 1992 Nov - Dec; 37(3): 167 – 83
1. Idowu O, Akang EEU, Malomo A. Symptomatic primary intracranial in neoplasms in Nigeria, West-Africa. J Neurol Sci 2007 Jan; 24(3): 212 – 8
2. Olasode BJ, Shokunbi MT, Aghadiuno PU. Intracranial neoplasms Ibadan, Nigeria. East Afr Med J 2000 Jan; 7(1): 4 – 8
3. Soyemi SS, Oyewole OO. Spectrum of intracranial tumours in a tertiary health care facility: our findings. Pan Afr Med J 2015 Jan; 20: 24
4. Ndubuisi CA, Ohaegbulam SC, Iroegbu LU, Ekuma ME, Mezue WC, Erechukwu UA. Histologically confirmed intracranial tumours managed at Enugu, Nigeria. J Neurosci Rural Pract 2017 October – December; 8(4): 585 – 90
5. Chikani MC, Messi M, Okwunodulu O, Mezue W, Ohaegbulam S, Nubuisi C Et al. Pattern of Presentation and Surgical Management of Spine Tumor in Southeast Nigeria over a 10-year period. Niger J Clin Pract 2020 Aug; 23(8): 1167 – 71
6. Ekpene U, Ametefe M, Akoto H, Bankah P, Totimeh T, Wepeba G Et al. Pattern of intracranial tumours in a tertiary hospital in Ghana. Ghana Med J 2018; 52(2): 79 - 83
7. Zalata KR, El-Tantawy DA, Abdel-Aziz A, Ibraheim AM, Halaka AH, Gawish HH et al. Frequency of central nervous system tumours in delta region, Egypt. Indian J Pathol Microbiol 2011; 54(2): 299 – 306
8. Jaiswal J, Shastry AH, Ramesh A, Chickabasaviah YT, Arimappamagan A, Sentosh V. Spectrum of primary intracranial tumours at a tertiary care neurological institute: a hospital-based brain tumour registry. Neurol India 2016 May – June; 64(3): 494 – 501
9. Wiemels J, Wrensch M, Claus EB. Epidemiology and etiology of meningiomas. J Neurooncol 2010; 99(3): 307 – 14
10. Salami AA, Okunlola AI, Ajani MA, Adekanmbi AA, Balogun JA. Pediatric Meningiomas in Southwestern Nigeria: A Single Institutional Experience. World Neurosurg 2019; 125: e94 – e97
11. Olasode BJ, Onyia CU. Pediatric Neuropathology in Africa: Local experience in Nigeria and challenges and prospects for the continent. J Neuropathol Exp Neurol 2016; 75(11): 1000 – 4
12. Sadamori N, Shibata S, Mine M, Miyazaki H, Miyake H, Kurihara M Et al. Incidence of Intracranial Meningioma in Nagasaki Atomic-Bomb Survivors. Int J Cancer 1996 67(3): 318 – 22
13. Ostrom QT, Patil N, Cioffi G, Waite K, Kruchko C, Barnholtz-Sloan JS. CBTRUS Statistical Report: Primary Brain and Other Central Nervous System Tumors Diagnosed in the United States in 2013 – 2017. Neurooncol 2020; 22(1): 1- 96
14. Elder T, Ejikeme T, Felton P, Raghavan A, Wright J, Wright CH Et al. Association of Race with Survival in WHO grade II and III Meningioma in USA: Systematic Literature Review. World Neurosurg 2020; 138: 361 – 9
15. Kerr K, Qualmann K, Esquenazi Y, Hagan J, Kim DH. Familial Syndrome Involving Meningiomas Provide Mechanistic Insight into Sporadic Disease. Neurosurg 2018; 83(6): 1107 – 18
16. Moody P, Murtagh K, Piduru S, Brem S, Murtagh R, Rojiani AM. Tumour-to-tumour metastasis: Pathology and Noeuroimaging Considerations. Int. J Clin Exp Pathol 2012; 5(4): 367 – 73
17. Ostrom QT, Gittelman H., Liao P., Rouse C, Chen Y, Dowling J Et al. CBTRUS Statistical Report: Primary Brain and Central Nervous System Tumours Diagnosed in the United States in 2007 – 2011. Neuro Oncol. 2014 October; 16(4): iv1 – 63
18. Gump W. C. Meningiomas of the paediatric skull base: a review. J Neurol Surg B, Skull Base 2015 Feb; 76(1): 66 – 73
19. Fan M, Fang W, Liu K, Wang C, Deng W, Sun P Et al. Paediatric intracranial meningiomas: eight-year experience with 32 cases. Chin Neurosurg J 2017 Jul; 3(1): 1186
20. Kotecha RS, Junckerstorff RC, Lee S, Cole CH, Gottardo NG. Pediatric meningioma: current approaches and future direction. J Neurooncol 2011 Aug; 104(1): 1 – 10
21. Mezue WC, Ohaegbulam SC, Ndubuisi CA, Chikani MC, Achebe DS. Management of Intracranial Meningiomas in Enugu, Nigeria. Surg Neurol Int 2012 Sep; 3:110
22. Shah SA, Gonsai R, Makwana R. Histopathological study of meningioma in Civil Hospital, Ahmedabad. Int J Curr Res Rev 2013; 5(3): 76 – 82
23. Benson VS, Pirie K, Green J, Bull D, Casabonne D, Reeves GK Et al. Hormone replacement therapy and incidence of central nervous system tumours in the million women study. Int J Cancer 2010 Oct; 127(7): 1692 – 8
24. Chourmouzi D, Papadoloulou E, Kontopoulos A, Drevelegas A. Radiation-induced intracranial meningiomas and multiple cavernomas. BMJ Case Rep 2013 Sep: 1 – 3
25. Hosking FJ, Feldman D, Bruchim R, Olver B, Lloyd A, Vijayakrishnan J Et al. Search for inherited susceptibility to radiation-associated meningioma by genome wide SNP linkage disequilibrium mapping. Br J Cancer 2011 Mar; 104(6): 1049 – 54
26. Yen YS, Sun LM, Lin CL, Chang SN, Sung FC, Kao CH. Higher risk of meningioma with uterine myoma: a nation-wide population-based retrospective cohort study. J Neurosurg 2014 Mar; 120(3): 655 – 61
27. Schwartzbaum J, Jonsson F, Ahlbom A, Preston-Martin S, Malmer B, Lonn S Et al. Prior hospitalization for epilepsy, diabetes, and stroke and subsequent glioma and meningioma risk. Cancer Epidemiol Biomarkers Prev 2005 Mar; 14(3): 643 – 50
28. Kuan AS, Chen YT, Teng CJ, Wang SJ, Chen MT. Risk of meningioma in patients with head injury: a nation-wide population-based study. J Chin Med Assoc 2014 Sep; 77(9): 457 – 62
29. Meng Y, Tang C, Yu J, Meng S, Zhang W. Exposure to lead increases the risk of meningioma and brain cancer: A meta-analysis. J Trace Elem Med Biol 2020 Jul; 60: 126474
30. Choy W, Kim W, Nagasawa D, Stramotas S, Yew A, Gopen Q Et al. The molecular genetics and tumour pathogenesis of meningiomas and the future directions of meningioma treatments. Neurosurg Focus 2011 May; 30(5): E6
31. Brastianos PK, Horowitz PM, Santagata S, Jones RT, McKenna A, Getz G Et al. Genomic sequencing of meningiomas identifies oncogenic SMO and AKT 1 mutations. Nat Genet 2013 Mar; 45(3): 285 – 9
32. Clark VE, Erson-Omay EZ, Serin A, Yin J, Cotney J, Ozduman K Et al. Genomic analysis of non-NF2 meningiomas reveals mutations in TRAF7, KLF4, AKT 1 and SMO. Science 2013 Mar; 339(6123): 1077 – 80
33. Battu S, Kumar A, Pathak P, Purkait S, Dhaman L, Sharma MC Et al. Clinicopathological and molecular characteristics of pediatric meningiomas. Neuropathology 2018 Feb; 38(1): 22 – 33
34. Bhat AR, Wani MA, Kirmani AR, Ramzan AU. Histological subtypes and anatomical location correlated in meningeal brain tumours (meningiomas). J Neurosci Rural Pract 2014 Jul-Sep; 5(3): 244 – 9
35. Karim AK, Joarder MA, Islam S, Akhter N, Orin M, Hossain J Et al. Clinical Profile and Outcome of Intracranial Meningioma in Apollo Hospital, Dhaka. Pulse 2016; 9(1): 22 – 6
36. Mezue WC, Ohaegbulam SC, Ndubuisi CC, Chikani MC, Achebe DS. Intracranial meningiomas managed at Memfys Hospital for Neurosurgery in Enugu, Nigeria. J Neurosci Rural Pract 2012 Sep; 3(3): 320 – 3
37. Ikeri NZ, Anunobi CC, Bankole OB. Progesterone receptor expression and Ki-67 labelling index in meningiomas in Lagos University Teaching Hospital. Niger Postgrad Med J 2018; 25(1): 17 – 20
38. Louis D. N, Perry A, Reifenberger G. The 2016 World Health Organization Classification of Tumours of the Central Nervous System: a summary. Acta Neuropathol. 2021; 23(8): 1231 – 1251
39. Samadi N, Ahmadi SA. Meningioma: A Clinicopathological Evaluation. Malays J Med Sci 2007 Jan; 14(1): 46 – 52
40. Shri Lakshmi S. Meningioma: A Clinicopathologic study. Int J Med Res Health Sci 2015 Sep; 4(4): 827 – 31
41. Telugu RB, Chowhan AK, Rukmangadha N, Patnayak R, Phaneendra BV, Prasad BCM Et al. Histopathological and Immunihistochemical Evaluation of Meningiomas with Reference to Proloferative Markers p53 and Ki-67. J Clin Diagn Res 2016 Jan; 10(1): EC15 – EC9
42. Wang D, Xie Q, Gong Y, Ying M, Wang Y, Cheng H Et al. Histopathological Classification and Location of Consecutively Operated Meningiomas at a Single Institution in China from 2001 to 2010. Chin Med J (Engl). 2013 Feb; 126(3): 488 – 93
43. Rai T, Shenoy VS, Varshney P, Bhatt AS. Primary Ectopic Meningioma of Nasal Cavity: A Rare Presentation. Indian J Otolaryngol Head Neck Surg 2020 Nov: 1 – 5
44. Kane AJ, Sughrue ME, Rutkowski MJ, Shangari G, Fang S, McDermott MW Et al. Anatomic location is a risk factor in atypical and malignant meningiomas. Cancer 2011 Mar; 117(6): 1272 – 8
45. Liang RF, Xiu YJ, Wang X, Li M, Yang Y, Mao Q Et al. The Potential Risk Factors for Atypical and Anaplastic Meningiomas: Clinical Series of 1,239 Cases. Int J Clin Exp Med. 2014 Dec; 7(12): 5696 – 700
46. Westwick HJ, Shamji MF. Effects of Sex on the Incidence and Prognosis of Spinal Meningiomas: A Surveillance, Epidemiology and End Results Study. J Neurosurg Spine 2015 Sep; 23(3): 368 – 73
47. Toland A, McNulty SN, Pekmezci M, Evenson M, Huntoon K, Pierson CR Et al. Pediatric Meningioma: A Clinicopathologic and Molecular Study with Potential Grading Implications. Brain pathol 2020 Nov; 30(6): 1134 – 43
48. Greene S, Nair N, Ojemann JG, Ellenbogen RG, Avellino AM. Meningiomas in Children. Pediatr Neurosurg 2008; 44(1): 9 – 13
49. Dutton JJ. Optic Nerve Sheath Meningioma. Surv Ophthalmol 1992 Nov - Dec; 37(3): 167 – 83
How to Cite
Aniume, O. I., Dr Chdiebere Chidubem Eluke, & Dr Okechukwu Charles Okafor. (2023). Histologic subtypes of Meningiomas: Review and variation in an African population . Tropical Journal of Pathology and Microbiology, 9(2), 13-21. Retrieved from https://pathology.medresearch.in/index.php/jopm/article/view/623
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Copyright (c) 2023 Author (s). Published by Siddharth Health Research and Social Welfare Society
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