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ORIGINAL ARTICLE
Year : 2012  |  Volume : 26  |  Issue : 2  |  Page : 66-72

Pattern of skin sensitivity to various aeroallergens in patients of bronchial asthma and/or allergic rhinitis in India


National Centre of Respiratory Allergy, Asthma and Immunology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India

Date of Web Publication27-May-2013

Correspondence Address:
Raj Kumar
National Centre of Respiratory Allergy, Asthma and Immunology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi - 110 007
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-6691.112550

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  Abstract 

Nine hundred and eighteen patients with bronchial asthma and/or allergic rhinitis including 548 (59.69%) males and 370 (40.31%) females with a mean age of 30.10 years were studied for skin sensitivity to various aeroallergens by skin prick test. The maximum numbers of patients (261; 28.43%) were between age group of 20 to 29 years. Patients diagnosed with bronchial asthma were 191 (20.81%), allergic rhinitis were 305 (33.22%), and both bronchial asthma and allergic rhinitis were 422 (45.97%). Significant skin positive reactions (2+ and above) were found in 657 (71.57%) subjects, which included 130 (14.16%) of bronchial asthma patients, 208 (22.66%) of allergic rhinitis patients, and 319 (34.75%) of both. The younger adults aged 20-29 years were the most commonly affected group with 197 (21.46%) significant skin positive patients. Insects (43.90%) followed by various types of weed pollens (21.79%), tree pollens (15.14%), dust (14.49%), house dust mite (12.42%), fungal spores (11.98%), grass pollens (7.73%), kapok cotton (2.18%), silk (1.31%), and wool (0.76%) were the offending allergens. Among individual allergens, most common aeroallergen was moth (33%), and least common was ehretia (0.54%). Among grass pollens, Cynodon (3.05%) was most common, and least common grass pollen aeroallergen was Pennisetum (1.74%). Among weed pollens, Ageratum (5.45%) was most common, and least common was Chenopodium album (1.53%). Among tree pollens, Holoptelia (5.01%), was most common, and least common was Ehretia (0.54%). Among dust, the wheat dust (8.28%) was the most common, followed by house dust (7.08%), and least common was paper dust (1.53%). Among the fungal spores, Aspergillus fumigatus (4.25%) were the most common, and least common was Candida (1.09%). Among insects, moth (33%) followed by mosquito (31.92%) were the most common, and least common was rice weevil (12.75%). When compared with the pattern of our study, there was significantly increased in sensitization to various allergens.

Keywords: Aaeroallergens, allergic rhinitis, bronchial asthma, skin prick test


How to cite this article:
Kumar R, Sharan N, Kumar M, Bisht I, Gaur S N. Pattern of skin sensitivity to various aeroallergens in patients of bronchial asthma and/or allergic rhinitis in India. Indian J Allergy Asthma Immunol 2012;26:66-72

How to cite this URL:
Kumar R, Sharan N, Kumar M, Bisht I, Gaur S N. Pattern of skin sensitivity to various aeroallergens in patients of bronchial asthma and/or allergic rhinitis in India. Indian J Allergy Asthma Immunol [serial online] 2012 [cited 2017 Mar 22];26:66-72. Available from: http://www.ijaai.in/text.asp?2012/26/2/66/112550


  Introduction Top


The clinical association of upper and lower airway inflammation is well-recognized. Both bronchial asthma (BA) and allergic rhinitis (AR) frequently co-exist and are now thought to be a continuum of inflammation involving one common airway. [1] Allergic rhinitis is a recognized risk factor for bronchial asthma, with 20%-30% of such patients having bronchial asthma; conversely 60%-80% of patients with bronchial asthma have co-existing AR. [2],[3] Asthma is a major cause of chronic morbidity and mortality throughout the world that is characterized by paroxysmal spasmodic narrowing of the bronchial airway due to inflammation of the bronchial tree and contraction of the bronchial smooth muscle. [4] Allergens can initiate an acute attack of asthma in sensitized subjects. Allergic rhinitis is an inflammatory condition of the nasal mucosa characterized by the symptoms of pruritus, sneeze, discharge, and stuffiness induced by an immunoglobulin-E (IgE) - mediated response. [5] Allergic rhinitis occurs when inhaled allergens interact with IgE antibodies on cells in the airway, subsequently causing degranulation of mast cells and release of chemical medicators. [6] While allergic rhinitis is not a life-threatening condition (unless accompanied by severe asthma or anaphylaxis), complications can occur, and the condition can significantly impair quality of life. [7] BA and AR are the most common allergic condition. Allergic condition have increased since past decades and are posing a heavy burden on health care system. [5] Exposures to various aeroallergens play an important role in pathogenesis of bronchial asthma and allergic rhinitis. The types of aeroallergens, however, differ widely depending on localities and even varies both within and between countries. [8] Identification of the most prevalent aeroallergens, to which the patients are sensitized, has an important role in the diagnosis and treatment of BA and AR. Skin allergy testing via skin prick test (SPT) is a useful method to demonstrate hypersensitivity to a specific antigen. Skin prick testing has been found to be more sensitive and specific than radio-allergosorbent test (RAST). [9]

The present research was carried out to investigate the pattern of skin prick test reactivity to various aeroallergens among patients of respiratory allergy, i.e., BA and/or AR in India, in order to facilitate effective strategies for management of these allergic conditions.


  Materials and Methods Top


Subjects

A retrospective study was conducted in patients with bronchial asthma and/or allergic rhinitis, attending department of Respiratory Allergy and Applied Immunology at the National Center of Respiratory Allergy, Asthma and Immunology, Vallabhbhai Patel Chest Institute (VPCI), University of Delhi, Delhi, India. Allergy testing was performed during the period of august 2008 to august 2011. A total of 918 patients consisting of 548 (59.69%) males and 370 (40.31%) females, in the age group of 6-80 years (mean age of 30.10 years), were included in the study. Diagnosis of bronchial asthma and allergic rhinitis was made according to the GINA [10] and ARIA [11] guidelines, respectively.

All patients were non-smokers. There was no associated history of tuberculosis, diabetes mellitus, hypertension, endocrine disease, or coronary artery disease. Pregnant females were excluded from the study. Hemogram, sputum, and chest radiography were done to rule out an alternative diagnosis.

Skin prick tests

Skin prick test was done with 58 different types of allergens, which included 5 types of grass pollens, 16 types of weed pollens, 11 types of tree pollens, 4 types of dusts, 12 types of fungi, 6 types of insects, house dust mite, kapok cotton, wool, and silk antigens. Buffered saline and histamine were used as negative and positive controls, respectively. Skin prick test was performed by applying a drop of antigen on healthy skin on the volar surfaces of the forearm, and pricking it with 26.5 gauge needle. Reading was interpreted after 15 to 20 minutes. Assessment of skin reactivity was done by calculating the mean diameter as (D + d)/2; D = largest diameter and d = orthogonal or perpendicular diameter at the largest width of D after 15 to 20 minutes. A positive result (2 + and above) to a specific allergen is indicated by a mean wheal diameter measuring 3 mm or more, greater than negative control (buffered saline). [12] A mean wheal diameter measuring 3 mm or more greater than negative control (buffered saline) but less than 5 mm was taken as 2+. Similarly, a mean wheal diameter measuring ≥5 mm and <7 mm was taken as 3+, ≥7 mm and <9 mm as 4 + and so on, respectively. [12] Only 2+, 3+, and 4 + reactions were labeled as significantly positive skin reactions because of the high incidence of 1 + reaction in non-allergic normal people. [12]

Before performing SPT, oral drugs including anti-histamines, steroids, and any other drugs considered to affect SPT were stopped 1 week prior to the tests, but inhaled drugs were continued. Oral short acting anti-histamines were stopped 1 week before, and long acting anti-histamines were stopped 4 weeks before performing the tests.


  Results Top


There were a total of 918 patients consisting of 548 (59.69%) males and 370 (40.31%) females, in the age group of 6-80 years (mean age of 30.10 years). The patient's age distribution is given in [Table 1]. The maximum numbers of patients (261; 28.43%) were between age group of 20 to 29 years. The maximum number of patients (57; 62.53%) had duration of suffering ranging from 1 to 10 years [Table 2].
Table 1: Number of patients in different age groups and positive reactions

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Table 2: Number of patients and duration of suffering

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Patients diagnosed with bronchial asthma were 191 (20.81%), allergic rhinitis were 305 (33.22%), and both bronchial asthma and allergic rhinitis were 422 (45.97%) [Figure 1].
Figure 1: Number of patients suffering from BA and/or AR

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In our study, a total of 53244 skin prick tests were performed with a total of 58 allergens on 918 patients, out of which only 6 (0.65%) patients had no reaction at all from SPT, whereas 255 (27.78%) patients had a positive SPT up to the 1+ grade (mean wheal diameter measuring less than 3 mm). Significant skin positive reactions (2+ and above) were found in 657 (71.57%) subjects. The younger adults aged 20-29 years were the most commonly affected group with 197 (21.46%) significant skin positive patients [Table 3].
Table 3: Results of the antigens tested

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Insects (43.90%) followed by various types of weed pollens (21.79%), tree pollens (15.14%), dust (14.49%), house dust mite (12.42%), fungal spores (11.98%), grass pollens (7.73%), kapok cotton (2.18%), silk (1.31%), and wool (0.76%) were the offending allergens [Figure 2].
Figure 2: Offending allergens

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Among individual allergens, most common aeroallergen was moth (33%) and least common was ehretia (0.54%).

Among grass pollens, Cynodon (3.05%) was most common allergen showing significant positive SPT followed by Cenchrus (1.96%), Sorghum (1.85%), Pennisetum (1.74%), and Imperata (1.74%).

Among weed pollens, Ageratum (5.45%) was most common followed by Brassica (4.90%), Amaranthus spinosus (4.58%), Gynandropsis (4.36%), Cassia occidentalis (3.38%), Asphodelous (3.38%), Artemisia (3.16%), Adhatoda (2.83%), Argemone (2.51%), Parthenium (2.29%), Dodonaea (2.29%), Cannabis (2.18%), Suaeda (2.07%), Chenopodium M (2.07%), Xanthium (1.85%), and Chenopodium album (1.53%).

Among tree pollens, Holoptelia (5.01%) was most common followed by Salvadora (4.36%), Prosopis (3.81%), Ricinus (3.70%), Cassia siamea (3.70%), Morus (3.27%), Melia (2.94), Putranjiva (1.85%), Kigelia (0.87%), Eucalyptus (0.76%), and least common was Ehretia (0.54%).

Among dust, the wheat dust (8.28%) was the most common, followed by house dust (7.08%), and cotton dust (1.63%), but the least common was paper dust (1.53%).

House dust mite was significantly positive in 114 (12.42%) of subjects.

Among the fungal spores, Aspergillus fumigatus (4.25%) was the most common followed by Rhizopus (3.81%), Aspergillus tamari (3.38%), Epicoccum (2.83%), Phoma (2.51%), Helminthosporium (2.51%), Alternaria (2.40%), Trichoderma (2.29%), Curvularia (1.85%), Cladosporium (1.20%), and Mucor (1.20%), but the least common was Candida (1.09%).

Among insects, moth (33%) was the most common allergen showing significant positive skin reaction, followed by mosquito (31.92%), housefly (26.36%), cockroach-male (19.06), and cockroach-female (18.63). The least common was rice weevil (12.75%).

Kapok Cotton was significantly positive in 20 (2.18%) patient, wool in 7 (0.76%), and silk in 12 (1.31%) [Table 4].
Table 4: Detailed results of all antigens tested

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  Discussion Top


Aeroallergens are the prominent causes of allergic symptoms in patients with BA or AR. Different types of environmental aeroallergens are known to play a role in triggering or exacerbating BA or AR. Identification of the most prevalent aeroallergens in each area has a very important role in diagnosis and treatment of BA and/or AR. The SPT is the recommended initial investigation to find out the offending aeroallergens. [13] In our study, this was validated as significant skin positive reactions (2+ and above) were found in 657 (71.57%) subjects, and only 6 (0.65%) patients had no reaction at all from SPT, whereas 255 (27.78%) patients had a positive SPT up to the 1+ grade. In our study, all the patients showing significant skin positive reaction had poly-sensitization to more than two aeroallergens. Similar study done in 1997-2000 at Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India by us had shown that 29.03% of the patients who suffer BA and/or AR do not have an allergic component, 19.35% had grades of 1 + to some of the antigens tested, and 51.62% showed significant skin positive reaction [14] using intra-dermal skin test method compare is summarized in [Figure 3]. A study done in Iran by Ghaffari J et al. showed that SPT was positive for 156 (41.5%) patients with diagnosis of BA and/or AR. [15] A retrospective cross-sectional study done by Almogren A showed that SPT was positive for 75% of patient with respiratory allergy, i.e., BA and/or AR. [16] A cross-sectional retrospective study done recently by Farhoudi A et al. on patients with similar diagnosis showed significant positive SPT reaction in 154 (68%) subjects. [17]
Figure 3: Comparison of significant positive aeroallergens between our two studies. *These aeroallergens were not tested in 1997-2000 stud

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In our study, maximum numbers of patients (261; 28.43%) were the younger adults aged 20-29 years, and they were the most commonly affected group with 197 (21.46%) significant skin positive patients. Study done earlier at VPCI also showed maximum number of patients (120; 35.19%) in age group of 20-30 years, but further assessment was not carried out for most sensitized age group. [14]

In our study, insects were most common offending aeroallergens with 43.90%, followed by various types of weed pollens (21.79%), tree pollens (15.14%), dust (14.49%), house dust mite (12.42%), fungal spores (11.98%), grass pollens (7.73%), kapok cotton (2.18%), silk (1.30%), and wool (0.76%). A study done at our institute by us also revealed that most common aeroallergen showing markedly positive tests were insects with 17.29%, followed by various types of dust (4.39%), grass pollen (2.28%), weed pollens (2.18%), tree pollens (1.22%), fungal spores (1.22%), and kapok fiber (1.75%). [14] The comparison between our two studies is depicted in [Figure 3]. Study by Ghaffari J et al. showed that most common SPT reaction was with house dust mites, i.e., Dermatophagoides pteronyssinus (25.3%) and Dermatophagoides farina (24.8%), followed by cockroach (15.7%), and feather (7.5%). [15] Similar results were obtain in Jamaican study done by Madden J k, et al., which showed that most common significant SPT were due to Dermatophagoides pteronyssinus (33%) and Dermatophagoides farina (32%), followed by cockroach (23%). [18] A study by Almorgen A revealed that most frequently reacting indoor allergen was house dust mite (77.8%) followed by the cat (33.6%) and cockroach (19.2%) allergens. [16]

In this study among insects, moth (33%) was the most common allergen showing significant positive skin reaction followed by mosquito (31.92%), housefly (26.36%), cockroach-male (19.06), and cockroach-female (18.63). The least common was rice weevil (12.75%). Previous study done at VPCI revealed that housefly was the most important insect allergen with 25.21% of the patients showing a markedly positive skin reaction, followed by mosquito (21.11%), moth (19.94%), female cockroach (17.59%), male cockroach (9.97%), and rice weevil (9.38%) in that order. [14]

Among weed pollens, Ageratum (5.45%) followed by Brassica (4.90%) and Amaranthus spinosus (4.58%) were most common, and least common was Chenopodium album (1.53%). Previous study done at VPCI showed that Brassica (5.27%), Amaranthus spinosus (4.98%), Argemone (4.98%), and Amaranthus H. (3.51%) were the common weed allergens. [14]

In our study, when tree pollens were tested via SPT, Holoptelia (5.01%) followed by Salvadora (4.36%) were most common, and least common was Ehretia (0.54%). In previous study done at VPCI, Salvadora (2.34%), Ailunthus (1.75%), Prosopis (1.75%), Cassia siamea (1.46%) were the more commonly implicated tree pollens, and Morus did not show any markedly positive result at all. [14]

In our study among dust, the wheat dust (8.28%) was the most common, followed by house dust (7.08%), and cotton dust (1.63%), but the least common was paper dust (1.53%). Earlier study at VPCI showed that cotton dust (6.47%) was the most commonly implicated dust followed by wheat dust (5.86%), paper dust (3.81%), and house dust (1.46%). [14]

Aspergillus fumigates (4.25%) followed by rhizopus (3.81%) were the most common, and least common was candida (1.09%) among the fungal spores. Singhal and Rajkumar showed that most common fungal spores with significant skin reaction were Mucor (2.05), Aspergillus Fumigatus (2.05%), Rhizopus (1.75%), and Fusarium (1.75%). [14]

Among grass pollens, Cynodon (3.05%) followed by Cenchrus (1.96%) were most common, and least common was Pennisetum (1.74%) as revealed by our study. Previous study showed that Cynodon (4.10%), Pennisetum (2.63%), and Imperata (2.34%) were the most common allergens [Table 5]. [14]
Table 5: Comparison of various offending aerollergens between our two studies

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Kapok Cotton was significantly positive in 20 (2.18%) patient, wool in 7 (0.76%), and silk in 12 (1.31%). House dust mite was significantly positive in 114 (12.42%) of subjects. Earlier study reported that Kapok fiber was marked positive in 1.76% patient, but they didn't test for wool, silk, and house dust mite. [14] Study from different parts of world has implicated house dust mites as most common offending aeroallergens among Malaysian asthmatic patients [19] and patients with AR in Thailand, [20] Singapore, [21] and Mexico City. [22]

High prevalence of skin reactivity to insects, weed pollens, tree pollens, dust, house dust mite, and fungal spores demonstrates the increase in significant skin reactivity than previous study. This is in line with increasing prevalence of respiratory allergy, i.e., BA and/or AR. The variation in the prevalence of aeroallergen reactivities in different region is due to different geo-climatic condition and adaptation of specific microbiological flora and fauna in specific climate. The variation of skin reactivity may also be attributed to change in specific pattern of vegetation over a period of time as a result of changes in geo-climatic condition. The increasing trend in skin reactivity as compared to our previous study may also be due to addition of prevalent aeroallergen like house dust mite in our study.

One of the management protocols can be avoidance of common aeroallergens prevalent in that part of world although it is not so easy. The identification of most prevalent and also the full spectrum of aeroallergens responsible for respiratory allergies (BA and/or AR) has a very important role in management of these conditions. Our study will help in selecting the most specific and most cost-effective panel of aeroallergen antigens for SPT as the appropriate diagnostic test, and hence will help in finding the best formulation of allergen specific immunotherapy as an effective treatment.


  Conclusion Top


The study concluded that 657 (71.57%) patients of respiratory allergy, i.e., BA and/or AR in the study sample, suffered from poly-sensitization from different aeroallergens. There was a marked increase in sensitization as compared to our previous study. [14] Sensitization was most common in the younger age group of 20 to 29 years with 197 (21.46%) patients. In our study, insects (43.90) were most common offending aeroallergens, followed by various types of weed pollens (21.79%), tree pollens (15.14%), dust (14.49%), house dust mite (12.42%), fungal spores (11.98%), grass pollens (7.73%), kapok cotton (2.18%), silk (1.30%) and wool (0.76%).

The information from our study may be useful to clinicians managing patients suffering from respiratory allergies. Allergen-specific immunotherapy is a viable option for these patients. It can be used in combination with conventional therapy to maximize the outcome.

 
  References Top

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2.Smith JM. Epidemiology and natural history of asthma, allergic rhinitis, and atopic dermatitis (eczema). In: Middleton E Jr, Reed CE, Ellis EF, editors. Allergy: Principles and Practice. 2 nd ed. St. Louis: Mosby; 1983. p. 771-803.  Back to cited text no. 2
    
3.Grossman J. One air way, one disease. Chest 1997;111:11S-6.  Back to cited text no. 3
    
4.Morris MJ. Asthma. Available from: http://www.emedicine.com/med/topic177.htm. [Last accessed on 2005 Jun].  Back to cited text no. 4
    
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6.Holgate ST, Broide D. New targets for allergic rhinitis- a disease of civilization. Nat Rev Drug Discov 2003;2:902-14.  Back to cited text no. 6
    
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8.Van Cauwenberge P, Bachert C, Passalacqua G, Bousquet J, Canonica GW, Durham SR, et al. Consensus statement on the treatment of allergic rhinitis. European Academy of Allergology and Clinical Immunology. Allergy 2000;55:116-34.  Back to cited text no. 8
    
9.Williams PB, Dolen WK, Koepke JW, Selner, JC. Comparison of skin testing and three in vitro assays for specific IgE in the clinical evaluation of immediate hypersensitivity. Ann Allergy 1992;68:35-45.  Back to cited text no. 9
    
10.From the Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2011. Available from: http://www.ginasthma.org/. [Last accessed on 2012 Oct 31].  Back to cited text no. 10
    
11.Brozek JL, Bousquet J, Baena-Cagnani CE, Bonini S, Canonica GW, Casale TB, et al. Global Allergy and Asthma European Network; Grading of Recommendations Assessment, Development and Evaluation Working Group. J Allergy Clin Immunol 2010;126:466-76.  Back to cited text no. 11
    
12.Shivpuri DN. Comparative evalution of the sensitivity of common methods of diagnostic antigen tests in patients of respiratory allergy. Ind J Chest Dis 1962;4:102-8.  Back to cited text no. 12
    
13.International Consensus Report on diagnosis and management of rhinitis. International rhinitis management working group. Allergy 1994;49:1-34.  Back to cited text no. 13
    
14.Singhal P, Rajkumar. A study of skin sensitivity to various allergens by intradermal test in patients with respiratory allergy (bronchial asthma and allergic rhinitis) in India. Intern Med J Thai 2003;19:202-7.  Back to cited text no. 14
    
15.Ghaffari J, Khademloo M, Saffar M, Rafiei A, Masiha F. Hypersensitivity to house dust mite and cockroach is the most common allergy in north of Iran. Iran J Immunol 2010;7:234-9.  Back to cited text no. 15
    
16.Almogren A. Airway allergy and skin reactivity to aeroallergens in Riyadh. Saudi Med J 2009;3:392-6.  Back to cited text no. 16
    
17.Farhoudi A, Razavi A, Chavoshzadeh Z, Heidarzadeh M, Bemanian MH, Nabavi M. Descriptive study of 226 patients with allergic rhinitis and asthma. Iran J Allergy Asthma Immunol 2005;4:99-101.  Back to cited text no. 17
    
18.Madden KJ, Forrester TE, Hambleton IR, Lewis N, Greenough A. Skin test reactivity to aeroallergens in Jamaicans: Relationship to Asthma. West Indian Med J 2006;55:142-7.  Back to cited text no. 18
    
19.Bener A, Safa W, Abdulhalik S, Lestringant GG. An analysis of skin prick test reactions in asthmatics in a hot climate and desert environment. Allerg Immunol 2002;34:281-6.  Back to cited text no. 19
    
20.Liam CK, Loo KL, Wong CM, Lim KH, Lee TC. Skin prick test reactivity to common aeroallergens in asthmatic patients with and without rhinitis. Respirology 2002;7:345-50.  Back to cited text no. 20
    
21.Pumhirun P, Towiwat P, Mahakit P. Aeroallergen sensitivity of Thai patients with allergic rhinitis. Asian Pac J Allergy Immunol 1997;15:183-5.  Back to cited text no. 21
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

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


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