scholarly journals Subcutaneous Anti-D versus intravenous methylprednisolone for the treatment of immune thrombocytopenic purpura

2018 ◽  
Vol 5 (5) ◽  
pp. 1719
Author(s):  
Olia Sharmeen ◽  
Mohammod Hasanur Rashid ◽  
Md Abdur Rouf ◽  
Afiqul Islam
Keyword(s):  
Platelet Count ◽  
Single Dose ◽  
Immune Thrombocytopenic Purpura ◽  
Hemoglobin Concentration ◽  
Complete Response ◽  
Response To Treatment ◽  
High Dose ◽  
Thrombocytopenic Purpura ◽  
Methyl Prednisolone ◽  
Change Response

Background: Established treatment option for immune thrombocytopenic purpura (ITP) are intravenous immunoglobulin (IVIg), anti-D immunoglobulin’ and high dose intravenous methyl prednisolone (HIVMP). The present study was undertaken to compare the efficacy of subcutaneous bolus anti-D over HIVMP in the treatment of ITP.Methods: A randomized clinical trial was conducted on a total 20 children with ITP, presented with extensive bleeding manifestation and platelet count <20 × 109/L;10 children received single dose subcutaneous anti-D (75 microgram/kg) and 10 children received HIVMP (30 mg/kg/dose) for 3 consecutive days. Patients were monitored for response to treatment and adverse events, platelet count and hemoglobin label were done in all patients at 24-hour, 48-hour, 72 hour, 1st week, 2nd week, 1st month, 2nd month and 3rd month after treatment to observe the change. Response rate define as a platelet count over 20 × 109/L within 72 hours of treatment. All the data were analyzed with the help of SPSS software version 16.0.Results: By 24 hours of treatment 40% patient of anti-D and 10% patients of HIVMP group had platelet count >20 x109/L, by 72 hours 90% patients of both group achieved complete response (P =1.750). In HIVMP group the rate of remission gradually decreasing but in anti-D group it was persistently remain high. In anti-D group hemoglobin concentration decreased in 80% cases (P=0.023) but rate of decrease was not significant. New hemorrhage or significant extension of hemorrhage did not observe in any group.Conclusions: A single dose of subcutaneous anti-D raised platelet count in children with ITP more rapidly and effectively than HIVMP (30 mg/kg/dose) with an acceptable safety profile.

Anti-D Immunglobulin in the Treatment of Childhood Chronic Idiopathic Thrombocytopenic Purpura.

Blood ◽  
2006 ◽  
Vol 108 (11) ◽  
pp. 3967-3967
Author(s):  
Emine Turkkan ◽  
Fugen Pekun
Keyword(s):  
Platelet Count ◽  
Intravenous Immunoglobulin ◽  
Immune Thrombocytopenic Purpura ◽  
Response To Treatment ◽  
High Dose ◽  
Thrombocytopenic Purpura ◽  
Cheap Alternative ◽  
The Mean ◽  
Acute Itp ◽  
Renal Function Tests

Abstract Chronic idiopathic (immune) thrombocytopenic purpura (ITP) develops in approximately 20% of children with acute ITP. The therapies for chronic refractory ITP include splenectomy, steroids, intravenous immunoglobulin (Ig), anti-D Ig, monoclonal antibodies, danazol, chemotherapy, plasma exchange, and others. We report five 5 RhD-positive, pediatric,, non-splenectomized patients with chronic immune thrombocytopenic purpura (ITP), treated with anti-D. Patients were refractory to steroids and high dose intravenous immunoglobulin (IVIG). The mean age of the patients was 10.5 years, duration of thrombocytopenia was more than 6 months, and the median platelet count was 6x 10(9)/l. Patients received a single intravenous dose of 75 microg/kg anti-D, and were monitored for response to treatment and adverse events. Complete blood cell and renal function tests were assessed at baseline and 1, 7, 14 and 28 days after infusion. By 24 hours after treatment two of patients had achieved a platelet count>20 x 10(9)/l. Mild headache, fever, or chills occurred in one patients and ameliorated with prednisone and acetaminophen premedication. None of the patients had more than 0.5 gm/dl fall in the hemoglobin level and renal dysfunction following anti-D infusion by day 1,7, 14, 28. A single 75 microg/kg dose of anti-D may increase the platelet count in some children with chronic resistant immune thrombocytopenic purpura with an acceptable safety profile. It is a valuable, safe, well tolerated, and cheap alternative to conventional chronic ITP treatments in selected non-splenectomized patients.

Thrombopoietin Levels May Predict Responsiveness to Therapy with Thrombopoietin Agonists Among Patients with Immune Thrombocytopenic Purpura,

Blood ◽  
2011 ◽  
Vol 118 (21) ◽  
pp. 3288-3288 ◽  
Author(s):  
Robert Makar ◽  
Olga S. Zhukov ◽  
Mervyn A. Sahud ◽  
David J. Kuter
Keyword(s):  
Platelet Count ◽  
Clinical Response ◽  
Immune Thrombocytopenic Purpura ◽  
Myeloproliferative Disorders ◽  
Interquartile Range ◽  
Wilcoxon Test ◽  
Response To Treatment ◽  
Thrombocytopenic Purpura ◽  
Platelet Production ◽  
Platelet Counts

Abstract Abstract 3288 INTRODUCTION: Thrombopoietin (TPO) is the major regulator of platelet production. In prior clinical studies, thrombopoietin levels have been shown to vary inversely with circulating platelet mass and with the rate of platelet production. Thus, TPO levels may help distinguish between the various disorders of thrombocytopenia. In addition, the introduction of TPO agonists has created an interest in predicting the response of patients to these agents. Determining TPO levels may help predict such treatment responses. METHODS: Sera from 121 patients with a history of abnormal platelet counts were tested using a novel, commercially available ELISA assay that measures TPO levels. The TPO assay detected TPO levels as low as 7 pg/mL and was linear for levels up to 2000 pg/mL. The coefficient of variation ranged from 27% near the lower limit of detection to 9% at a TPO concentration of 669 pg/mL. The reference range for TPO was established in serum samples from 118 apparently healthy individuals (58 males and 60 females) and was 7–99 pg/mL. The Wilcoxon test was used to compare continuous variables and the Fisher's exact test was used to compare categorical variables. RESULTS: The patient population included 40 patients with a consumptive thrombocytopenia (38 with primary or secondary immune thrombocytopenic purpura (ITP), 2 with thrombotic thrombocytopenic purpura), 34 patients with myeloproliferative disorders (23 with essential thrombocytosis, 9 with polycythemia vera, 2 with an ill-defined myeloproliferative disorder), and 47 patients with hypoproliferative thrombocytopenia (29 with chemotherapy-related thrombocytopenia, 19 with primary or secondary bone marrow failure syndromes). Among the 38 patients with ITP, 11 were taking TPO agonists (9 on romiplostim, 2 on eltrombopag), 19 were taking immunomodulatory agents (16 on steroids alone or in combination with other therapies, 2 on azathioprine, 1 on danazol), and 12 were off ITP-specific therapy when the TPO level was measured. 9 out of 38 (24%) patients with ITP had undergone splenectomy and/or been previously treated with rituximab. The median serum TPO level in patients with consumptive thrombocytopenia was 64.5 pg/mL (interquartile range, 48.5–97.5 pg/mL) and the corresponding median platelet count was 68,000/μL (interquartile range, 27,000–144,500) (Figure). While patients with myeloproliferative disorders had similar TPO levels [median 87.0 pg/mL (38.0–125.5)], their platelet counts were significantly higher than those of patients with consumptive thrombocytopenia [median 549,500/mL (431,250–693,000] (P <0.0001). Contrastingly, comparable platelet counts [median 61,000/μL (31,000–118,000)] were observed among patients with hypoproliferative thrombocytopenia, but serum TPO levels were significantly higher than those of patients with consumptive thrombocytopenia [844 pg/mL (409.5–1551.5), P <0.0001]. Among 22 evaluable patients meeting diagnostic criteria for primary or secondary ITP who had taken a TPO agonist for at least 1 month, serum TPO levels appeared to predict responsiveness to the drug. A clinical response to a TPO agonist was defined as achieving a platelet count ≥50,000/μL after starting the drug and maintaining it at or above that count in ≥50% of subsequent complete blood counts from initiation until discontinuation of the drug, loss to follow-up, or 6 months had passed, whichever was longest, without the need for recurrent rescue therapy. Whereas 14 out of 16 (88%) ITP patients with a TPO level <99 pg/mL met our definition for a clinical response to treatment with a TPO agonist, only 1 out of 6 patients (17%) with a TPO level >99 pg/mL responded (P <0.005 for the difference in clinical response to TPO agents.) CONCLUSIONS: TPO levels may have diagnostic utility in discriminating between patients with hypoproliferative and consumptive thrombocytopenia. High TPO levels among patients with ITP may predict a poor clinical response to treatment with TPO agonists. Further studies are required to confirm these data. Disclosures: Zhukov: Quest Diagnostics: Employment. Sahud:Quest Diagnostics: Employment. Kuter:Quest Diagnostics: Consultancy, Research Funding.

scholarly journals Treatment of adult chronic autoimmune thrombocytopenic purpura with repeated high-dose intravenous immunoglobulin

Blood ◽  
1993 ◽  
Vol 82 (5) ◽  
pp. 1415-1421 ◽  
Author(s):  
B Godeau ◽  
S Lesage ◽  
M Divine ◽  
V Wirquin ◽  
JP Farcet ◽  
...  
Keyword(s):  
Body Weight ◽  
Platelet Count ◽  
Treatment Protocol ◽  
Complete Response ◽  
Long Term Results ◽  
High Dose ◽  
Thrombocytopenic Purpura ◽  
Autoimmune Thrombocytopenic Purpura ◽  
Platelet Counts

Intravenous (i.v.) infusions of Ig concentrates are an effective but expensive treatment for patients with autoimmune thrombocytopenic purpura (AITP). The optimal treatment protocol and the long-term results are uncertain, and the precise mechanism by which the platelet count increases is poorly understood. Twenty adult patients with chronic AITP were enrolled in a prospective study to compare the respective efficacy of two high-dose IVIgG induction regimens (1 g v 2 g/kg body weight) and the long-term effect of six 1 g/kg body weight i.v. IgG reinfusions. An initial response was observed in all 18 evaluable patients: the platelet count increased to a mean value of 251 x 10(9)/L (range 72 to 836 x 10(9)/L) and the mean pretreatment platelet count was multiplied by 14.6. No difference in efficiency was observed between the two i.v. IgG dosages. The degree of the platelet count increment correlated in both groups with the increase in the clearance of antibody-coated red blood cells, measured by an isotopic method, but not with the serum IgG elevation. Treatment was considered to have failed in 11 patients, 90 days after the last i.v. IgG reinfusion (D90), because the platelet counts were comparable with pretreatment values. In contrast, a complete response was observed at D90 in five patients (mean platelet count: 184 x 10(9)/L; range: 150 to 250 x 10(9)/L) and a partial response at D90 was obtained in the remaining two patients (platelet counts: 70 and 104 x 10(9)/L). Five of the 7 responders at D90 kept a platelet count above 50 x 10(9)/L during the entire follow-up period (mean 33 months; range: 5 to 66) with no further treatment; unfortunately, no clinical or biologic criteria were found to be predictive of the long-term response. This study shows that an i.v. IgG infusion regimen of 1 g/kg body weight could safely replace the classical 2 g/kg body weight dosage, at least in patients who do not have life-threatening thrombocytopenia. Moreover, repeated i.v. IgG reinfusion could be an alternative for AITP patients in whom splenectomy is contraindicated.

scholarly journals Treatment of adult chronic autoimmune thrombocytopenic purpura with repeated high-dose intravenous immunoglobulin

Blood ◽  
1993 ◽  
Vol 82 (5) ◽  
pp. 1415-1421 ◽  
Author(s):  
B Godeau ◽  
S Lesage ◽  
M Divine ◽  
V Wirquin ◽  
JP Farcet ◽  
...  
Keyword(s):  
Body Weight ◽  
Platelet Count ◽  
Treatment Protocol ◽  
Complete Response ◽  
Long Term Results ◽  
High Dose ◽  
Thrombocytopenic Purpura ◽  
Autoimmune Thrombocytopenic Purpura ◽  
Platelet Counts

Abstract Intravenous (i.v.) infusions of Ig concentrates are an effective but expensive treatment for patients with autoimmune thrombocytopenic purpura (AITP). The optimal treatment protocol and the long-term results are uncertain, and the precise mechanism by which the platelet count increases is poorly understood. Twenty adult patients with chronic AITP were enrolled in a prospective study to compare the respective efficacy of two high-dose IVIgG induction regimens (1 g v 2 g/kg body weight) and the long-term effect of six 1 g/kg body weight i.v. IgG reinfusions. An initial response was observed in all 18 evaluable patients: the platelet count increased to a mean value of 251 x 10(9)/L (range 72 to 836 x 10(9)/L) and the mean pretreatment platelet count was multiplied by 14.6. No difference in efficiency was observed between the two i.v. IgG dosages. The degree of the platelet count increment correlated in both groups with the increase in the clearance of antibody-coated red blood cells, measured by an isotopic method, but not with the serum IgG elevation. Treatment was considered to have failed in 11 patients, 90 days after the last i.v. IgG reinfusion (D90), because the platelet counts were comparable with pretreatment values. In contrast, a complete response was observed at D90 in five patients (mean platelet count: 184 x 10(9)/L; range: 150 to 250 x 10(9)/L) and a partial response at D90 was obtained in the remaining two patients (platelet counts: 70 and 104 x 10(9)/L). Five of the 7 responders at D90 kept a platelet count above 50 x 10(9)/L during the entire follow-up period (mean 33 months; range: 5 to 66) with no further treatment; unfortunately, no clinical or biologic criteria were found to be predictive of the long-term response. This study shows that an i.v. IgG infusion regimen of 1 g/kg body weight could safely replace the classical 2 g/kg body weight dosage, at least in patients who do not have life-threatening thrombocytopenia. Moreover, repeated i.v. IgG reinfusion could be an alternative for AITP patients in whom splenectomy is contraindicated.

Rituximab Treatment in Childhood Chronic Immune Thrombocytopenic Purpura (ITP).

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 4461-4461 ◽  
Author(s):  
Ji Yoon Kim ◽  
Kun Soo Lee ◽  
Hyoung Jin Kang ◽  
Hoon Kook ◽  
Hong Hoe Koo ◽  
...  
Keyword(s):  
Platelet Count ◽  
Immune Thrombocytopenic Purpura ◽  
Medical Records ◽  
Conflicts Of Interest ◽  
Complete Response ◽  
Thrombocytopenic Purpura ◽  
Chronic Itp ◽  
New Treatment ◽  
Lost To Follow Up

Abstract Abstract 4461 Background Immune thrombocytopenic purpura (ITP) is characterized by mucocutaneous purpura and thrombocytopenia caused by circulating anti-platelet auto-antibodies. ITP is usually self-limited in children, but around 20% of patients will develop chronic ITP. The conventional treatments for children chronic ITP include intravenous immunoglobulin (IVIG), corticosteroid therapy, anti-D immune globulin, or splenectomy. Some children with chronic ITP are refractory to these treatments and nowadays begun to try new treatment agents such as rituximab. Rituximab as a monoclonal antibody to CD-20, has shown promising reports to these patients with refractory chronic ITP in adults groups and a few children groups. We investigated this study to evaluate the efficacy of rituximab for childhood chronic ITP in Korea. Methods We reviewed the questionnaires and medical records about the clinical progresses and results in thirteen children from eight clinical institutes, retrospectively. Complete response (CR) was considered if the platelet count was > 100,000/uL. Results Thirteen patients with chronic thrombocytopenia who had been treated with rituximab were investigated. Two patients were lost to follow-up after rituximab. Finally eleven patients were evaluated including one patient with Evans syndrome. Median age was 6.5 year (range, 0.5 ∼ 15.4). Median platelet count at baseline was 13,700/uL (3,000∼46,000). All patients had been treated with conventional therapy including IVIG and steroids. One had done splenectomy. Median follow-up duration was 2.8 years (1.1-5.9). Among 11 patients, CR was achieved in 3 patients (27%). Their platelet count prior to rituximab were < 10,000/uL. They were treated as the regimen of 375 mg/m2/dose weekly for 4 doses. Time from the first rituximab dose to achievement of complete response was 3.9, 4.9 and 5.7 weeks respectively. One patient who was relapsed 6months after the first course of rituximab was received second course of rituximab using the same regimen and achieved a new CR at 9.3 weeks after. There were no reports about severe complication or interruption of medication. Conclusions Therefore, we suggest that rituximab is effective treatment choice in childhood refractory chronic ITP and well tolerated. Disclosures: No relevant conflicts of interest to declare.

Single Dose of Anti-CD20 Monoclonal Antibody (Rituximab) Treatment in Adults with Refractory Immune Thrombocytopenic Purpura (ITP).

Blood ◽  
2006 ◽  
Vol 108 (11) ◽  
pp. 1077-1077
Author(s):  
Eri Tanaka ◽  
Shuji Hayashi ◽  
Katsumichi Fujimaki ◽  
Hiroyuki Fujita
Keyword(s):  
Platelet Count ◽  
Single Dose ◽  
Gastrointestinal Bleeding ◽  
Immune Thrombocytopenic Purpura ◽  
Intravenous Immunoglobulins ◽  
Thrombocytopenic Purpura ◽  
Platelet Counts ◽  
History Of ◽  
Refractory Itp

Abstract Refractory Immune Thrombocytopenic Purpura (ITP) is a difficult disease to treat effectively and the mortality approaches nearly 10% over 10 years. Moreover, the side effect profile of chronic steroid administration is undesirable due to the multi-systemic actions of these drugs. Recently, it has been reported in the literature that Rituximab is effective treatment for chronic ITP and it has been used at a dose of 375mg/m2 weekly for up to four weeks, as with lymphoma therapy. Rituximab is an expensive treatment, but according to previous data, patients treated with this drug have responded with increased and sustained platelet counts following only one infusion. Based on this, we treated five refractory ITP patients with single-dose Rituximab and all responded well. Patient 1 is with a 15 year history of ITP and Patient 2 is with a 34 year long history of ITP. Following treatment with Rituximab, although there was an interval of up to 7 months, both eventually responded well. Patient 3 is a 93 year old male who presented to our hospital with an acute presentation of ITP which involved severe gastrointestinal bleeding and this proved to be refractory to both steroids and intravenous immunoglobulins, but responded very quickly to Rituximab within 24 days. Patient 4 is a 75 year old female with diabetes mellitus and three-vessel coronary artery disease who presented with a bleeding diathesis. She was treated with steroids, intravenous immunoglobulins, danazol and azathioprine but with no response. Single-dose Rituximab was effective within 20 days with an improvement in platelet counts. Patient 5 is a 51 year old male with a six year history of ITP who presented to our hospital with massive intraabdominal and gastrointestinal bleeding and after Rituximab therapy his platelet count responded appropriately after 45 days. These patient responses were not associated with prior response to therapy, age, previous splenectomy, duration of ITP or platelet count. All patients tolerated treatment well except one patient who developed SLE-nephrotic syndrome 15 months later although it cannot be proven that such therapy induced this collagen-vascular diseases because Rituximab can be used to actually treat such conditions. Three patients remained in remission for more than one year after just one dose of the Rituximab therapy. Even from our small number of refractory ITP patients treated with Rituximab, it is our experience that single-dose treatment is also effective in some cases of refractory ITP and its effect may continue to provide long-term remission whereby it is now possible to decrease and even stop long-term steroid treatment in such patients.

Rituximab Is Effective in Refractory Adult Immune Thrombocytopenic Purpura Associated with Chronic Lymphocytic Leukemia.

Blood ◽  
2004 ◽  
Vol 104 (11) ◽  
pp. 3952-3952
Author(s):  
Thein H. Oo ◽  
Neela Natarajan
Keyword(s):  
Platelet Count ◽  
Chronic Lymphocytic Leukemia ◽  
B Cell ◽  
Immune Thrombocytopenic Purpura ◽  
Peripheral Blood ◽  
Lymphocytic Leukemia ◽  
High Dose ◽  
Thrombocytopenic Purpura ◽  
Platelet Counts ◽  
Refractory Itp

Abstract Chronic lymphocytic leukemia ( CLL ) is the commonest leukemia in the western world. 2% of CLL patients present with immune thrombocytopenic purpura ( ITP ). Corticosteroids, intravenous immune globulins ( IVIG ) and splenectomy have been the mainstay of treatment of ITP. Rituximab is the monoclonal antibody against CD-20 antigen expressed on the B-lymphocytes. It has established its role in the treatment of many B-cell malignancies in the last one decade. Due to its B-cell depletion capability, interests in employing rituximab in the treatment of many autoimmune diseases have grown in the last few years. Recently, many small case reports/series and a few small trials have reported the efficacy of rituximab in the treatment of refractory ITP. However, not much is known about its efficacy in the ITP associated with CLL. Here, a patient with CLL initially presenting with ITP is described. A 67-year-old white female with a past history of hysterectomy for fibroids and hypertension presented with rectal bleeding and multiple ecchymoses. Physical examination was unremarkable except for skin eccymoses on the extremities and abdomen. Colonscopy revealed hemorrhoids only. Computerized tomograms showed no lymphadenopathy or other abnormalities. Here laboratory data were as follows; hemoglobin 5.8g/dl, WBC 29,400/mm3, platelet 13,000/mm3, lymphocyte 52%, neutrophil 45%, monocyte 2.5%. Chemistry profile was unremarkable. Her blood group was O, Rh-negative. She was initially treated at another institution with packed Red Blood Cells, prednisone 1.5mg/kg qd and daily IVIG 0.4g/kg for 5 days for presumed ITP. Platelet transfusions did not raise the platelet counts. She remained profoundly thrombocytopenic and was subsequently transferred to our hospital. Review of the blood smear revealed anisopoikilocytosis, few tear-drop RBCs, many small-to-medium sized mature lymphocytes, occasional smudge cells, large platelets, few Pseudo-Pelgar-Huet cells but no blasts. Given moderate absolute lymphocytosis ( 15,200/mm3 ), blood film findings and profound thrombocytopenia, a working diagnosis of CLL-associated ITP was entertained. Peripheral blood flow cytometry showed lymphocytes positive for CD5, CD19, CD20 (dim ) and CD23, kappa/lambda ratio of 248:1. Bone marrow biopsy showed moderate lymphocytosis with the same immunophenotype as peripheral blood. Megakaryocytes were abundant. The diagnosis was confirmed. She was treated with a course of high dose methylprednisone, 2 courses of IVIG 1g/kg x 2days with very transient response. Due to this, she underwent splenectomy but her platelet counts remained low. She required another 5 courses of IVIG resulting in brief responses over the next 3 weeks. She was subsequently put on po danazol 200mg bid with short-lived responses. Eventually, she received iv rituximab 375mg/m2 weekly for 4 weeks. She achieved complete remission within 1 month. Two months later, she transferred her care to another facility. Review of the literature showed 1 case report of CLL-associated refractory ITP successfully treated with rituximab and the response duration was 6 months. Three CLL patients with refractory fludarabine-associated ITP also responded to rituximab. Of them, two achieved a platelet count over 100,000/mm3 and 1 achieved a platelet count of 72,000/mm3 within 4 weeks. Duration of responses ranged from 6 to 17 months. Those results together with our case suggest rituximab is an alternative agent for the treatment of CLL-associated ITP. Its potential in ITP associated with B-cell lymphoid malignancies should be explored further.

scholarly journals Severe Immune Thrombocytopenic Purpura Treated with Plasma Exchange

2012 ◽  
Vol 10 (1) ◽  
pp. 77-82 ◽  
Author(s):  
MR Sigdel ◽  
DS Shah ◽  
MP Kafle ◽  
KB Raut
Keyword(s):  
Platelet Count ◽  
Plasma Exchange ◽  
Immune Thrombocytopenic Purpura ◽  
Low Dose ◽  
High Dose ◽  
Severe Thrombocytopenia ◽  
First Line ◽  
Thrombocytopenic Purpura ◽  
Steroid Resistant ◽  
Low Platelet Count

Immune thrombocytopenic purpura (ITP) is a hematological disorder characterized by immunologically mediated destruction of platelets and absence of other causes of thrombocytopenia. Treatment is required when the low platelet count entails risk of serious bleeding. Steroid is the first line of management. Acute refractory ITP with very low platelet count is variably treated with high dose steroid, intravenous immunoglobulin (IVIg), anti D or emergency splenectomy. Here, we present a case of steroid resistant ITP with severe thrombocytopenia treated with plasma exchange and low dose IVIg who responded dramatically to the therapy with maintained platelet count till one month from the institution of therapy. KATHMANDU UNIVERSITY MEDICAL JOURNAL  VOL.10 | NO. 1 | ISSUE 37 | JAN - MAR 2012 | 85-87 DOI: http://dx.doi.org/10.3126/kumj.v10i1.6922

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