The efficacy of akapulko (Senna alata) decoction as a treatment for tinea imbricata among the T’boli tribe in Kiamba, Sarangani: A pilot study

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Mycoses. 2020;00:1–9. wileyonlinelibrary.com/journal/myc
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1© 2020 Wiley-VCH GmbH
Received: 7 May 2020
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Revised: 4 August 2020
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Accepted: 5 August 2020
DOI : 10.1111/myc .13159
ORIGINAL ARTICLE
Senna (Cassia) alata (Linn.) Roxb. leaf decoction as a treatment
for tinea imbricata in an indigenous tribe in Southern
Philippines
Kathleen May V. Eusebio-Alpapara1 | Belen L. Dofitas1 |
Cherry Lou A. Balita-Crisostomo1 | Giselle Marie S. Tioleco-Ver1 | Lilibeth E. Jandoc2 |
Ma. Lorna F. Frez1
1Depar tment of Dermatology, Uni versit y of
the Philippines–Philippine General Hospital,
Manila, Philippines
2Rural He alth Unit, Muni cipality of Kia mba,
Philippines
Correspondence
Kathle en May V. Eusebio-Alpap ara, V.E.
Eusebio S kin Center, 2nd floor, V.E. Eusebio
Building, 8758 Baton g Malake, Los Baños,
Laguna 4030, Philippines.
Email: kathleenmayalpapara@gmail.com
Funding information
Philippine Dermatological Society, Grant/
Award Number: pa rtial fundin g
Abstract
Background: Tinea imbricata, a rare form of tinea corporis caused by Trichophyton
concentricum, is endemic to the T’boli tribe in the Southern Philippines. Temporary
remissions and limited access to antifungal medications make its treatment a pressing
public health concern. Anecdotal reports about the use of Senna alata leaf decoction
as treatment exist.
Objective: To determine the efficacy of community-prepared S alata leaf decoction
in the treatment of tinea imbricata.
Methods: Tinea imbricata patients were instructed to apply S alata leaf decoction for
4 weeks (28 ± 3 days). Disease severity, pruritus visual analogue scale scores (VAS)
and potassium hydroxide (KOH) mounts of skin scrapings were evaluated before and
after treatment. Two assessors evaluated disease severity based on photographs.
Cohen's kappa statistics were used to assess diagnostic concordance. Adverse drug
events were recorded.
Results: Twenty patients were enrolled. After 4 weeks, 95% had decreased pruritus
VAS scores, with a mean decreased of 4.05 after treatment (P < .0001). There was a
significant difference in disease severity scores before and after treatment (P ≤ .05)
with an overall agreement of ‘moderate’ for both assessors (κ = 0.6, 95% CI [0.33,
0.87]). Forty per cent had negative KOH tests after treatment. None had adverse
drug events.
Conclusion: This is the first study that showed the potential of a community-pre-
pared leaf decoction as a treatment option for tinea imbricata. Larger clinical trials
establishing its efficacy, effectiveness and safety profile are recommended to enable
its promotion among the indigenous people and health authorities as an accessible
and affordable treatment for tinea imbricata.
KEYWORDS
dermatomycosis, dermatophytes, dermatophytosis, leaf decoction, Senna alata L., tinea
corporis, tinea imbricata, Trichophyton concentricum

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EUSEBIO-ALPAPARA E t AL.
1 | INTRODUCTION
Tinea imbricata is a rare form of tinea corporis caused by Trichophyton
concentricum, an anthropophilic dermatophyte. Its lesions pres-
ent as ‘maze-like’ or lace-like pattern of embossed concentric rings
mainly on the trunk and the extensor surfaces of both extremities,
sparing the palms, soles, hair and nails1,2 (Figure 1). The first case
of tinea imbricata was discovered in the southern Philippines by
William Dampier in 1789.3,4 Other cases are scat tered in the Pacific,
Southeast Asia, and Central and South America.5 In 2010, tinea im-
bricata was found to still exist among members of the T’boli tribe
who live in the mount ainous areas of Sarangani, a province in the
southern Philippines.4
The inherited susceptibility of T. concentricum infection ex-
plains why the disease affects only a specific group of individuals.
The most accepted inheritance pattern is autosomal recessive at-
tributing to the inherited defect in cell-mediated immunity, wherein
T-lymphocytes fail to become sensitised to the fungi and mount an
immune response.6 Other risk factors are isolated and primitive liv-
ing conditions in humid areas, poor hygiene and overcrowding.6 ,7
Antifungals are the mainstay treatment against T concentricum.
Oral intake of Griseofulvin, 1 g daily or terbinafine 250 mg daily
for at least 4 weeks leads to complete resolution of the lesions but
remission would only last for 8 weeks.8 Furthermore, commercial
antifungal drugs are costly, have guaranteed harmful effects from
prolonged use and not readily available in the area.4,9 Hence, alter-
native treatment options that will promote clearance and inhibit re-
currence that are accessible, inexpensive and practical to use should
be explored.
Senna (Cassia) alata (L.) Roxb, also known as ringworm senna
from family Fabaceae or Leguminosae, is a tropical ornamental shrub
which grows throughout the low and medium altitude areas of the
country including the southern Philippines.9,10 It is lo cally cal led 'aka-
pulko' and is well-studied for its antifungal activity, making it one of
the ten herbal medicines endorsed by the Philippines Department
of Health.9
It was its leaf extract that was first documented clinically to have
antifungal properties against the yeast, Malassezia furfur, without
causing side effect s in humans. In this case report, the leaf extract
was prepared by mashing cleaned leaflets (20 0 g) by hand using dis-
tilled water (50 mL). Complete clearance of the lesions was observed
after 9 months of application.11
The antifungal property of plants can be attributed to the pres-
ence of phytochemicals which are biologically active compounds
dedicated for their survival and adaption.9 Some of the factors that
can determine the phytochemicals that can be obtained from a plant
part are the type of solvent used and the extraction technique.9
Examples of extraction techniques are maceration, percolation,
Soxhlet extraction and decoction. Among these techniques, macer-
ation, whether with water, hexane, ethyl acetate and alcohol most
especially ethanol, is still the extraction method that yields extracts
with the greatest antifungal properties.12,13 S alata ethanolic crude
leaf extract is fungicidal against Microsporum canis, Trichophyton ver-
rucosum, T mentagrophytes and Epidermophyton floccosum and fungi-
static against M canis, T verruscosum and T mentagrophytes.9,14
Meanwhile, its aqueous leaf extract exhibited a dose-depen-
dent therapeutic effect against M canis and T mentagrophytes.9,14
Phytochemicals with antifungal activity such as alkaloids, couma-
rins, flavonoids, glycosides, phenols, saponins, tannins, terpenoids,
rhein and anthraquinones can all be found in S alata leaves when
macerated using water as a solvent.9 These phytochemicals, specif-
ically the anthraquinones and its glycoside derivatives aloe-emodin,
chrysophanol and rhein, were found to inhibit the grow th of derma-
tophytes such as T rubrum, T mentagrophytes and M gypseum.9 They
FIGURE 1 Tinea imbricata lesions with
classic lamellar and concentric pattern on
the (A) right upper forearm, (B) right upper
extremity and (C) left thigh
(a) (b) (c)

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EUSEBIO -ALPAPARA E t AL.
are readily oxidised to form a phenolate ion or quinone, an elec tron
acceptor, which aids in the scavenging and entrapment of microor-
ganisms.15-17 Moreover, they impair a variet y of enzyme systems
that are involved in energy production, disrupt the integrit y of the
cell membrane and interfere with the synthesis of the cell's struc-
tural components.16,17
A decoction is the liquid resulting from concentrating the es-
sence of the substance by heating or boiling a medicinal preparation
made from a part of a plant, such as the leaves.10 In a st u dy of ant hra -
quinone extraction methods from Cassia fistula pods, although the
highest content of total anthraquinones can be found in macerated
extracts, the highest content of total anthraquinone glycosides, such
as rhein and aloe-emodin, can be obt ained in the extract s prepared
by decoction in water.18
The first case of tinea imbricata successfully treated with S alata
leaves was first reported in Papua New Guinea last 1982. Individuals
with tinea imbricata, who resided in Gogol-Valley, Madang Province,
would use local rubs with S alata leaves as treatment.19 In the
Philippines, the use of S alata leaf decoction as treatment for tinea
imbricata was first at tempted by Non and Dofit as in 2009 on three
patients with extensive disease from the T'boli indigenous people
group in Sarangani, Southern Philippines. They reported that the
daily application of the leaf decoction resulted in clearance of the
lesions.20 A larger case series conducted in 2010 among tinea imbri-
cata patients from the same community repor ted par tial clearance
of the lesions among those who applied the leaf decoction.
The favourable result s from these repor ts paved the way for in-
vestigating S alata decoction as a potential accessible and af fordable
treatment for tinea imbricata. Senna alata was found to grow abun-
dantly in the villages of the T'boli. The local health centre could be
reached after a 6-hour walk from the mountain villages and could
not provide regular antifungal medications for this chronic and re-
curring fungal infection. The investigators therefore thought of the
leaf decoction as a treatment that would be af fordable and easy to
prepare by the T'boli themselves within their villages.
This study aimed to assess the ef ficacy and safety of S alata leaf
decoction applied once daily in the treatment of tinea imbricata.
Specific objectives were to determine the treatment response at
the end of four weeks (28 days ± 3 days) as measured by disease
severity, pruritus visual analogue scale score (VAS) and potassium
hydroxide (KOH) smear conversion of the patients and to document
the adverse reactions associated by the application of S alata leaf
decoction.
This study was presented as a scientific poster in 2017, and its
abstract was subsequently published in the Journal of American
Academy of Dermatology.21
2 | METHODS
This study is a clinical case series conducted with the approval of the
University of the Philippines Manila Research Ethics Board and the
National Commission on Indigenous People of the region where the
study was conducted. It took place at Kiamba Municipality, Sarangani
Province in Southern Philippines from November 2014 to January
2015. The participants were the T'boli, one of the indigenous tribes
in Southern Philippines, who reside in upland villages of Sarangani.
Patient recruitment was done through an outreach skin clinic
manned by dermatologist s and trainees in the town's local health
centre, located below the mountain range where the T’boli tribe re-
side. Adult patients with any skin disease and suspected tinea im-
bricata were invited to consult. A dermatologist investigator who
was experienced in clinically diagnosing tinea imbricata assessed
the eligibility of the participants. The case definition used for tinea
imbricata was lesions that start as an erythematous pruritic papules
or hypopigmented patches which commonly appear on the upper
extremities, followed by the trunk, then the lower extremities. These
lesions then become larger and generalised plaques and assume the
following configuration: lamellar, concentric or annular. The con-
centric plaques would exhibit minimal scaling and appear to be em-
bossed on the skin.
Patients with clinically diagnosed tinea imbricata and microscop-
ically confirmed fungal elements in the KOH mounts were included
in the study. One of the dermatologist investigators performed the
microscopic confirmation of fungal elements in skin scrapings on-
site at the health centre. Patients who were treated or were under-
going treatment with topical antifungal for 2 weeks or oral antifungal
1 month before the study were excluded.
2.1 | Securing consent and enrolment of
participants
The purpose, duration, benefits and possible adverse effects were
explained to all participants. All of them signed consent forms that
were secured by the healthcare worker and research aid who could
speak T’boli dialect. A thumb mark was obtained in place of a signa-
ture for illiterate participants.
Enrolled patients underwent detailed history-taking and physi-
cal examination, photographic documentation and collec tion of skin
scrapings. A dermatologist investigator was assigned to rate the
baseline disease severity based on erythema, scaling and body sur-
face area of involvement, while another investigator recorded each
patient's VAS pruritus score (Table 1).
2.2 | Preparation and application of the
leaf decoction
The enrolled participants attended a demonstration of the prepara-
tion of the leaf decoction and were provided basic cooking imple-
ments. The method of preparing the leaf decoction was based on
the recommendation of the Philippine Council of Health Research
and Development.22
One glassful (350 mL) of closely packed chopped leaflets from
the rachis of mature leaves was boiled in 2 glasses of clean water

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(700 mL). The water is boiled for 10 to 15 minutes until the fluid
was reduced to half, the mixture was cooled and strained using
cheesecloth.23-25
The participants were instructed to prepare fresh decoction daily,
take a bath once a day using a synthetic detergent cleansing bar, to
towel dry their skin before applying 350 mL of the leaf decoction on the
whole body especially on the affected areas and to leave it on to dry.
Daily application was done for 4 weeks (28 days ± 3) or until the next
outcome assessment. A health worker who was a member of the tribe
was trained to monitor the adherence of the participants of this study.
2.3 | Outcome assessement
After 1 month of treatment, the research aide and public health
nurse visited the village of the T'boli. They took medical photographs
and assessed level of pruritus using a visual analogue scale. The dis-
ease severity (based on ery thema, scaling and body surface area of
involvement) was assessed independently by two dermatologist in-
vestigators based on standard photographs (Table 1).
For mycologic cure, the research aides or the public health nurse per-
formed KOH scraping on the same body site as the pretreatment KOH.
Samples were sent to the investigators who performed direct microscopic
examination in the Dermatology clinic at the Philippine General Hospital.
Adverse drug events reported by the patients were recorded.
If patients exhibited clearance or improvement of the lesions
within the initial 28 day treatment period, they were instructed to
continuously apply the decoction with proper monitoring to assess
the ability of the decoction to clear the infection and prevent recur-
rence. Monitoring was done by the trained T’boli healthcare worker
who would report appearance of new lesions to the investigators.
3 | RESULTS
Twenty adult patients were enrolled in this study. Majority (60%) of the
patients were males, and the mean age was 35.3 years (range: 20-51).
Majority (85%) had a family history of tinea imbricata. None had con-
comitant illnesses or used previous antifungal medications. (Figure 1).
After 4 weeks of treatment, 19 (95%) had decreased pruritus
scores with a mean reduction of 4.05 (Mean VAS before treatment:
7.75, after treatment: 3.7). Only 1 patient with an initial disease se-
verity of severe did not experience pruritus relief. Wilcoxon signed
ranked test indicated that the posttreatment test ranks were statis-
tic ally sig nifica nt ly lower than the pre tr ea tm ent ra nk s. (z = −3.823, P
value = .00014, which is significant at P < .05) (Table 2).
Disease severity classification improved in 8 (40%) subjects ac-
cording to one outcome assessor and 9 (45%) according to the other.
(Figure 2) Only one patient had worsened disease severity. (Table 3)
The overall magnitude of agreement was moderate (free marginal
kappa (κ) = 0.6, 95% CI [0.33, 0.87]). (Appendix A) Wilcoxon paired
signed ranked test showed that the posttreatment ranks were sig-
nificantly lower than the pretreatment ranks for both assessors (as-
sessor 1: z = −2.10 15, P value = .3572; assessor 2: z = −2.20 12, P
value = .0278, which are both significant at P < .05).
Eight patients (40%) had KOH conversion or negative KOH mounts
after the treatment period; two with an initial disease severity of mild,
five had moderate and 1 had severe disease. None of the patients ex-
hibited erythema, pruritus, stinging, dryness, pain and infection that
were attributed to the application of the decoction. (Appendix A).
The 19 patients who exhibited any improvement of the lesions
were asked to continuously apply the decoction after bathing, as
part of their daily regimen even after the end of the study treatment
period. There were no reported new lesions within the whole year of
application of the decoction. The patient who did not improve was
treated with Griseofulvin 1 g daily for 4 weeks.
4 | DISCUSSION
Tinea imbricata is a chronic, recurrent superficial fungal infection re-
quiring frequent treatment with antifungal medications. Prolonged
and repeated use of these commercially available antifungal raise
concerns on their toxicity and cost. The geographical distribution of
afflicted T’boli people, who are spread out in the mountain region,
and the limited access to the antifungal medications available in the
TABLE 1 Disease severity criteria
Grade Disease severity characteristic
Body sur face area involvement
0a No lesions
1Lesions occupy an ag gregate surface area less than
or equal to 5 × 5cm
2Aggregate sur face area greater than 5 × 5 cm but
less than 10 × 10 cm
3Aggregate sur face area of greater than 10 × 10 cm
Erythema
0No erythema
1Nearly imperceptible erythema
2Moderate ery thema (pinkish skin)
3Intense erythema
Scaling
0No scaling
1Fine white scales
2Moderate scales
3Large scales
Total disease severity score based on scaling, er ythema and area of
involvement
Category Score
No disease 0
Mild For composite score of 1-3
Moderate For composite score of 4-6
Severe For composite score of 7-9
aApplic able post-treatment (after 4 weeks).

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EUSEBIO -ALPAPARA E t AL.
health centr es and loca l pharmac ie s, make th e treatme nt of ti ne a im-
bricata a pressing public health concern for the T’boli. Hence, there
is a need to explore treatment options that will promote clearance of
infection and prevent recurrence while being accessible, inexpensive
and prac tical to use.
The study showed that the application of community-prepared S
alata leaf decoction improved tinea imbricata lesions within 28 days
based on subjective (VAS for pruritus) and objective (disease se-
verity and KOH conversion) clinic al parameters. Majority (95%) of
the patients had pruritus relief which improved their quality of life.
Dis ea se seve ri ty improved in 40% of part icipant s based on dermato-
logical assessment and KOH skin smear examination.
Aside from the antifungal effects of the community-prepared
decoction, other requisites of this study may have contributed to
the improvement of the disease. Proper hygienic practices were
vital in this s tu dy. Patients wer e required to bat he daily wi th clean
water and soap prior to the application of the decoction. Family
influence may have contributed to the adherence or compliance
to the treatment regimen. Lack of adherence can decrease the
efficacy of the decoction. The patient who did not have disease
improvement had no family members who were enrolled in the
stud y.
In actual clinical practice in a remote setting, the form of ex-
traction method used as treatment of cutaneous diseases would
not be solely based on the type of extract that would give the
greatest in vitro result. Long-term toxicity, ease of application,
accessibility and favourable long-term results of the end product
should also be considered.12 Boiling leaves in water and applying
the de coc tion on the sk in as a body wash are a pr ac tica l and appro-
priat e me thod for in digenous peo pl e. Tinea im br ic at a often affect s
alm ost all par t s of the sk in , making a bo dy wash e asier to app ly and
more economical.
This initial investigation on S alata's efficacy is limited by the
small sample size, lack of a control arm and randomisation to treat-
ment groups. More frequent outcome assessments were not feasible
due to the remoteness of the T'boli villages.
TABLE 2 Mean pruritus VAS scores before and after treatment
Baseline disease severity (n)/patient
code Before treatment After treatment Mean difference
Number of patients with
improved in VAS score (%)
Mild (4)
43 0 4 (100%)
7 3 1
910 5
43 6 2
Mean 5.5 23.5
Moderate (13) 13 (100%)
110 6
610 5
343
510 7
38 10 6
39 7 2
41 7 3
42 6 1
44 82
45 82
46 82
47 7 2
48 8 4
Mean 7.9 2 3.46 4.46
Severe (3)
11 10 63.0 3 (66.7%)
29 10 5
25 10 10
Mean 10 7
Overall (20) 7.7 5 3.7 4.05 19 (95%); P < .0001

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EUSEBIO-ALPAPARA E t AL.
Despite these limitations, the study findings indicate that the S
alata decoction has potential to treat and prevent recurrent tinea
imbricata if used regularly. The empowering effect of enabling an
indigenous people to prepare their own herbal remedy rather than
depend on pharmaceuticals enhances treatment compliance. The
favourable result s of this study provided hope for the members of
the T’boli tribe who used to think that their long-standing disease
had no cure.
5 | CONCLUSION
Senna alata leaf decoction showed potential as an accessible and
acceptable home-prepared treatment for tinea imbricata. Once its
efficacy, effectiveness and good safet y profile are validated by ran-
domised controlled clinical trials, the community-prepared S alata
leaf de co ction can be recommended and promote d am ong the in di g-
enous people and the health authorities as an alternative treatment
and prevention for recurrence of tinea imbricata.
ACKNOWLEDGMENTS
We would like to thank the Department of Dermatolog y, Philippine
General Hospital consultants for your inputs and suggestions, Ms
Mylene Tagum, Mrs Apelina Tagum, Ms Greta Tagum, Genniedelle
Fria Ballan-Jandoc RN, Cesar Mondragon Jr. RN and Mr Angelo Sayo
RN for your assistance throughout the duration of the study pe-
riod, Nelson Mabaquiao and Rick y Trecero of the NCIP, Rosario E.
Sequitin and Dr Joseph Symon Concha for the Visayantranslation
of the forms, and Dr Romeo Villarta Jr (statistician). We would also
like to thank Dr Judith Valdez Eusebio for your unwavering suppor t.
Dr Danilo Alpapara Jr and Dr Vergel Eusebio for helping the authors
edit the final manuscript of this paper.
CONFLICT OF INTEREST
There were no conflicts of interest in the conduct of this research.
AUTHOR CONTRIBUTION
Kathleen May V. Eusebio-Alpapara: Conceptualization (lead);
Data curation (lead); Formal analysis (lead); Funding acquisition
FIGURE 2 Representative lesions before (A) (C) and after (B) (D) the 28 day treatment with Senna alata decoction
(a) (b) (c) (d)
Baseline
disease
severit y (n)
Number of patients
with improved disease
classification (%)
Number of patients
with maintained disease
classification (%)
Number of
patients with
worsened disease
classification (%)
A1 A2 A1 A2 A1 A2
Mild (4) 1 (25) 02 (50) 3 (75) 1 (25) 1 (25)
Moderate (13) 5 (38.46) 6 (46.15) 8 (61.54) 7 (53.85) 0 0
Severe (3) 2 (66.67) 3 (100) 1 (33.33) 0 0 0
Overall (20) 8 (40) 9 (45) 11 (55) 10 (50) 1 (5) 1 (5)
Note: A1—Assessor 1; A2—Assessor 2.
TABLE 3 Summary of disease severity
outcome after treatment

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EUSEBIO -ALPAPARA E t AL.
(lead); Investigation (lead); Methodolog y (equal); Project admin-
istration (lead); Resources (lead); Software (lead); Super vision
(equal); Validation (equal); Visualization (lead); Writing-original
draft (lead); Writing-review & editing (equal). Belen L. Dofitas:
Conceptualization (equal); Data curation (supporting); Formal anal-
ysis (supporting); Funding acquisition (supporting); Investigation
(supporting); Methodology (equal); Project administration (equal);
Resources (supporting); Software (supporting); Supervision
(equal); Validation (supporting); Visualization (supporting);
Writing-original draft (supporting); Writing-review & editing
(equal). Cherry Lou A. Balita-Crisostomo: Investigation (support-
ing); Methodology (supporting); Project administration (support-
ing); Resources (supporting); Supervision (supporting); Validation
(supporting); Writing-original draft (supporting); Writing-review
& editing (supporting). Lilibeth E. Jandoc: Investigation (support-
ing); Methodology (supporting); Project administration (equal);
Resources (supporting); Supervision (supporting); Writing-review
& editing (supporting). Giselle Marie S. Tioleco-Ver: Investigation
(supporting); Methodology (supporting); Project administration
(supporting); Resources (supporting); Supervision (supporting);
Validation (supporting); Writing-review & editing (supporting).
Ma. Lorna F. Frez Conceptualization (supporting); Formal analy-
sis (supporting); Investigation (supporting); Methodology (sup-
porting); Project administration (supporting); Supervision (equal);
Visualization (supporting); Writing-review & editing (supporting).
DATA AVAILAB ILITY STATE MEN T
The data that support the findings of this study are available on re-
quest from the corresponding author. The data are not publicly avail-
able due to privacy or ethical restrictions.
ORCID
Kathleen May V. Eusebio-Alpapara https://orcid.
org/0000-0001-9856-7985
Belen L. Dofitas https://orcid.org/0000-0001-5494-9455
Cherry Lou A. Balita-Crisostomo https://orcid.
org/0000-0003-0080-8774
Giselle Marie S. Tioleco-Ver https://orcid.
org/0000-0002-3724-1719
Lilibeth E. Jandoc https://orcid.org/0000-0002-8108-8774
Ma. Lorna F. Frez https://orcid.org/0000-0001-8611-767X
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APPENDIX A
Disease severity scores and KOH microscopic examination results after treatment
Code
Before treatment After tr eatment Assessor 1 After tr eatment Assessor 2
Kappa statistic
KOH
result s after
treatment
Body
surface
area Erythema Scaling
Composite
score
Body
surface
area Erythema Scaling
Composite
score
Body
surface
area Erythema Scaling
Composite
score
Mild k = 0.6 (95% CI
[0.33, 0 .87]
41 0 1 2 1 0 1 2 2 0 0 2 −
7 3 0 0 3 3 1 1 530 14+
9 3 0 0 3 2 0 1 3 2 0 1 3 +
43 3 0 0 3 0 0 0 0 2 0 0 2 −
Moderate
1 3 0 2 530 2530 14+
6 3 0 1 40 0 0 0 3 0 0 3 −
2 3 0 1 432 16 22 15+
531 26 30 1430 14+
38 30 1432 053 1 2 6 +
39 30 141 0 1 2 1 0 0 1 −
41 30 252 0 1 3 1 0 0 1 −
42 31 150 0 0 0 1 0 0 1 −
44 30 1430 1430 14+
45 31 26 30 252 0 0 2 +
46 30 143 1 2 6 3 2 1 6 −
47 31 150 0 0 0 1 0 0 1 +
48 31 26 30 2530 14+
Severe
11 32 383 2 1 6 3 2 1 6 +
29 3 1 3 7 3 0 0 3 2 0 1 3 −
25 32 3833 2831 15+
K, Cohen's Kappa Statistic.