Research Article
Year 2019,
Volume: 41 Issue: 3, 506 - 515, 30.09.2019
Abstract
References
- 1. Hunter TM, Boytsov NN, Zhang X, Schroeder K, Michaud K, Araujo AB. Prevalence of rheumatoid arthritis in the United States adult population in healthcare claims databases, 2004-2014. Rheumatol Int. 2017 Sep;37(9):1551–7.
- 2. Tuncer T, Gilgil E, Kaçar C, Kurtaş Y, Kutlay Ş, Bütün B, et al. Prevalence of Rheumatoid Arthritis and Spondyloarthritis in Turkey : A Nationwide Study. 2018;33(2):128–36.
- 3. van Vollenhoven RF. Sex differences in rheumatoid arthritis: more than meets the eye.. BMC Med. 2009;7:12.
- 4. Crowson CS, Liao KP, Davis JM 3rd, Solomon DH, Matteson EL, Knutson KL, et al. Rheumatoid arthritis and cardiovascular disease. Am Heart J. 2013 Oct;166(4):622–628.e1.
- 5. Mellana WM, Aronow WS, Palaniswamy C, Khera S. Rheumatoid arthritis: cardiovascular manifestations, pathogenesis, and therapy. Curr Pharm Des. 2012;18(11):1450–6.
- 6. Kaplan MJ. Cardiovascular complications of rheumatoid arthritis: assessment, prevention, and treatment. Rheum Dis Clin North Am. 2010 May;36(2):405–26.
- 7. Avina-Zubieta JA, Thomas J, Sadatsafavi M, Lehman AJ, Lacaille D. Risk of incident cardiovascular events in patients with rheumatoid arthritis: a meta-analysis of observational studies. Ann Rheum Dis. 2012 Sep;71(9):1524–9.
- 8. Corrao S, Messina S, Pistone G, Calvo L, Scaglione R, Licata G. Heart involvement in Rheumatoid Arthritis : Systematic review. Int J Cardiol. 2012;
- 9. England BR, Thiele GM, Anderson DR, Mikuls TR. Increased cardiovascular risk in rheumatoid arthritis : mechanisms and implications. :1–17.
- 10. Wu Y, Zhang A, Hamilton DJ, Deng T. Epicardial Fat in the Maintenance of Cardiovascular Health. Methodist Debakey Cardiovasc J. 2017;13(1):20–4.
- 11. Bertaso AG, Bertol D, Duncan BB, Foppa M. Epicardial fat: definition, measurements and systematic review of main outcomes. Arq Bras Cardiol. 2013 Jul;101(1):e18-28.
- 12. Ormseth MJ, Lipson A, Alexopoulos N, Hartlage GR, Oeser AM, Bian A, et al. Association of epicardial adipose tissue with cardiometabolic risk and metabolic syndrome in patients with rheumatoid arthritis. Arthritis Care Res (Hoboken). 2013 Sep;65(9):1410–5.
- 13. Lima-Martínez M, Campo E, Salazar J, Paoli M, Maldonado I, Acosta C, et al. Epicardial Fat Thickness as Cardiovascular Risk Factor and Therapeutic Target in Patients with Rheumatoid Arthritis Treated with Biological and Nonbiological Therapies. Arthritis. 2014;2014:782850.
- 14. Fatma E, Bunyamin K, Savas S, Mehmet U, Selma Y, Ismail B, et al. Epicardial fat thickness in patients with rheumatoid arthritis. Afr Health Sci. 2015 Jun;15(2):489–95.
- 15. Nafakhi H, Al-Mosawi A, Al-Nafakh H, Tawfeeq N. Association of pericardial fat volume with coronary atherosclerotic disease assessed by CT angiography. Br J Radiol. 2014 Jun 21;87(1038):20130713.
- 16. Hwang I-C, Park HE, Choi S-Y. Epicardial Adipose Tissue Contributes to the Development of Non-Calcified Coronary Plaque: A 5-Year Computed Tomography Follow-up Study. J Atheroscler Thromb. 2017 Mar;24(3):262–74.
- 17. Mancio J, Azevedo D, Saraiva F, Azevedo AI, Pires-Morais G, Leite-Moreira A, et al. Epicardial adipose tissue volume assessed by computed tomography and coronary artery disease: a systematic review and meta-analysis. Eur Heart J Cardiovasc Imaging. 2018 May;19(5):490–7.
- 18. Demircelik MB, Yilmaz OC, Gurel OM, Selcoki Y, Atar IA, Bozkurt A, et al. Epicardial adipose tissue and pericoronary fat thickness measured with 64-multidetector computed tomography: potential predictors of the severity of coronary artery disease. Clinics (Sao Paulo). 2014 Jun;69(6):388–92.
- 19. Nagy E, Jermendy AL, Merkely B, Maurovich-Horvat P. Clinical importance of epicardial adipose tissue. Arch Med Sci. 2017 Jun;13(4):864–74.
- 20. Mahabadi AA, Balcer B, Dykun I, Forsting M, Schlosser T, Heusch G, et al. Cardiac computed tomography-derived epicardial fat volume and attenuation independently distinguish patients with and without myocardial infarction. 2017;1–11.
- 21. Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF, Cooper NS, et al. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum. 1988 Mar;31(3):315–24.
- 22. Aletaha D, Neogi T, Silman AJ, Funovits J, Felson DT, Bingham CO 3rd, et al. 2010 Rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis Rheum. 2010 Sep;62(9):2569–81.
- 23. Sokka T, Abelson B, Pincus T. Mortality in rheumatoid arthritis: 2008 update. Clin Exp Rheumatol. 2008;26(5 Suppl 51):S35-61.
- 24. Avina-Zubieta JA, Choi HK, Sadatsafavi M, Etminan M, Esdaile JM, Lacaille D. Risk of cardiovascular mortality in patients with rheumatoid arthritis: a meta-analysis of observational studies. Arthritis Rheum. 2008 Dec;59(12):1690–7.
- 25. Okada K, Ohshima S, Isobe S, Harada K, Hirashiki A, Funahashi H, et al. Epicardial fat volume correlates with severity of coronary artery disease in nonobese patients. J Cardiovasc Med (Hagerstown). 2014 May;15(5):384–90.
- 26. Giles JT, Allison M, Blumenthal RS, Post W, Gelber AC, Petri M, et al. Abdominal adiposity in rheumatoid arthritis: association with cardiometabolic risk factors and disease characteristics. Arthritis Rheum. 2010 Nov;62(11):3173–82.
- 27. Oikawa M, Owada T, Yamauchi H, Misaka T, Machii H, Yamaki T, et al. Epicardial adipose tissue reflects the presence of coronary artery disease: comparison with abdominal visceral adipose tissue. Biomed Res Int. 2015;2015:483982.
- 28. Amigues I, Tugcu A, Russo C, Giles JT, Morgenstein R, Zartoshti A, et al. Myocardial Inflammation, Measured Using 18-Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography (FDG PET-CT) is Associated with Disease Activity in Rheumatoid Arthritis. Arthritis Rheumatol. 2018;
- 29. Kalinkovich A, Gabdulina G, Livshits G. Autoimmunity, inflammation, and dysbiosis mutually govern the transition from the preclinical to the clinical stage of rheumatoid arthritis. Immunol Res. 2018 Nov;
- 30. Taguchi R, Takasu J, Itani Y, Yamamoto R, Yokoyama K, Watanabe S, et al. Pericardial fat accumulation in men as a risk factor for coronary artery disease. Atherosclerosis. 2001 Jul;157(1):203–9.
- 31. Iacobellis G, Ribaudo MC, Zappaterreno A, Iannucci CV, Leonetti F. Relation between epicardial adipose tissue and left ventricular mass. Am J Cardiol. 2004 Oct;94(8):1084–7.
- 32. Iacobellis G, Assael F, Ribaudo MC, Zappaterreno A, Alessi G, Di Mario U, et al. Epicardial fat from echocardiography: a new method for visceral adipose tissue prediction. Obes Res. 2003 Feb;11(2):304–10.
- 33. Iacobellis G, Ribaudo MC, Assael F, Vecci E, Tiberti C, Zappaterreno A, et al. Echocardiographic epicardial adipose tissue is related to anthropometric and clinical parameters of metabolic syndrome: a new indicator of cardiovascular risk. J Clin Endocrinol Metab. 2003 Nov;88(11):5163–8.
- 34. Abbara S, Desai JC, Cury RC, Butler J, Nieman K, Reddy V. Mapping epicardial fat with multi-detector computed tomography to facilitate percutaneous transepicardial arrhythmia ablation. Eur J Radiol. 2006 Mar;57(3):417–22.
- 35. Kessels K, Cramer M-JM, Velthuis B. Epicardial adipose tissue imaged by magnetic resonance imaging: an important risk marker of cardiovascular disease. Heart. 2006 Jul;92(7):962.
- 36. Wallberg-Jonsson S, Ohman ML, Dahlqvist SR. Cardiovascular morbidity and mortality in patients with seropositive rheumatoid arthritis in Northern Sweden. J Rheumatol. 1997 Mar;24(3):445–51.
- 37. O’Neill TW, McCabe PS, McBeth J. Update on the epidemiology, risk factors and disease outcomes of osteoarthritis. Best Pract Res Clin Rheumatol [Internet]. 2018;(xxxx). Available from: https://doi.org/10.1016/j.berh.2018.10.005
- 38. Oyama N, Goto D, Ito YM, Ishimori N, Mimura R, Furumoto T, et al. Single-slice epicardial fat area measurement: do we need to measure the total epicardial fat volume? Jpn J Radiol. 2011 Feb;29(2):104–9.
- 39. Kiris A, Kiris G, Turan OE, Ozturk M, Sahin M, Ilter A, et al. Relationship between epicardial fat tissue and left ventricular synchronicity: An observational study. Anatol J Cardiol. 2015;15(12):990–4.
- 40. Watanabe K, Kishino T, Sano J, Ariga T, Okuyama S, Mori H, et al. Relationship between epicardial adipose tissue thickness and early impairment of left ventricular systolic function in patients with preserved ejection fraction. Heart Vessels. 2016 Jun;31(6):1010–5.
- 41. Cui X, Li Y, Liu J, He S, Liu M. Aortic arch atheroma and the risk of stroke: a meta-analysis. J Evid Based Med. 2014 Aug;7(3):185–91.
- 42. Lee R, Kim J, Paeng JC, Byun JW, Cheon GJ, Lee DS, et al. Measurement of (68)Ga-DOTATOC Uptake in the Thoracic Aorta and Its Correlation with Cardiovascular Risk. Nucl Med Mol Imaging (2010). 2018 Aug;52(4):279–86.
- 43. Nguyen-Thu H, Ohyama Y, Taketomi-Takahashi A, Nguyen-Cong T, Sugimoto A, Sato M, et al. Association of Aortic Arch Width Assessed by Noncontrast Cardiac Computed Tomography with Cardiac Remodeling, Cardiac Function, and Atherosclerosis in a Japanese Cohort. J Thorac Imaging. 2018;33(4):240–5.
- 44. Canga A, Kocaman SA, Cetin M, Erdogan T, Durakoglugil ME, Cicek Y, et al. Increased epicardial adipose tissue thickness is correlated with ascending aortic diameter. Tohoku J Exp Med. 2012 Mar;226(3):183–90.
Examination of the epicardial fat area in patients with rheumatoid arthritis by computed tomography of the thorax
Abstract
Objective: Rheumatoid arthritis (RA) is
an autoimmune and inflammatory disease. The prevalence of cardiovascular
diseases (CVDs) increases in RA.
The CVDs were shown as the major cause of death in RA. In this study, it was
aimed to determine the difference between the patients and the control group by
measuring the epicardial adipose tissue (EAT) at the left major coronary
artery, which is known as one of the major risk factors for CVDs in RA patients
who underwent computerized tomography (CT) of the thorax due to any reason,
through the CT.
Method: The study includes 87 patients diagnosed with RA in
the remission period and 45 healthy people as the control group. The files and
archive records were reviewed and the clinical features of the patient and
control groups, the EAT areas in the thorax CT performed, ascending aorta,
pulmonary truncus, and pulmonary artery diameters, as well as, the cardiothoracic
rates (CTR) measured with CT were recorded.
Results: There was no significant difference between the
groups in terms of age and gender (p>0.05). It was determined that the EAT
measured with CT increased in patients diagnosed with RA compared to the control
group and this increase was closely related to the aortic and pulmonary artery
width (p<0.05). In addition, the increase in the EAT area was directly
proportional with the CTR in patients diagnosed with RA (p<0.05). It was
seen that the ascending aorta diameter, pulmonary truncus diameter, and right
and left pulmonary artery diameters increased compared to the control group
(p<0.05).
Conclusions:
In the present
study, it was determined that the EAT measured with CT increased in patients
with RA compared to normal people and this increase was closely related to the
aortic and pulmonary artery width. In addition, the increase in the EAT area
was directly proportional with the CTR in patients diagnosed with RA. The
patients with RA were under a significant risk compared to normal people in
terms of the development of CVDs. It is considered that more prospective
studies including patients diagnosed with RA should be conducted.
Keywords
Rheumatoid Arthritis Epicardial adipose tissue EAT Cardiovascular Disease Computerized Tomography
References
- 1. Hunter TM, Boytsov NN, Zhang X, Schroeder K, Michaud K, Araujo AB. Prevalence of rheumatoid arthritis in the United States adult population in healthcare claims databases, 2004-2014. Rheumatol Int. 2017 Sep;37(9):1551–7.
- 2. Tuncer T, Gilgil E, Kaçar C, Kurtaş Y, Kutlay Ş, Bütün B, et al. Prevalence of Rheumatoid Arthritis and Spondyloarthritis in Turkey : A Nationwide Study. 2018;33(2):128–36.
- 3. van Vollenhoven RF. Sex differences in rheumatoid arthritis: more than meets the eye.. BMC Med. 2009;7:12.
- 4. Crowson CS, Liao KP, Davis JM 3rd, Solomon DH, Matteson EL, Knutson KL, et al. Rheumatoid arthritis and cardiovascular disease. Am Heart J. 2013 Oct;166(4):622–628.e1.
- 5. Mellana WM, Aronow WS, Palaniswamy C, Khera S. Rheumatoid arthritis: cardiovascular manifestations, pathogenesis, and therapy. Curr Pharm Des. 2012;18(11):1450–6.
- 6. Kaplan MJ. Cardiovascular complications of rheumatoid arthritis: assessment, prevention, and treatment. Rheum Dis Clin North Am. 2010 May;36(2):405–26.
- 7. Avina-Zubieta JA, Thomas J, Sadatsafavi M, Lehman AJ, Lacaille D. Risk of incident cardiovascular events in patients with rheumatoid arthritis: a meta-analysis of observational studies. Ann Rheum Dis. 2012 Sep;71(9):1524–9.
- 8. Corrao S, Messina S, Pistone G, Calvo L, Scaglione R, Licata G. Heart involvement in Rheumatoid Arthritis : Systematic review. Int J Cardiol. 2012;
- 9. England BR, Thiele GM, Anderson DR, Mikuls TR. Increased cardiovascular risk in rheumatoid arthritis : mechanisms and implications. :1–17.
- 10. Wu Y, Zhang A, Hamilton DJ, Deng T. Epicardial Fat in the Maintenance of Cardiovascular Health. Methodist Debakey Cardiovasc J. 2017;13(1):20–4.
- 11. Bertaso AG, Bertol D, Duncan BB, Foppa M. Epicardial fat: definition, measurements and systematic review of main outcomes. Arq Bras Cardiol. 2013 Jul;101(1):e18-28.
- 12. Ormseth MJ, Lipson A, Alexopoulos N, Hartlage GR, Oeser AM, Bian A, et al. Association of epicardial adipose tissue with cardiometabolic risk and metabolic syndrome in patients with rheumatoid arthritis. Arthritis Care Res (Hoboken). 2013 Sep;65(9):1410–5.
- 13. Lima-Martínez M, Campo E, Salazar J, Paoli M, Maldonado I, Acosta C, et al. Epicardial Fat Thickness as Cardiovascular Risk Factor and Therapeutic Target in Patients with Rheumatoid Arthritis Treated with Biological and Nonbiological Therapies. Arthritis. 2014;2014:782850.
- 14. Fatma E, Bunyamin K, Savas S, Mehmet U, Selma Y, Ismail B, et al. Epicardial fat thickness in patients with rheumatoid arthritis. Afr Health Sci. 2015 Jun;15(2):489–95.
- 15. Nafakhi H, Al-Mosawi A, Al-Nafakh H, Tawfeeq N. Association of pericardial fat volume with coronary atherosclerotic disease assessed by CT angiography. Br J Radiol. 2014 Jun 21;87(1038):20130713.
- 16. Hwang I-C, Park HE, Choi S-Y. Epicardial Adipose Tissue Contributes to the Development of Non-Calcified Coronary Plaque: A 5-Year Computed Tomography Follow-up Study. J Atheroscler Thromb. 2017 Mar;24(3):262–74.
- 17. Mancio J, Azevedo D, Saraiva F, Azevedo AI, Pires-Morais G, Leite-Moreira A, et al. Epicardial adipose tissue volume assessed by computed tomography and coronary artery disease: a systematic review and meta-analysis. Eur Heart J Cardiovasc Imaging. 2018 May;19(5):490–7.
- 18. Demircelik MB, Yilmaz OC, Gurel OM, Selcoki Y, Atar IA, Bozkurt A, et al. Epicardial adipose tissue and pericoronary fat thickness measured with 64-multidetector computed tomography: potential predictors of the severity of coronary artery disease. Clinics (Sao Paulo). 2014 Jun;69(6):388–92.
- 19. Nagy E, Jermendy AL, Merkely B, Maurovich-Horvat P. Clinical importance of epicardial adipose tissue. Arch Med Sci. 2017 Jun;13(4):864–74.
- 20. Mahabadi AA, Balcer B, Dykun I, Forsting M, Schlosser T, Heusch G, et al. Cardiac computed tomography-derived epicardial fat volume and attenuation independently distinguish patients with and without myocardial infarction. 2017;1–11.
- 21. Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF, Cooper NS, et al. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum. 1988 Mar;31(3):315–24.
- 22. Aletaha D, Neogi T, Silman AJ, Funovits J, Felson DT, Bingham CO 3rd, et al. 2010 Rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis Rheum. 2010 Sep;62(9):2569–81.
- 23. Sokka T, Abelson B, Pincus T. Mortality in rheumatoid arthritis: 2008 update. Clin Exp Rheumatol. 2008;26(5 Suppl 51):S35-61.
- 24. Avina-Zubieta JA, Choi HK, Sadatsafavi M, Etminan M, Esdaile JM, Lacaille D. Risk of cardiovascular mortality in patients with rheumatoid arthritis: a meta-analysis of observational studies. Arthritis Rheum. 2008 Dec;59(12):1690–7.
- 25. Okada K, Ohshima S, Isobe S, Harada K, Hirashiki A, Funahashi H, et al. Epicardial fat volume correlates with severity of coronary artery disease in nonobese patients. J Cardiovasc Med (Hagerstown). 2014 May;15(5):384–90.
- 26. Giles JT, Allison M, Blumenthal RS, Post W, Gelber AC, Petri M, et al. Abdominal adiposity in rheumatoid arthritis: association with cardiometabolic risk factors and disease characteristics. Arthritis Rheum. 2010 Nov;62(11):3173–82.
- 27. Oikawa M, Owada T, Yamauchi H, Misaka T, Machii H, Yamaki T, et al. Epicardial adipose tissue reflects the presence of coronary artery disease: comparison with abdominal visceral adipose tissue. Biomed Res Int. 2015;2015:483982.
- 28. Amigues I, Tugcu A, Russo C, Giles JT, Morgenstein R, Zartoshti A, et al. Myocardial Inflammation, Measured Using 18-Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography (FDG PET-CT) is Associated with Disease Activity in Rheumatoid Arthritis. Arthritis Rheumatol. 2018;
- 29. Kalinkovich A, Gabdulina G, Livshits G. Autoimmunity, inflammation, and dysbiosis mutually govern the transition from the preclinical to the clinical stage of rheumatoid arthritis. Immunol Res. 2018 Nov;
- 30. Taguchi R, Takasu J, Itani Y, Yamamoto R, Yokoyama K, Watanabe S, et al. Pericardial fat accumulation in men as a risk factor for coronary artery disease. Atherosclerosis. 2001 Jul;157(1):203–9.
- 31. Iacobellis G, Ribaudo MC, Zappaterreno A, Iannucci CV, Leonetti F. Relation between epicardial adipose tissue and left ventricular mass. Am J Cardiol. 2004 Oct;94(8):1084–7.
- 32. Iacobellis G, Assael F, Ribaudo MC, Zappaterreno A, Alessi G, Di Mario U, et al. Epicardial fat from echocardiography: a new method for visceral adipose tissue prediction. Obes Res. 2003 Feb;11(2):304–10.
- 33. Iacobellis G, Ribaudo MC, Assael F, Vecci E, Tiberti C, Zappaterreno A, et al. Echocardiographic epicardial adipose tissue is related to anthropometric and clinical parameters of metabolic syndrome: a new indicator of cardiovascular risk. J Clin Endocrinol Metab. 2003 Nov;88(11):5163–8.
- 34. Abbara S, Desai JC, Cury RC, Butler J, Nieman K, Reddy V. Mapping epicardial fat with multi-detector computed tomography to facilitate percutaneous transepicardial arrhythmia ablation. Eur J Radiol. 2006 Mar;57(3):417–22.
- 35. Kessels K, Cramer M-JM, Velthuis B. Epicardial adipose tissue imaged by magnetic resonance imaging: an important risk marker of cardiovascular disease. Heart. 2006 Jul;92(7):962.
- 36. Wallberg-Jonsson S, Ohman ML, Dahlqvist SR. Cardiovascular morbidity and mortality in patients with seropositive rheumatoid arthritis in Northern Sweden. J Rheumatol. 1997 Mar;24(3):445–51.
- 37. O’Neill TW, McCabe PS, McBeth J. Update on the epidemiology, risk factors and disease outcomes of osteoarthritis. Best Pract Res Clin Rheumatol [Internet]. 2018;(xxxx). Available from: https://doi.org/10.1016/j.berh.2018.10.005
- 38. Oyama N, Goto D, Ito YM, Ishimori N, Mimura R, Furumoto T, et al. Single-slice epicardial fat area measurement: do we need to measure the total epicardial fat volume? Jpn J Radiol. 2011 Feb;29(2):104–9.
- 39. Kiris A, Kiris G, Turan OE, Ozturk M, Sahin M, Ilter A, et al. Relationship between epicardial fat tissue and left ventricular synchronicity: An observational study. Anatol J Cardiol. 2015;15(12):990–4.
- 40. Watanabe K, Kishino T, Sano J, Ariga T, Okuyama S, Mori H, et al. Relationship between epicardial adipose tissue thickness and early impairment of left ventricular systolic function in patients with preserved ejection fraction. Heart Vessels. 2016 Jun;31(6):1010–5.
- 41. Cui X, Li Y, Liu J, He S, Liu M. Aortic arch atheroma and the risk of stroke: a meta-analysis. J Evid Based Med. 2014 Aug;7(3):185–91.
- 42. Lee R, Kim J, Paeng JC, Byun JW, Cheon GJ, Lee DS, et al. Measurement of (68)Ga-DOTATOC Uptake in the Thoracic Aorta and Its Correlation with Cardiovascular Risk. Nucl Med Mol Imaging (2010). 2018 Aug;52(4):279–86.
- 43. Nguyen-Thu H, Ohyama Y, Taketomi-Takahashi A, Nguyen-Cong T, Sugimoto A, Sato M, et al. Association of Aortic Arch Width Assessed by Noncontrast Cardiac Computed Tomography with Cardiac Remodeling, Cardiac Function, and Atherosclerosis in a Japanese Cohort. J Thorac Imaging. 2018;33(4):240–5.
- 44. Canga A, Kocaman SA, Cetin M, Erdogan T, Durakoglugil ME, Cicek Y, et al. Increased epicardial adipose tissue thickness is correlated with ascending aortic diameter. Tohoku J Exp Med. 2012 Mar;226(3):183–90.
There are 44 citations in total.
Details
| Primary Language | English |
|---|---|
| Subjects | Health Care Administration |
| Journal Section | Medical Science Research Articles |
| Authors | |
| Publication Date | September 30, 2019 |
| Acceptance Date | September 2, 2019 |
| Published in Issue | Year 2019Volume: 41 Issue: 3 |