• Users Online: 239
  • Home
  • Print this page
  • Email this page
Home Current issue Archives Ahead of print Search Subscribe Instructions Submit article About us Editorial board Contacts Login 

 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 39  |  Issue : 3  |  Page : 127-132

Disordered eating behaviors among adolescent patients with type I diabetes mellitus


Department of Psychiatry, Faculty of Medicine, Cairo University, Cairo, Egypt

Date of Submission31-Oct-2017
Date of Acceptance27-Nov-2017
Date of Web Publication11-Oct-2018

Correspondence Address:
Nagwan M Madbouly
Department of Psychiatry, Faculty of Medicine, Cairo University, 7 New Club Street, New Maadi, Cairo, 11965
Egypt
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejpsy.ejpsy_41_17

Rights and Permissions
  Abstract 


Background Clinical and subclinical eating disorders (EDs) are common in adolescents with type I diabetes. Diabetes is associated with a high prevalence of risk factors for EDs such as high BMI, depression, low self-esteem, and anxiety.
Aim This work aimed to study the prevalence of abnormal eating behaviors in adolescent patients with type I diabetes mellitus, and its association with depressive and anxiety symptoms.
Patients and methods Seventy-five patients were recruited from the Endocrinology and Diabetes Clinic at Kasr Al Ainy Hospital. Eating Disorders Examination Questionnaire and Diabetes Eating Problem Survey were used to screen for abnormal eating behaviors. The diagnosis was checked using the criteria for EDs according to the fifth ed. of the Diagnostic and Statistical Manual of Mental Disorders. Subsequent assessments for depression and anxiety were performed using the Hamilton Depression Rating Scale and the Hamilton Anxiety Rating Scale, respectively.
Results Disordered eating behaviors (DEB) were found in 34.7% of the study group; all were diagnosed with EDs not otherwise specified. Fifty percent of the participants had depressive symptoms and 54% had anxiety symptoms.
Conclusion DEBs were found in adolescent patients with type I diabetes. Depression and anxiety were found in nearly half of the patients with DEBs.

Keywords: anxiety, depression, eating disorders, type I diabetes


How to cite this article:
El-Bakry AA, Mahmoud AA, Kamal AM, Madbouly NM, Ayoub DR, Kamel RM. Disordered eating behaviors among adolescent patients with type I diabetes mellitus. Egypt J Psychiatr 2018;39:127-32

How to cite this URL:
El-Bakry AA, Mahmoud AA, Kamal AM, Madbouly NM, Ayoub DR, Kamel RM. Disordered eating behaviors among adolescent patients with type I diabetes mellitus. Egypt J Psychiatr [serial online] 2018 [cited 2018 Dec 12];39:127-32. Available from: http://new.ejpsy.eg.net/text.asp?2018/39/3/127/243027




  Introduction Top


The prevalence of diabetes in some Eastern Mediterranean countries is among the highest in the world and is expected to increase rapidly in the coming decades (Majeed et al., 2014).

Clinical, subclinical eating disorders (EDs), and abnormal eating behaviors are common in adolescents with type I diabetes. Impulse control disorders (EDs in particular) were associated significantly with a diagnosis of diabetes after comorbidity adjustment (De Jonge et al., 2014). Diabetes has been associated with a higher prevalence of risk factors for the emergence of ED, such as high BMI, depression, low self-esteem (Markowitz et al., 2010; Koyuncuoğlu Güngör, 2014), and anxiety, in particular, obsessive–compulsive symptoms (Urbanski et al., 2009). Psychological factors may adversely influence the efforts to optimize glycemic control (Shaban, 2015).

Disordered eating behaviors (DEB) are defined as the presence of any of the following in the past month: objective binge eating; self-induced vomiting for weight control; the use of diuretics, laxatives, or insulin omission for weight control; or intense and excessive exercise for weight control (defined as >30 min/day, predominantly for weight control, and not for fitness or leisure) (Peyrot et al., 2010; Larrañaga et al., 2011).

Many diabetics face a constant struggle with their weight when controlling diabetes with insulin injections as insulin encourages fat storage. Thus, many patients with type I diabetes have discovered the relationship between reducing the amount of insulin that they take and their corresponding weight loss (Larrañaga et al., 2011). As weight management during this state of development can be especially difficult, some diabetics may restrict or omit insulin, a condition known as diabulimia, as a form of weight control (Pinhas-Hamiel and Levy-Shraga, 2013). Disturbance of eating habits and subthreshold eating problems can cause clinically important disturbances of self-care and glycemic control in diabetics (2010).

It is hypothesized that the prevalence of abnormal eating behaviors is higher in patients with uncontrolled diabetes than in patients with proper diabetes control. The aim of this work is to (a) study the prevalence of DEBs and the factors associated with their presence among adolescent patients with type I diabetes mellitus and (b) assess the presence of anxiety and depressive symptoms in these patients.


  Patients and methods Top


This was a cross sectional study that was carried over a period of 3 months (from 15 September 2014 to 15 December 2014). Patients were recruited from the outpatient Endocrinology and Diabetes Clinic at Kasr Al Ainy Hospital, Cairo University, on 3 specific days of the week. According to our selection criteria, adolescents (aged 14–18 years), who had a diagnosis of type I diabetes established by a diabetologist, were included during this period. Patients who had a current or a previous history of any medical or psychiatric illnesses were excluded to avoid the effect of other disorders on the results. The study was approved by the Scientific and Ethical Committees of the Psychiatry Department, Faculty of Medicine, Cairo University.

After obtaining an informed written consent from each participant and an informed written consent from the parent, the adolescents were screened for the presence of DEBs using the Eating Disorder Examination Questionnaire (version 6) (EDE-Q6.0) (Fairburn and Beglin, 1994). This is a 28-item questionnaire that consists of four subscales (restrain subscale, eating concern subscale, weight concern subscale, and shape concern subscale), with their global score obtained by averaging their means, a binge ED module, and items assessing some behavioral features of EDs such as vomiting, laxative use, and exercise that may affect patients with diabetes. Then, the Diabetes Eating Problem Survey (DEPS-R) (Markowitz et al., 2010) was conducted. This is a self-report screening measure for DEBs, insulin restriction, and omissions. Those scoring more than 20 are at a higher risk for insulin omission and disturbed eating behaviors. Permissions from Professor Fairburn and Dr Markowitz were obtained to translate the EDE-Q6.0 and DEPS-R, respectively, into Arabic for use in Egypt for this study. Both questionnaires were translated into Arabic and then back translated into English by the senior staff (with ≥15 years of experience) at the Psychiatry Department, Faculty of Medicine, Cairo University (El Bakry et al., 2014). Those who scored above 20 for DEPS-R and had high scores for EDE-Q6.0 were assessed by the Kasr Al Ainy semistructured psychiatric interview and were diagnosed according to DSM-5 criteria for EDs. The Hamilton Depression Rating Scale (Hamilton, 1967), Arabic version (Fatim, 1994a), and the Hamilton Anxiety Rating Scale (HAM-A) (Hamilton, 1969), Arabic version (Fatim, 1994b), were used to assess the severity of depression and anxiety, respectively, in affected individuals.

Additional information on diabetes medical history was collected from patients’ files such as the duration of illness, height, and weight to calculate the BMI, family history of diabetes, complications of diabetes, history of previous hospital admissions related to diabetes, hemoglobin A1c (HbA1c) level, and episodes of diabetic ketoacidosis (DKA). Proper diabetic control was defined as HbA1c less than 7.5 mmol/l.

Statistical analysis

Statistics were calculated using the SPSS 17 package (SPSS Inc., Chicago, Illinois, USA). Numerical variables were described as mean±SD, number, and percentages. Comparisons were performed using Student’s t-test for numerical variables and the χ2-test for categorical variables. Spearman correlation (r) was used to study the correlation between numerical variables. P value was considered significant if less than 0.05.


  Results Top


Participant characteristics

Seventy-five adolescents with type I diabetes mellitus fulfilled our selection criteria; 57% (n=43) were females and 43% (n=32) were males. 61.3% (n=46) of the sample were from urban areas. 97.3% (n=73) had completed at least 6 years of formal education. The demographic and clinical characteristics of the sample are shown in [Table 1].
Table 1 Demographic and clinical characteristics of the sample

Click here to view


Results of the screening questionnaires showed that 26 (34.7%) patients scored more than 20 (cut-off score) on the DEPS-R, with average mean 26.0±14.8. These patients also had significantly high scores on the EDE-Q6.0 (including the global score and all its four subscales). Moreover, they had the highest mean value for the weight concern subscale (3.3±1.5) ([Table 2]). For the additional items of the EDE-Q, patients with EDs (n=26) reported binge eating (n=14, 0.3±1.0), vomiting (n=12, 0.2±0.4), laxative abuse (n=8, 0.1±0.3), and exercising activities (n=6, 0.1±0.3) compared with those with non-EDs, who did not report on any of the above additional items.
Table 2 Scores of eating questionnaires in patients with and without eating disorders

Click here to view


None of the patients with EDs fulfilled a specific DSM-5 EDs criterion; they were diagnosed as having ED otherwise specified. 53.8% (n=14) fulfilled the diagnosis of binge eating of low frequency type, 27% (n=7) fulfilled the diagnosis of bulimia low frequency type, and 19.2% (n=5) fulfilled the clinical diagnosis of atypical anorexia nervosa.

Most patients (96.2%, n=25) with EDs were females. Patients with EDs had significantly higher BMI and HbA1c levels than patients with non-ED. 73.1% of patients with EDs had a previous history of DKA ([Table 1]).

Prevalence of depression and anxiety in participants with eating disorders

Fifty percent (n=13) of the patients with EDs showed depression on the Hamilton Depression Rating Scale; 46% (n=6) of these patients had moderate severity of depression. 54% (n=14) of patients with EDs showed anxiety on HAM-A; 57% (n=8) of these patients had mild anxiety ([Figure 1]).
Figure 1 Percentage of participants with depression and anxiety assessed by Hamilton Depression Rating Scale (HDRS) and Hamilton Anxiety Rating Scale (HAM-A), respectively.

Click here to view


There was a positive correlation between the severity of anxiety measured by HAM-A and the binge ED module of the EDE-Q6.0 (P=0.028, r=0.431).


  Discussion Top


This study showed that 34.7% of the adolescent participants with type I diabetes mellitus had EDs otherwise specified. This was in agreement with Nasser (1986) in his comparative study of the prevalence of abnormal eating attitudes among Arab students of both London and Cairo Universities; only partial syndromes were found. This result was also consistent with the studies of Okasha and Mahmoud (1998) and Fawzi et al. (2010), who reported more atypical cases of EDs than typical ones.

However, our findings were in contrast with the study of Ackard et al. (2008), who found that diabetics reported higher satisfaction with their weight and lower rates of abnormal eating behaviors than the healthy controls. Nevertheless, the difference between both results could be explained by the different setting of the Ackard et al. (2008) study as the participants in their study were treated regularly at a clinic and had better metabolic control as indicated by their lower HbA1c level.

In this study, we used two eating questionnaires: DEPS-R and EDE-Q6.0. DEPS-R had the advantage of having a clear cut-off score (>20), thus enabling differentiation of patients at high risk for insulin omission and disturbed eating behaviors. The EDE-Q was widely considered the gold standard for the assessment of ED psychopathology as it was designed to assess the full range of the specific psychopathology of EDs. In addition, EDE-Q6.0 was considered more suitable for diabetic patients as it avoided questions on restriction of carbohydrates, which was a part of their diet regimen to control diabetes. The 26 patients, who scored more than 20 on DEPS-R, also showed a high mean score on the global score of EDE-Q6.0 (2.6±1.3), with the highest mean score on the weight concern subscale (3.3±1.5). These findings showed a highly statistically significant difference between patients with and those without EDs. Furthermore, the diagnoses of these patients fulfilled the DSM-5 criteria for EDs. This reflected the high concordance of clinical diagnoses according to DSM-5 criteria and the EDs questionnaires used in the study.

Females constituted 96.2% of the disordered eating group of patients (n=26) in our study. This was consistent with the studies of Bryden et al. (1999), Sztainer et al. (2002), Grylli et al. (2004), and Peveler et al. (2005). Although the Egyptian society used to accept large female sizes and chubbiness as a sign of beauty, the emergence of abnormal eating behaviors could be explained by the increasing effect of rapid social changes and acculturation (Fawzi et al., 2010).

In the present study, patients with EDs tended to have higher BMI than those without EDs, with a highly statistically significant difference (P<0.001). This is in agreement with other studies; Meltzer et al. (2001), Sztainer et al. (2002), and Svenssom et al. (2003) found that diabetic adolescent females, with greater BMIs, were likely to be less satisfied with their bodies and wished to lose weight. In this study, the increased incidence of EDs in type I diabetes could be explained by the occurrence of weight gain following insulin treatment. This weight gain caused body dissatisfaction, which in turn raised concern about weight control in adolescent patients with diabetes. Further longitudinal studies are needed to adequately confirm this finding.

Patients with EDs had poorer control of their diabetes than those without EDs as they had statistically significantly higher values of HbA1c levels (P=0.011). This was in agreement with Reyna et al. (2003), who found that glycosylated hemoglobin values were higher in diabetic patients with EDs than in those without EDs. Moreover, patients with EDs had a statistically higher incidence of DKA than those without EDs. The above two findings in the current study have a direct clinical implication. Patients with EDs reported to us that they used to omit some insulin doses as they discovered after some time of their illness that high insulin doses were causing weight gain. This was supported by the insignificant difference between the patients with eating and non-EDs in terms of their usual insulin dose (P=0.72).

In terms of the presence of complications, unexpectedly, we found no statistically significant difference between patients with EDs and those without EDs. This could be explained by the poor level of education in our study sample and the consequent lack of education of the onset of early signs of complications. Moreover, the medical insurance in Egypt provides insulin free of cost, whereas most of the physicians treating the patients were general practitioners and not specialized endocrinologists. Thus, early signs of complications might have been missed as most of our patients did not regularly attend follow-up in Kasr Al Ainy clinics because of the distance and costs of travel. However, a European study reported that 86% of those with EDs showed evidence of retinal damage compared with 24% of those with diabetes alone (Nielsen, 2002).

Patients with EDs showed no statistically significant difference in regularity of follow-up, duration of diabetes, or insulin regimen compared with patients without EDs. This was in agreement with Tse et al. (2012), who used DEPS-R for the assessment of psychopathological EDs and insulin omission. Their study concluded that the risk group was not associated significantly with age, sex, duration of diabetes, or insulin regimen. They claimed that adolescent diabetic patients with EDs often missed their medical appointments to avoid being prescribed higher insulin doses, which might lead to more weight gain.

In terms of insulin dosage, there was no statistical significance between patients with EDs and those without EDs. This might be explained by two reasons: (a) the clinicians’ fear of hypoglycemia that might occur when reaching optimal doses as patients intentionally restricted food intake to control their weight; (b) the patients’ poor regularity on follow-up visits hindered adjusting the proper insulin dose.

The results of Hamilton scales for depression and anxiety showed that adolescent patients with EDs commonly suffer from depressive and anxiety symptoms (50 and 54%, respectively). Olmsted et al. (2008) found that depression was associated significantly with the onset of DEB in adolescent girls with type I diabetes. In addition, in a 5-year cohort study carried out by Colton et al. (2013), it was found that 12.2% of girls reported depressive symptoms, 49% reported DEB, and 13.3% had a full or a subthreshold ED. 75% of girls with current depressive symptoms had current DEB or ED compared with 45.3% of girls with no current depressive symptoms. However, their study found a weak association of depression and DEB with metabolic control in the adolescent girls. In contrast to the findings in adult populations, a moderate to strong association was usually supported between metabolic control and both DEB and depression.

This study highlighted a special association between binge eating behavior and anxiety. This was similar to the study carried out by Touchette et al. (2011), who concluded that girls with subclinical bulimia nervosa or binge ED reported significantly more anxiety symptoms (separation anxiety and generalized anxiety) compared with girls reporting no EDs.

Unexpectedly, our study did not find an association between depression in adolescent patients with EDs and the scores of the eating questionnaires. The relatively small number of patients with EDs could possibly be a limitation.

Clinical implication

It is recommended that adolescents with diabetes, who have clinical or subclinical EDs, should be investigated concomitantly for mood and anxiety disorders, whereas those with mood and anxiety disorders should be investigated simultaneously for EDs. Early psychiatric assessment of adolescent female patients with diabetes and adequate intervention may prevent further development of any ED during adulthood.


  Conclusion Top


Considerable number of adolescent patients, especially females, with type I diabetes were at risk for EDs and abnormal eating behaviors. A significant association was found between EDs and (HbA1C levels, BMI, and DKA). Depression and anxiety were common in patients with EDs. Adolescent diabetic patients with binge eating were likely to suffer from anxiety.

Limitations

The number of patients with EDs was relatively small to enable further subgrouping. Only DEPS-R and EDE-Q positives were interviewed (those who scored at or above 20 or had behavioral symptoms) and this might underestimate the presence of eating pathology among those who did not achieve the cut-off score. This was a cross sectional study; thus, it lacked the follow-up or longitudinal dimension to test the significance of the results over time.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ackard D, Vik N, Neumark-Sztainer D, Schmitz K, Hannan P, Jacobs D Jr (2008). Disordered eating and body dissatisfaction in adolescents with type I diabetes and a population-based comparison sample: comparative prevalence and clinical implications. Pedia Diabetes 9:312–319.  Back to cited text no. 1
    
2.
Bryden K, Neil A, Mayou R, Peveler R, Fairburn C, Dunger D (1999). Eating habits, body weight, and insulin misuse. Diabetes Care 22:1956–1960.  Back to cited text no. 2
    
3.
Colton PA, Olmsted MP, Daneman D, Rodin GM (2013). Depression, disturbed eating behavior, and metabolic control in teenage girls with type I diabetes. Pediatr Diabetes 14:372–376.  Back to cited text no. 3
    
4.
De Jonge P, Alonso J, Stein DJ, Kiejna A, Aguilar-Gaxiola S, Viana MC, Lepine JP (2014). Associations between DSM-IV mental disorders and diabetes mellitus: a role for impulse control disorders and depression. Diabetologia 57:699–709.  Back to cited text no. 4
    
5.
El Bakry A, Madbouly N, Eltabie D, Adel N, Kamel R (2014). Translation and back translation of the EDE-Q 6.0 and DEPS-R questionnaires to Arabic. 2014; unpublished master thesis. Cairo University.  Back to cited text no. 5
    
6.
Fairburn C, Beglin S (1994). Assessment of eating disorder psychopathology: interview or self-report questionnaire?. Int J Eat Disord 16:363–370.  Back to cited text no. 6
    
7.
Fatim L (1994a). Hamilton checklist of symptoms of depressive illness (Arabic version). Cairo, Egypt; Egypt. Anglo Library.  Back to cited text no. 7
    
8.
Fatim L (1994b). Hamilton checklist of anxiety (Arabic version). Cairo, Egypt; Egypt. Anglo Library.  Back to cited text no. 8
    
9.
Fawzi M, Haitham M, Hashim M, Fouad A, Abdel-Fattah N (2010). Prevalence of eating disorders in a sample of rural and urban secondary school-girls in Sharkia, Egypt. Curr Psychol J 17:1–12.  Back to cited text no. 9
    
10.
Figueroa S, Evangelista P, Mazza C (2010). Three-year follow-up of metabolic control in adolescents with type I diabetes with and without eating disorders. Arch Argent Pediatr 108:130–135.  Back to cited text no. 10
    
11.
Grylli V, Hafferl-Gattermayer A, Schober E, Karwautz A (2004). Prevalence and clinical manifestations of eating disorders in Austrian adolescents with type I diabetes. Wien Klin Wochenschr 116:230–234.  Back to cited text no. 11
    
12.
Hamilton M (1967). Development of a rating scale for primary depressive illness. Br J Soc Clin Psychol 6:278–296.  Back to cited text no. 12
    
13.
Hamilton M (1969). Diagnosis and rating of anxiety. Br J Psychiatr 3:76–79.  Back to cited text no. 13
    
14.
Koyuncuoğlu Güngör N (2014). Overweight and obesity in children and adolescents. J Clin Res Pediatr Endocrinol 6:129–143.  Back to cited text no. 14
    
15.
Larrañaga A, Docet MF, García-Mayor RV (2011). Disordered eating behaviors in type 1 diabetic patients. World J Diabetes 2:189–195.  Back to cited text no. 15
    
16.
Majeed A, El-Sayed AA, Khoja T, Alshamsan R, Millett C, Rawaf S (2014). Diabetes in the Middle-East and North Africa: an update. Diabetes Res Clin Pract 103:218–222.  Back to cited text no. 16
    
17.
Markowitz J, Butler D, Volkening L, Jeanne E, Antisdel JE, Anderson BJ, Laffel LM (2010). Brief screening tool for disordered eating in diabetes. Internal consistency and external validity in a contemporary sample of pediatric patients with type I diabetes. Diabetes Care 33: 495–500.  Back to cited text no. 17
    
18.
Meltzer L, Johnson S, Prine J, Banks R, Desrosiers P, Silverstein J (2001). Disordered eating, body mass, and glycemic control in adolescents with type I diabetes. Diabetes Care 24:678–682.  Back to cited text no. 18
    
19.
Nasser M (1986). Comparative study of the prevalence of abnormal eating attitudes among Arab female students of both London and Cairo universities. Psychol Med 16:621–625.  Back to cited text no. 19
    
20.
Nielsen S (2002). Eating disorders in females with type I diabetes: an update of a meta-analysis. Eur Eat Disord Rev 10:241–254.  Back to cited text no. 20
    
21.
Okasha A, Mahmoud S (1998). Prevalence of eating disorders among female students. Psych. Clin Neurosci 2:S129–S133.  Back to cited text no. 21
    
22.
Olmsted MP, Colton PA, Daneman D, Rydall AC, Rodin GM (2008). Prediction of the onset of disturbed eating behavior in adolescent girls with type 1 diabetes. Diabetes Care 31:1978–1982.  Back to cited text no. 22
    
23.
Peveler R, Bryden K, Andrew H, Fairburn C, Dunger D, Turner H (2005). The relationship of disordered eating habits and attitudes to clinical outcomes in young adult females with type I diabetes. Diabetes Care 28:84–88.  Back to cited text no. 23
    
24.
Peyrot M, Rubin RR, Kruger DF, Travis LB (2010). Correlates of insulin injection omission. Diabetes Care 33:240–245.  Back to cited text no. 24
    
25.
Pinhas-Hamiel O, Levy-Shraga Y (2013). Eating disorders in adolescents with type 2 and type 1 diabetes. Curr Diab Rep 13:289–297.  Back to cited text no. 25
    
26.
Reyna G, Gussinyer N, Gussinyer S, Raich M, Carrascosa A (2003). Eating disorders in 12 to 16-year-old diabetic and non-diabetic adolescents from Barcelona. Diabetes Care 26:2695.  Back to cited text no. 26
    
27.
Shaban C (2015). Psychological themes that influence self-management of type 1 diabetes. World J Diabetes 6:621–625.  Back to cited text no. 27
    
28.
Svenssom M, Engstromi I, Aman J (2003). Higher drive for thinness in adolescent males with insulin-dependent diabetes mellitus compared with healthy controls. Acta Paediatr 92:114–117.  Back to cited text no. 28
    
29.
Sztainer DN, Patterson J, Mellin A, Ackard D, Utter J, Story M, Sockalosky J (2002). Weight control practices and disordered eating behaviors among adolescent females and males with type 1 diabetes: associations with socio-demographics, weight concerns, familial factors, and metabolic outcomes. Diabetes Care 25:1289–1296.  Back to cited text no. 29
    
30.
Touchette E, Henegar A, Godart N, Falissard B, Tremblay R, Cote S (2011). Subclinical eating disorders and their comorbidity with mood and anxiety disorders in adolescent girls. Psychiatry Res 30:185–192.  Back to cited text no. 30
    
31.
Tse J, Nansel T, Haynie D, Mehta S, Laffel MP (2012). Disordered eating behaviors are associated with poorer diet quality in adolescents with type I diabetes. J Acad Nutr Diet 112:1810–1814.  Back to cited text no. 31
    
32.
Urbanski P, Goebel-Fabbri A, Powers M, Taylor D (2009). Diabetes educators role in managing eating disorders and diabetes. Diabetes Spec 22:159–162.  Back to cited text no. 32
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Patients and methods
Results
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed176    
    Printed1    
    Emailed0    
    PDF Downloaded21    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]