The Open Cardiovascular Medicine Journal




ISSN: 1874-1924 ― Volume 14, 2020
RESEARCH ARTICLE

The Relationship between the Risks of Developing Type 2 Diabetes Mellitus and Cardiovascular Diseases



Carlos Sotomayor-Beltran1, *, Rosa Perez-Siguas2, Eduardo Matta-Solis3, Hernan Matta-Solis1, 2, 3
1 Facultad de Ciencias de la Salud, Universidad de Ciencias y Humanidades, Lima, Peru
2 Facultad de Ciencias de la Salud, Universidad María Auxiliadora, Lima, Peru
3 Facultad de Ciencias de la Salud, Universidad Privada Norbert Wiener, Lima, Peru

Abstract

Background:

Type 2 Diabetes Mellitus (T2DM) has significantly increased in the past decades due to changes in lifestyles. This chronic disease is expected to be ranked in the seventh position by the year 2030 among the 15 leading causes of death. Poorly treated T2DM can be an important risk factor for cardiovascular diseases as well (CVD).

Objective:

We have sought to determine a relationship between the risks of developing T2DM and CVD in a healthcare facility in the district of Breña (Lima, Peru).

Methods:

The Finnish Diabetes Risk Score survey and the Pan American Health Organization risk calculator were used on a sample of 150 patients. The inclusion criteria were: patient age 40-80 years, attended their medical appointment more than once, were overweight or showed cholesterol levels above normal values and lived within the catchment area of the healthcare center where the study was carried out.

Results:

Only 8.7% of our sample was at a low risk of developing T2DM, whereas the rest was at a slightly elevated, moderate and high risk. Additionally, 79.3% of the patients were at low risk of developing CVD. Using the Fisher’s Exact test, there was a significant difference (p=0.026) between the risk grading of developing T2DM and CVD.

Conclusion:

The risk of developing CVD in our population is expected to rise in the future due to the already observed high risk of developing T2DM. It is hoped that this work serves Peruvian (and other) health authorities to bolster their prevention programs, especially focusing on lifestyle interventions (e.g. increased physical activity), which have proven to be successful and economical.

Keywords: Type 2 Diabetes Mellitus, Cardiovascular disease, Healthcare facilities, Lifestyle, Interventions, Developing.


Article Information


Identifiers and Pagination:

Year: 2020
Volume: 14
First Page: 13
Last Page: 17
Publisher Id: TOCMJ-14-13
DOI: 10.2174/18741924020140100013

Article History:

Received Date: 21/01/2020
Acceptance Date: 21/03/2020
Electronic publication date: 04/06/2020
Collection year: 2020

© 2020 Sotomayor-Beltran et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: (https://creativecommons.org/licenses/by/4.0/legalcode). This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Facultad de Ciencias de la Salud, Universidad de Ciencias y Humanidades, Lima, Peru, Tel: +51 17151533; E-mail: csotomayor@uch.edu.pe





1. INTRODUCTION

In the past decades, changes in lifestyles globally have brought about the propagation of some chronic diseases like Type 2 Diabetes Mellitus (T2DM), which in the past mainly affected adults but nowadays is also increasingly seen in children [1World Health Organization. https://www.who.int/news-room/fact-sheets/detail/diabetes, 2Dabelea D, Mayer-Davis EJ, Saydah S, et al. SEARCH for Diabetes in Youth Study. Prevalence of type 1 and type 2 diabetes among children and adolescents from 2001 to 2009. JAMA 2014; 311(17): 1778-86.
[http://dx.doi.org/10.1001/jama.2014.3201] [PMID: 24794371]
]. Some of the risk factors for developing T2DM are overweight, age, family history of T2DM and a sedentary lifestyle [3Centers for Disease Control and Prevention. https://www.cdc.gov/diabetes/basics/risk-factors.html].

Several studies have demonstrated that people of low socioeconomic status and with T2DM are more likely to suffer higher mortality rates [4Connolly V, Unwin N, Sherriff P, Bilous R, Kelly W. Diabetes prevalence and socioeconomic status: a population based study showing increased prevalence of type 2 diabetes mellitus in deprived areas. J Epidemiol Community Health 2000; 54(3): 173-7.
[http://dx.doi.org/10.1136/jech.54.3.173] [PMID: 10746110]
-7Dalsgaard EM, Skriver MV, Sandbaek A, Vestergaard M. Socioeconomic position, type 2 diabetes and long-term risk of death. PLoS One 2015; 10(5)e0124829
[http://dx.doi.org/10.1371/journal.pone.0124829] [PMID: 25942435]
]. Moreover, T2DM is more widespread in developing countries, because their health infrastructures do not have enough resources to prevent this kind of chronic disease [7Dalsgaard EM, Skriver MV, Sandbaek A, Vestergaard M. Socioeconomic position, type 2 diabetes and long-term risk of death. PLoS One 2015; 10(5)e0124829
[http://dx.doi.org/10.1371/journal.pone.0124829] [PMID: 25942435]
]. Moreover, a study has indicated that diabetes mellitus, which was ranked in the 11th position in 2002 among the 15 leading causes of death, will be ranked in the 7th position by the year 2030 [8Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med 2006; 3(11)e442
[http://dx.doi.org/10.1371/journal.pmed.0030442] [PMID: 17132052]
]. In 2017, the International Diabetes Federation (IDF) indicated that this disease affected 425 million people globally and it is predicted that by the year 2045, it will affect 629 million people [9Noh JW, Chang Y, Park M, Kwon YD, Ryu S. Self-rated health and the risk of incident type 2 diabetes mellitus: A cohort study. Sci Rep 2019; 9(1): 3697.
[http://dx.doi.org/10.1038/s41598-019-40090-y] [PMID: 30842537]
].

Cardiovascular (CV) diseases (CVD) are the number one cause of deaths among people with T2DM [10Fetit AE, Doney AS, Hogg S, et al. A multimodal approach to cardiovascular risk stratification in patients with type 2 diabetes incorporating retinal, genomic and clinical features. Sci Rep 2019; 9(1): 3591.
[http://dx.doi.org/10.1038/s41598-019-40403-1] [PMID: 30837638]
]. Badly handled, T2DM can lead to CV complications and, in many cases, to high mortality rates [11Massey CN, Feig EH, Duque-Serrano L, Wexler D, Moskowitz JT, Huffman JC. Well-being interventions for individuals with diabetes: A systematic review. Diabetes Res Clin Pract 2019; 147: 118-33.
[http://dx.doi.org/10.1016/j.diabres.2018.11.014] [PMID: 30500545]
]. People with T2DM are at 2-4 times higher risk of CV events than those who do not have T2DM [12Chowdhury MZI, Yeasmin F, Rabi DM, Ronksley PE, Turin TC. Prognostic tools for cardiovascular disease in patients with type 2 diabetes: A systematic review and meta-analysis of C-statistics. J Diabetes Complications 2019; 33(1): 98-111.
[http://dx.doi.org/10.1016/j.jdiacomp.2018.10.010] [PMID: 30446478]
].

The National Institute of Health (in Spanish: Instituto Nacional de Salud; INS), in Peru, has defined 11 public health crises to be of high priority for research between the years 2016-2021 [13Instituto Nacional de Salud. https://web.ins.gob.pe/sites/default/files/Archivos/ogitt/prioridades/5a%20Prioridades%20Nacionales%20de%20Investigaci]. Among these is diabetes mellitus. In the capital of Peru, Lima, it has been reported that the prevalence of diabetes has significantly increased from 4.4% in 2004 to 8.4% in 2011 [14Seclen SN, Rosas ME, Arias AJ, Huayta E, Medina CA. Prevalence of diabetes and impaired fasting glucose in Peru: report from PERUDIAB, a national urban population-based longitudinal study. BMJ Open Diabetes Res Care 2015; 3(1)e000110
[http://dx.doi.org/10.1136/bmjdrc-2015-000110] [PMID: 26512325]
]. Furthermore, a recent study has indicated that Peru has become one of the countries with highest incidence of diabetes worldwide [15Seclen SN, Rosas ME, Arias AJ, Medina CA. Elevated incidence rates of diabetes in Peru: report from PERUDIAB, a national urban population-based longitudinal study. BMJ Open Diabetes Res Care 2017; 5(1)e000401
[http://dx.doi.org/10.1136/bmjdrc-2017-000401] [PMID: 28878935]
].

The present study attempts to assess the relationship between the risks of developing T2DM and CVD in a population of patients from a healthcare facility in the district of Breña, in the Peruvian capital (Lima).

2. MATERIALS AND METHODS

A cross-sectional survey was carried out daily, during April 2019, to find out if there was a relationship between the risks of developing T2DM and CVD. The participants received help from the nurses working in a healthcare center located in Breña to complete questionnaires. It took each participantabout 10-15 min to complete the survey.

The surveyed population included 150 men and women who attend a healthcare facility located in the district of Breña. The patients who visited this center suffered from different medical conditions (e.g. upper respiratory infections, fever, headaches) related to primary care. Only individuals who reported the following criteria were considered for the survey: age 40-80 years, attended a medical appointment more than once, were overweight or showed cholesterol levels above normal values and lived within the catchment area of the healthcare center where the study was carried out.

Table 1
The Finnish Diabetes Risk Score (FINDRISC) survey [16Lindström J, Tuomilehto J. The diabetes risk score: a practical tool to predict type 2 diabetes risk. Diabetes Care 2003; 26(3): 725-31.
[http://dx.doi.org/10.2337/diacare.26.3.725] [PMID: 12610029]
].



The screening tool used to evaluate the risk of T2DM was the Finnish Diabetes Risk Score (FINDRISC) [16Lindström J, Tuomilehto J. The diabetes risk score: a practical tool to predict type 2 diabetes risk. Diabetes Care 2003; 26(3): 725-31.
[http://dx.doi.org/10.2337/diacare.26.3.725] [PMID: 12610029]
]. This questionnaire is made up of 8 questions (Table 1), which served to assess the risk of developing T2DM. FINDRISC categorizes the risk of developing T2DM, according to the total score of the 8 questions as: low, slightly elevated, moderate and high.

We measured the risk of developing CVD within the next 10 years, by using the Pan American Health Organization (PAHO) risk calculator (https://www.paho.org/ cardioapp/ web/#). Six variables are considered: gender, age, smoking habit, systolic blood pressure, diabetes and cholesterol. The risk of developing CVD is categorized as: low, moderate, high and very high.

An association between the risks of developing T2DM and CVD was performed using IBM SPSS Statistics version 24.0 software. The Fisher’s Exact test for independence, was used for this purpose.

3. RESULTS

The ages of the 150 participants was between 40 to 78 years with a mean of 52.9 years (standard deviation 8.4). Table 2 shows the other characteristics of the participants.

Table 2
Sociodemographic profile of the participants (n = 150).


Some of the compelling results from the FINDRISC survey (Table 1) is that 47 (31.3%) participants do not practice any physical activity on a daily basis. With regard to eating daily vegetables and fruits, 61 (40.7%) patients revealed that they do not eat these so frequently. Our results also show that only 22 (14.7%) participants took medications for high blood pressure on a regular basis. Regarding high blood glucose levels; only 4 (2.7%) participants showed very high levels. For the question about history of diabetes in the family, 94 (62.6%) participants responded that there was no diagnosis of diabetes among their family members; 56 participants (37.3%) stated that parents, grandparents, uncles, aunts, or cousins had diabetes.

The FINDRISC classification of our surveyed population regarding the risk of developing T2DM is shown in (Fig. 1). It can be seen that 61 (40.7%) patients are at slightly elevated risk of developing T2DM. These are followed by 46 (30.7%) patients who show a moderate risk. From the rest, 30 (20%) patients are at high risk of developing T2DM, whereas only 13 (8.7%) patients are at low risk.

Regarding the risk of developing CVD (Fig. 2), 119 (79.3%) patients were at a low risk; 24 (16%), 3 (2%) and 4 (2.7%) patients showed moderate, high and very high risk, respectively.

Fig. (1)
Risk of developing type 2 diabetes mellitus (T2DM) among the 150 surveyed patients that attended the healthcare center of the district of Breña, Lima.


Fig. (2)
Risk of developing cardiovascular diseases (CVD) among the 150 surveyed patients that attended the healthcare center in the Breña district, Lima.


We compared the risks of developing T2DM and CVD using the Fisher’s Exact test, which accounts for low frequencies in more than 20% of the cells (Table 3). There was a significant difference (p=0.026) between the risk grading of developing T2DM and CVD.

Table 3
Association of risks of developing type 2 diabetes mellitus (T2DM) and cardiovascular diseases (CVD).


4. DISCUSSION

As indicated by a study [17Medina-Verástegui LA, Camacho-Sánchez JE, Ixehuatl-Tello O. Riesgo cardiovascular en pacientes con diabetes mellitus 2. Med Int Méx 2014; 30: 270-5.], individuals with detrimental changes in their lifestyles, such as poor physical activity or increased smoking habit, can be at a greater risk of developing CVD. Likewise, a deleterious change in physical activity and other risk factors, indicated in Table 1, can increase the risk of developing T2DM in the next 10 years, as suggested by the results of this study [18Cosansu G, Celik S, Özcan S, Olgun N, Yıldırım N, Gulyuz Demir H. Determining type 2 diabetes risk factors for the adults: A community based study from Turkey. Prim Care Diabetes 2018; 12(5): 409-15.
[http://dx.doi.org/10.1016/j.pcd.2018.05.001] [PMID: 29804712]
]. Hence, due to the high risk of developing T2DM in our population, it is expected that in future, the CVD risk of this very same population will rise; this is because there is a tendency for weight gain and insulin deficiency with aging [19Assar ME, Angulo J, Rodríguez-Mañas L. Diabetes and ageing-induced vascular inflammation. J Physiol 2016; 594(8): 2125-46.
[http://dx.doi.org/10.1113/JP270841] [PMID: 26435167]
]. This suggestion goes in agreement with the fact that T2DM is a risk factor for CVD [20Einarson TR, Acs A, Ludwig C, Panton UH. Prevalence of cardiovascular disease in type 2 diabetes: a systematic literature review of scientific evidence from across the world in 2007-2017. Cardiovasc Diabetol 2018; 17(1): 83.
[http://dx.doi.org/10.1186/s12933-018-0728-6] [PMID: 29884191]
].

In order to decrease the probability that individuals at high risk will develop T2DM, prevention programs can be established during the prediabetes stage [21López-Jaramillo P, Calderón C, Castillo J, Escobar ID, Melgarejo E, Parra GA. Prediabetes in Colombia: Expert Consensus. Colomb Med 2017; 48(4): 191-203.
[PMID: 29662261]
]; these programs will also help prevent CV, as a byproduct,. Some successful programs involve lifestyle intervention and the administration of metformin and acarbose [22Chiasson JL, Josse RG, Gomis R, Hanefeld M, Karasik A, Laakso M. STOP-NIDDM Trail Research Group. Acarbose for prevention of type 2 diabetes mellitus: the STOP-NIDDM randomised trial. Lancet 2002; 359(9323): 2072-7.
[http://dx.doi.org/10.1016/S0140-6736(02)08905-5] [PMID: 12086760]
-24Lindström J, Ilanne-Parikka P, Peltonen M, et al. Finnish Diabetes Prevention Study Group. Sustained reduction in the incidence of type 2 diabetes by lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study. Lancet 2006; 368(9548): 1673-9.
[http://dx.doi.org/10.1016/S0140-6736(06)69701-8] [PMID: 17098085]
], both of which are antidiabetic drugs. Among the aforementioned measures, lifestyle intervention has proven to be the most beneficial for patients with risk of developing T2DM. This can be implemented through campaigns that set weight loss goals, increase physical activity and promote the reduction of the intake of total and saturated fats [24Lindström J, Ilanne-Parikka P, Peltonen M, et al. Finnish Diabetes Prevention Study Group. Sustained reduction in the incidence of type 2 diabetes by lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study. Lancet 2006; 368(9548): 1673-9.
[http://dx.doi.org/10.1016/S0140-6736(06)69701-8] [PMID: 17098085]
]. Such enterprises, not only in Breña, but in different districts of the Peruvian capital can be organized with the support of the Peruvian Ministry of Health and other health institutions. This advice could also be applied to other nations.

CONCLUSION

We surveyed 150 patients that attend a healthcare center located in the district of Breña. Only 8.7% of our sample was at a low risk of developing T2DM, whereas the rest were found to be at a slightly elevated, moderate and high risk of developing this chronic disease. Due to this high risk of developing T2DM by the majority of the participants, we expect than in the years to come, the risk of developing CVD in this population (currently mainly at a low CVD risk) will increase substantially. We expect that this study will encourage the Peruvian Ministry of Health, health institutions and health practitioners in general to further promote intervention programs to avoid developing T2DM. A very successful and economical strategy in individuals at risk of developing T2DM can be the promotion of changes in lifestyle.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

The study was approved by the Ethics Committee of the Universidad de Ciencias y Humanidades, Lima, Peru.

HUMAN AND ANIMAL RIGHTS

No animals/humans were used for studies that are the basis of this research.

CONSENT FOR PUBLICATION

Informed consent has obtained from all participants.

AVAILABILITY OF DATA AND MATERIALS

The data supporting the findings of the article is available in GitHub at https://github.com/coto20/T2DM_CVD_BRENA

FUNDING

None.

CONFLICT OF INTEREST

The authors declare that there is no conflict of interest regarding the publication of this article.

ACKNOWLEDGEMENTS

We are very grateful to the nurses from the healthcare facility of Breña for their invaluable help in carrying out the surveys and also to the patients for completing the questionnaires.

REFERENCES

[1] World Health Organization. https://www.who.int/news-room/fact-sheets/detail/diabetes
[2] Dabelea D, Mayer-Davis EJ, Saydah S, et al. SEARCH for Diabetes in Youth Study. Prevalence of type 1 and type 2 diabetes among children and adolescents from 2001 to 2009. JAMA 2014; 311(17): 1778-86.
[http://dx.doi.org/10.1001/jama.2014.3201] [PMID: 24794371]
[3] Centers for Disease Control and Prevention. https://www.cdc.gov/diabetes/basics/risk-factors.html
[4] Connolly V, Unwin N, Sherriff P, Bilous R, Kelly W. Diabetes prevalence and socioeconomic status: a population based study showing increased prevalence of type 2 diabetes mellitus in deprived areas. J Epidemiol Community Health 2000; 54(3): 173-7.
[http://dx.doi.org/10.1136/jech.54.3.173] [PMID: 10746110]
[5] Robbins JM, Vaccarino V, Zhang H, Kasl SV. Socioeconomic status and diagnosed diabetes incidence. Diabetes Res Clin Pract 2005; 68(3): 230-6.
[http://dx.doi.org/10.1016/j.diabres.2004.09.007] [PMID: 15936465]
[6] Hwang J, Shon C. Relationship between socioeconomic status and type 2 diabetes: results from Korea National Health and Nutrition Examination Survey (KNHANES) 2010-2012. BMJ Open 2014; 4(8)e005710
[http://dx.doi.org/10.1136/bmjopen-2014-005710] [PMID: 25138810]
[7] Dalsgaard EM, Skriver MV, Sandbaek A, Vestergaard M. Socioeconomic position, type 2 diabetes and long-term risk of death. PLoS One 2015; 10(5)e0124829
[http://dx.doi.org/10.1371/journal.pone.0124829] [PMID: 25942435]
[8] Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med 2006; 3(11)e442
[http://dx.doi.org/10.1371/journal.pmed.0030442] [PMID: 17132052]
[9] Noh JW, Chang Y, Park M, Kwon YD, Ryu S. Self-rated health and the risk of incident type 2 diabetes mellitus: A cohort study. Sci Rep 2019; 9(1): 3697.
[http://dx.doi.org/10.1038/s41598-019-40090-y] [PMID: 30842537]
[10] Fetit AE, Doney AS, Hogg S, et al. A multimodal approach to cardiovascular risk stratification in patients with type 2 diabetes incorporating retinal, genomic and clinical features. Sci Rep 2019; 9(1): 3591.
[http://dx.doi.org/10.1038/s41598-019-40403-1] [PMID: 30837638]
[11] Massey CN, Feig EH, Duque-Serrano L, Wexler D, Moskowitz JT, Huffman JC. Well-being interventions for individuals with diabetes: A systematic review. Diabetes Res Clin Pract 2019; 147: 118-33.
[http://dx.doi.org/10.1016/j.diabres.2018.11.014] [PMID: 30500545]
[12] Chowdhury MZI, Yeasmin F, Rabi DM, Ronksley PE, Turin TC. Prognostic tools for cardiovascular disease in patients with type 2 diabetes: A systematic review and meta-analysis of C-statistics. J Diabetes Complications 2019; 33(1): 98-111.
[http://dx.doi.org/10.1016/j.jdiacomp.2018.10.010] [PMID: 30446478]
[13] Instituto Nacional de Salud. https://web.ins.gob.pe/sites/default/files/Archivos/ogitt/prioridades/5a%20Prioridades%20Nacionales%20de%20Investigaci
[14] Seclen SN, Rosas ME, Arias AJ, Huayta E, Medina CA. Prevalence of diabetes and impaired fasting glucose in Peru: report from PERUDIAB, a national urban population-based longitudinal study. BMJ Open Diabetes Res Care 2015; 3(1)e000110
[http://dx.doi.org/10.1136/bmjdrc-2015-000110] [PMID: 26512325]
[15] Seclen SN, Rosas ME, Arias AJ, Medina CA. Elevated incidence rates of diabetes in Peru: report from PERUDIAB, a national urban population-based longitudinal study. BMJ Open Diabetes Res Care 2017; 5(1)e000401
[http://dx.doi.org/10.1136/bmjdrc-2017-000401] [PMID: 28878935]
[16] Lindström J, Tuomilehto J. The diabetes risk score: a practical tool to predict type 2 diabetes risk. Diabetes Care 2003; 26(3): 725-31.
[http://dx.doi.org/10.2337/diacare.26.3.725] [PMID: 12610029]
[17] Medina-Verástegui LA, Camacho-Sánchez JE, Ixehuatl-Tello O. Riesgo cardiovascular en pacientes con diabetes mellitus 2. Med Int Méx 2014; 30: 270-5.
[18] Cosansu G, Celik S, Özcan S, Olgun N, Yıldırım N, Gulyuz Demir H. Determining type 2 diabetes risk factors for the adults: A community based study from Turkey. Prim Care Diabetes 2018; 12(5): 409-15.
[http://dx.doi.org/10.1016/j.pcd.2018.05.001] [PMID: 29804712]
[19] Assar ME, Angulo J, Rodríguez-Mañas L. Diabetes and ageing-induced vascular inflammation. J Physiol 2016; 594(8): 2125-46.
[http://dx.doi.org/10.1113/JP270841] [PMID: 26435167]
[20] Einarson TR, Acs A, Ludwig C, Panton UH. Prevalence of cardiovascular disease in type 2 diabetes: a systematic literature review of scientific evidence from across the world in 2007-2017. Cardiovasc Diabetol 2018; 17(1): 83.
[http://dx.doi.org/10.1186/s12933-018-0728-6] [PMID: 29884191]
[21] López-Jaramillo P, Calderón C, Castillo J, Escobar ID, Melgarejo E, Parra GA. Prediabetes in Colombia: Expert Consensus. Colomb Med 2017; 48(4): 191-203.
[PMID: 29662261]
[22] Chiasson JL, Josse RG, Gomis R, Hanefeld M, Karasik A, Laakso M. STOP-NIDDM Trail Research Group. Acarbose for prevention of type 2 diabetes mellitus: the STOP-NIDDM randomised trial. Lancet 2002; 359(9323): 2072-7.
[http://dx.doi.org/10.1016/S0140-6736(02)08905-5] [PMID: 12086760]
[23] Knowler WC, Barrett-Connor E, Fowler SE, et al. Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002; 346(6): 393-403.
[http://dx.doi.org/10.1056/NEJMoa012512] [PMID: 11832527]
[24] Lindström J, Ilanne-Parikka P, Peltonen M, et al. Finnish Diabetes Prevention Study Group. Sustained reduction in the incidence of type 2 diabetes by lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study. Lancet 2006; 368(9548): 1673-9.
[http://dx.doi.org/10.1016/S0140-6736(06)69701-8] [PMID: 17098085]
Track Your Manuscript:


Endorsements



"I am very satisfied by all the services, friendly communication and the attention that was given to my manuscript. My sincere gratitude tou you and the entire team of Bentham Open"


Aristofanis Gikas
Health Centre of Kalivia, K
alivia, Attiki,
Greece


Browse Contents




Webmaster Contact: info@benthamopen.net
Copyright © 2020 Bentham Open