|Year : 2019 | Volume
| Issue : 2 | Page : 339-349
|Status of fasting in Ramadan of chronic hemodialysis patients all over Egypt: A multicenter observational study
Abir Farouk Megahed1, Ghada El-Kannishy2, Nagy Sayed-Ahmed2
1 Department of Nephrology, Ministry of Health and Mansoura Military Hospital, Mansoura, Egypt
2 Mansoura Nephrology and Dialysis Unit (MNDU), Mansoura Faculty of Medicine, Mansoura, Egypt
Click here for correspondence address and email
|Date of Submission||03-Oct-2017|
|Date of Decision||28-Mar-2018|
|Date of Acceptance||01-Apr-2018|
|Date of Web Publication||23-Apr-2019|
| Abstract|| |
There is a paucity of data concerning safety of fasting in Ramadan in chronic kidney disease patients on hemodialysis (HD). The aim of the present study was to assess the frequency of fasting in Ramadan in HD patients in Egypt and the possible effect of fasting on clinical and biochemical variables. This observational multicentric study was carried out during 2016 when fasting duration was around 16 h.
|How to cite this article:|
Megahed AF, El-Kannishy G, Sayed-Ahmed N. Status of fasting in Ramadan of chronic hemodialysis patients all over Egypt: A multicenter observational study. Saudi J Kidney Dis Transpl 2019;30:339-49
|How to cite this URL:|
Megahed AF, El-Kannishy G, Sayed-Ahmed N. Status of fasting in Ramadan of chronic hemodialysis patients all over Egypt: A multicenter observational study. Saudi J Kidney Dis Transpl [serial online] 2019 [cited 2019 May 24];30:339-49. Available from: http://www.sjkdt.org/text.asp?2019/30/2/339/256841
| Introduction|| |
Chronic kidney disease (CKD) is a public health problem worldwide that is recently effectively managed with hemodialysis (HD). However, HD patients are at increased risk of mortality and morbidity as compared with the general population. In Egypt, there is nearly 56,000 HD patients all over the country as recorded by Egyptian Ministry of Health registry.
Ramadan, the ninth lunar month of Islamic calendar, is a sacred month for Muslims all around the world. Fasting in Ramadan is one of the five pillars of Islam and a fundamental religious duty for Muslims. During this month, healthy adult Muslims are obligated to abstain from eating and drinking from dawn to dusk. The hours of fasting can vary from 12 to 17 h, depending on the seasonal and regional features. It can last for 18–22 h on extremes of southern or northern regions based on the Islamic lunar month.
According to social traditions, Ramadan brings changes in diet and drinks that affect both fasting and nonfasting individuals as these changes are related to general habits of the population during Ramadan.
In the literature there is a limited data about the safety of fasting in Ramadan in patients with different renal diseases.,,
The aim of the present study was to estimate the prevalence of practice of fasting in the month of Ramadan among HD patients in Egypt and its possible impact on their physical health.
| Materials and Methods|| |
The study was conducted in the year 2016 when Ramadan, with average 16-h fasting, started at June 6 till July 5. Twenty-seven HD units were chosen across the country because of their easy accessibility and they consented to be part of this study; however, two of them were excluded because of inaccurate data. The remaining 25 units included 2158 maintenance HD patient, with ages ranging from 15 to 90 years and period of duration of dialysis ranging from one to 307 months. They comprised 2055 Muslims (882 females) and 103 Christians (36 females).
There was no intention from the authors of the study to interfere with the decision regarding fasting. A standardized data collection form was distributed to HD units to be completed for every patient to include the following data: name, age, gender, serology for hepatitis B, C, and serology for human immunodeficiency virus. In addition, data regarding the duration of dialysis plus pertinent comorbidities such as history of diabetes mellitus, hypertension (HTN), ischemic heart disease (IHD), and previous kidney transplantation were also collected. Clinical assessment included systolic and diastolic blood pressures, and dry weight. The dry weight was recorded both pre- and post-Ramadan. Pre- and post-Ramadan investigations including hemoglobin (Hb), serum creatinine, blood urea, urea reduction ratio (URR), serum albumin, serum calcium, serum phosphorus, serum potassium, iron studies, and parathyroid hormone were collected according to availability. We considered patients to have disturbances of parathyroid function when they had parathyroid hormone >800 pg/dL, <200, receiving cinacalcet or had been subjected to parathyroidectomy. Mortality was recorded when death occurred during Ramadan and the following six months; deaths occurring during Ramadan and one month after were considered early mortality.
The patients were divided according to their pattern of fasting into three groups: frequent fasting patients (Group 1) who fasted nearly all the month, infrequent fasting patients (Group 2) who fasted the days off dialysis session (17 days or less), and nonfasting patients (Group 3) who never fasted during this Ramadan.
Data were collected from the contributing centers and were recorded on an excel sheet, processed, and statistically analyzed.
| Statistical Analysis|| |
Data analysis was performed by Statistical Package for Social Science (SPSS) version 16.0 (Chicago, IL, USA). The quantitative data were presented in the form of means and standard deviations. The qualitative data were presented in the form of numbers and percentages. Chi-square was used to test the significance for qualitative data. Student’s t-test was used for comparison of quantitative data of two groups. Paired t-test was used to compare quantitative data before and after Ramadan. One-way analysis of variance test was used to compare more than two means. Differences were considered significant at P <0.05.
| Results|| |
Nine hundred and sixty-five patients (46.96%), out of 2055 Muslim patients, fasted at least few days of Ramadan [Table 1]. There is no statistical difference between both genders regarding the pattern of fasting. Similarly, there is no statistical difference between fasting groups considering viral serology and URR. However, frequent or infrequent fasting groups were younger and had been dialysis for a longer time with statistically significant difference compared to the nonfasting group.
|Table 1: Frequency of fasting Ramadan in the studied group according to patient's characteristics.|
Click here to view
[Table 2] shows frequency of fasting Ramadan and patients’ characteristics in Upper Egypt and Lower Egypt; the frequency of fasting is significantly less in Upper Egypt than Lower Egypt (35.4% vs. 48.5%; respectively). The mean durations of dialysis are 39.3 ± 31.9 and 55 ± 53.1 months in both Upper Egypt and Lower Egypt, respectively. The mean duration of dialysis is found to be significantly higher in fasting than in nonfasting groups in Lower Egypt, but not in Upper Egypt.
|Table 2: Frequency of fasting Ramadan and patients' characteristics according to geographical areas of Egypt (Upper Egypt and Lower Egypt).|
Click here to view
Relation between number of comorbidities and mortality and pattern of fasting in Ramadan is shown in [Table 3] and [Table 4]. Patients with less comorbidities were more likely to fast versus those with more comorbidities. Seven-month mortality is 14.7% in the total studied HD population. Early mortality is 0.83% in the fasting group compared to 2.3% in the nonfasting group, while total mortality is 4.3% in the fasting group compared to 9.2% in the nonfasting group with statistically significant differences.
|Table 3: Relation between number of comorbidities and mortality and pattern of Ramadan fasting.|
Click here to view
|Table 4: Relation between number of comorbidities and pattern of Ramadan fasting between Upper and Lower Egypt.|
Click here to view
Diabetes mellitus was present in 18.9% of the studied Muslim HD population with highly statistically significant less frequency of fasting in diabetics than nondiabetics [Table 5]. Similarly, there is statistically significant lower fasting rates in patients with IHD and in patients with Hb <9 g/dL. However, there is no statistically significant difference in the pattern of fasting in patients with HTN, in patients with previous kidney transplantation, and in patients with disturbance of parathyroid function (including 32 patients with parathyroidectomy) than those without.
|Table 5: Relation between specific comorbidities and pattern of fasting Ramadan.|
Click here to view
There is a mild but statistically significant drop in both systolic and diastolic blood pressures in the three groups [Table 6] and [Table 7]. Also, there is trivial changes in dry body weight in the three studied groups on comparing before and after Ramadan values [Table 6] and [Table 7].
Both hypotension and hypoglycemia symptoms and signs are more observed in both fasting groups than the nonfasting group with statistical significant difference. There is an increase in mean serum albumin, mean serum phosphorus, mean serum creatinine, and mean URR in all fasting groups.
| Discussion|| |
Fasting in Ramadan has a unique pattern; abstinence from eating, drinking, taking medications, and smoking from dawn to dusk is fundamental for those who intend to fast. There is a strong desire to participate in fasting, even among those who are eligible for exemption. Although there could be potential health effects of fasting on HD patients, there is an impression that many HD patients manage to fast Ramadan safely. Lack of evidence-based suggestions and guidelines makes it difficult for healthcare providers to give a definite advice in support of or against fasting.
The current observational study was designed to determine the frequency of fasting in Ramadan in HD patients in Egypt.
Among the 2055 included Muslim HD population, 965 (46.96%) succeeded to fast. Of those who fasted, 39.5% admitted that they could fast the whole month. In a previous report, 282 Pakistani HD patients were assessed by Imtiaz et al, and the frequency of fasting in Ramadan was 13.5%. In another study conducted in Saudi Arabia, 64.1% out of the included 635 HD patients fasted. The variation in the results of these studies and the current one could generally be ascribed to different personal, social, and environmental influences. Furthermore, it could be interpreted that the absence of specific guidelines advocating or prohibiting fasting in this special situation makes fasting in HD population an individual decision that mirrors patients’ own motivation and capability. It may be rational to think that the attitude of attending healthcare providers toward fasting could affect the motivation for fasting. In the present study, all the participating HD centers were given clear instructions to be neutral toward their patients’ attitude regarding the fasting decision unless they could anticipate an imminent health hazard attributable to fasting. Gender seemed to have no effect on patients’ ability to fast. On the other hand, patients in the fasting groups were younger and had been on dialysis for longer period of time.
Long-term illness often helps people learn how to adapt. HD patients perceive that the disease has a high impact on their lifestyle. However, they still believe that the treatment they received could control their illness. In a previous study, it was found that mean hopelessness scores of HD patients were low.,, Therefore, it is easily conceivable that patients living longer on HD would have better general heath perception and more positive self-esteem.
HD patients recruited from Lower Egypt significantly fast more frequently than those from Upper Egypt; a discrepancy that may be related to high temperatures and humidity in Upper Egypt during summer days, rendering abstinence from eating and drinking more difficult there. Moreover, patients from Lower Egypt were observed to be younger and had better URR and longer duration of HD (P <0.0001). However, the considerable smaller number of patients included from Upper Egypt makes drawing a solid conclusion in this aspect difficult.
Fasting frequency decreased significantly with increasing number of comorbidities. Practice of fasting during Ramadan was less frequent in patients with DM, IHD, and in those with Hb <9 g/dL, while there was no difference in frequency of fasting in patients with HTN, previous kidney transplantation, or disturbances of parathyroid function.
In the current study, nearly 20% of the surveyed HD patients had diabetes mellitus. Diabetic HD patients tended to practice fasting less frequently than their nondiabetic counterparts (~50%); however, many of them (35.8%) managed to fast at least part of the holy month of Ramadan. In a clear controversy to this, the International Diabetes Federation and Diabetes and Ramadan International Alliance guidelines categorized chronic dialysis or CKD Stage 4 and 5 as very high risk that should not fast. Patients who decide to fast need to be aware of the risks associated with fasting and of techniques to decrease this risk.
Similar to the diabetic patients, patients with IHD fasted less frequently. This finding was consistent with reports in the literature investigating the effect of fasting in Ramadan on patients with heart disease. Chamsi-Pasha and co-workers suggested that stable patients with cardiac disease could fast without significant detrimental effects. AlSuwaidi et al studied 465 patients with heart disease while fasting during the month of Ramadan and showed that the incidence of acute coronary syndromes (ACS) in Ramadan was not significantly different than in other months. In the same study, the baseline clinical characteristics, the mode of therapy administered, and the mortality rates among ACS patients admitted in Ramadan were comparable to those a month before and a month after Ramadan.
Intradialytic attacks of both hypotension and hypoglycemia, defined subjectively by reporting symptoms suggestive of hypoglycemia or hypotension, were observed more frequent in fasting groups. Intradialytic hypoglycemic episodes may be attributed to the use of glucose-free dialysate in all the HD units of the study. Salti et al in 2004 showed that a significant proportion of diabetic nonuremic patients continued to fast although they were informed about the risks. They also advised against excessive exercise during fasting.
A statistically significant drop in both mean systolic and diastolic blood pressure after, compared to before, Ramadan in both the fasting and nonfasting groups was observed. This drop in systolic blood pressure might be explained by changes in sleep hours, activities, eating patterns with less salty meals, and change in the timing of receiving antihypertensive medications.
In the present study, there was no deterioration in the mean hemoglobin level after Ramadan in studied groups (Group 1, 2, and 3). Sedaghat et al also reported no major changes in anemia parameters after fasting in non-HD individuals.
In total, 142 deaths (6.9%) were documented among the total observed HD Muslim patients. About 72% of total mortality occurred in the nonfasting group. The higher deaths in the nonfasting patients may be explained by their older age and the presence of more associated comorbidities. It might be difficult to compare the results of mortality in the present study to other researches as mortality rates among HD patients vary greatly across regions as reported by the Dialysis Outcomes and Practice Patterns Study.
Mean serum albumin, mean serum phosphorus, and mean serum creatinine were found to be increased after the month of Ramadan in all the studied patients’ groups, whether fasted or not. This observation might suggest partial improvement in the nutritional status in fasters and nonfasters during Ramadan. Similar data were reported by Alshamsi et al.
Fasting results in suppression of insulin release; this together with diminished response to epinephrine may be expected to contribute to development of high potassium level in fasting renal patients. Moreover, potassium-rich food are habitually consumed in large amount in Ramadan, which could aggravate the problem of hyperkalemia. Alshamsi et al reported that dates and Arabic coffee are usually served during the time of breaking the fasts. Juices made from various citrus fruits as well as from apricots are consumed in abundance in Ramadan meals. All these are very rich in potassium and would be expected to raise the serum potassium levels in patients during fasting Ramadan. However, Alshamsi et al, did not observe any increase in serum potassium in their study. Serum potassium was noticed to decrease in all studied patients’ groups during Ramadan whether fasted or not. This observation might indicate adjustment of consumption of dietary potassium.
| Conclusion|| |
Our observational study shows that the fasting may be possible in maintenance HD.
It may be recommended that HD patients should be encouraged to discuss the option of fasting in Ramadan with their HD staff who might be able to give advice on whether to allow them to fast in days off dialysis with special precautions regarding associated co-morbidities, especially diabetes and IHD. Close monitoring of dry body weight during HD sessions and restriction in potassium-containing diet in Ramadan must be considered essential parts of patient care during Ramadan. Indiscriminate prohibition of such practice may sometimes be unjustified and could have negative impact on patients’ emotional satisfaction and self-esteem.
| Acknowledgments|| |
The authors would like to thank the following:
Dr. Hesham Atta Youssif - Head of Therapeutic Sector – Ministry of Health, Egypt, Dr. Mohamed Shawqi - Assistant Head of Therapeutic Sector - Ministry of Health, Egypt, Dr Hassan El Azawy: Head of Nephrology - Ministry of health, Egypt, Dr Magdy Abdou Ibrahim Hegazy - Undersecretary of Ministry of Health in Alexandria, Dr. Mona Tawfeek - Lecturer of Nephrology and Internal Medicine, Dr Ghada El Said: Assistant Professor of Nephrology and Internal Medicine, Ms. Afaf Mohamed Fahmy - High Nurse and Supervisor on Nursing Staff in Hemodialysis in Alexandria, Dr. Huda Ahmed Mahmoud - Head of Hemodialysis Unit in El Agmy Hospital and Internal Medicine Consultant, Dr. Emad Hamdy Ahmed - Nephrology Specialist in Hemodialysis Unit in El Agmy Hospital, Ms. Shaimaa Mustafa - Head of Nursing Staff in Hemodialysis Unit in El Agmy Hospital, Dr. Elzahraa Ahmed Amar - Head of Hemodialysis Unit in Alexandria Fever Hospital, Dr. Marwa Mohamed Abd Elhafiez - Nephrology Specialist in Alexandria Fever Hospital, Ms. Hanan Mohamed Fawzi - Head of Nursing Staff in Hemodialysis Unit in Alexandria Fever Hospital, Dr. Ahmed Abdel Fattah - Nephrology Consultant in Mansoura Military Hospital, Ms. Huda Farag Mohamed, Staff Hurse in Hemodialysis Unit in Mansoura Military Hospital, Dr. Nahed AbdelMonem - Head of Hemodialysis Unit in Abu Qir hospital and Nephrology Consultant, Mr. Mohamed Gamal Diab - Head nurse in Hemodialysis Unit in El Gomhrya Hospital, Ms. Elham Mohamed Hafez - Staff Nurse in Hemodialysis Unit in Abo Qir Hospital, Ms. Hagar Hassan Mohamed - Staff Nurse in Hemodialysis Unit in Abo Qir Hospital, Dr. Abeer Mohamed Abdel Tawab - Head of Hemodialysis Unit in Ras El Tein Hospital and Nephrology Specialist, Dr. Aida Helmy - Nephrology Specialist in Ras El Tein Hospital, Dr. Emad Abdel Azim - Nephrology Specialist, Ms. Wadida Aly Mohamed - Head Nurse in Ras El Tein Hospital Hemodialysis Unit, Dr. Lobna Elgamal - Head of Hemodialysis Unit in El Gomhrya Hospital and Nephrology Specialist, Ms. Maha Nassar - Head Nurse in Hemodialysis Unit of El Gomhrya Hospital, Dr. Eman Ahmed Hussien - Nephrology Consultant in El Amrya Hospital, Ms. Doaa Elsayed Mohamed - Head Nurse in Hemodialysis Unit in El Amrya Hospital, -Dr. Tolba Abdou Elbasosy - Head of Hemodialysis Unit in Borg El Arb Hospital and Internal Medicine, Ms. Heba Ahmed Mahdy - Head Nurse in Hemodialysis Unit in Borg El Arb Hospital, Dr. Rabab Taha Zakaria Hassan - Head of Hemodialysis Unit in El Minya General Hospital, Dr. Eman Mohammed Taha Ali - Nephrology Specialist, Dr. Mohamed Abd Elaziz Eldiasty - Internal Medicine Consultant, Brigedone General Dr. Mohamed Shawky Ali Elmasry - Head of Mansoura Military Hospital, Ms. Basma El Nagar - Head Nurse in Hemodialysis Unit in Mansoura Military Hospital, Dr. Hany Helmy Saad Attia - Head of Hemodialysis Unit in Shobra General Hospital and Nephrology Consultant, Dr Silvia Adel Ibrahim - Nephrology Resident in Shobra General Hospital, Dr. Essam Abd Elazim Elsayed Elsayed - Head of Hemodialysis Unit in Rod El Farag Hospital and Nephrology Consultant, Dr. Asmaa Mahmoud Fakhry - Head of Hemodialysis Unit in 6th October Hospital, Mrs. Khadra Abdullah Ibrahim - Head Nurse of Hemodialysis Unit in 6th October Hospital, Mrs. Marwa Salah Ahmed - Staff Nurse in Hemodialysis Unit of 6th October Hospital, Dr. Amira Yousif Ali Elbeltagy - Head of Hemodialysis Unit in El Mounira Hospital, Dr. Hazem Fouad Sadek - Nephrology Specialist in El Mounira Hospital, Dr Dina Salah Abd Elaziz: Nephrology Specialist in El Mounira Hospital, Ms. Mahasen Abd Ullah - Head Nurse in Hemodialysis unit in El Mounira Hospital, Dr. Hanan Fouad - Nephrology Specialist in El Mounira Hospital, Dr. Hind Alaa Eldin - Nephrology Specialist in El Mounira Hospital, Dr. Eman Elkondakly - Nephrology Consultant in Hemodialysis Unit in Damietta General Hospital, Dr. Sherihan Mohamed - Nephrology Resident in Dameitta General Hospital, Dr. Ahmed Ahmed Khear Eldin - Head of Nephrology Department in Zefta Hospital – Nephrology Specialist, Ms. Amal Elsherbeny - Head Nurse in El Mahlla Fever Hospital, Dr. Gehan Awad Mekhail - Head of Nephrology Department in El Minshawy and Nephrology Specialist, Dr. Abd Elaal Kozah - Head of Hemodialysis Unit in Kafr El Zaiat Hospital and Internal Medicine Consultant, Dr. Mona El Saaed Khalf - Nephrology Specialistin Tanta Fever Hospital, Ms. Wageha Ali - Head Nurse in El Minshaway Hospital, Ms. Saeda Mohamed - Staff Nurse in El Minshaway Hospital, Ms. Salwa Abd El Nabi Swelm - Staff Nurse in El Minshaway Hospital, Ms. Fika Ahmed Basiwny - Staff Nurse in El Minshaway Hospital, Dr. Essam Abdel Aziz Mohamed - Nephrology Specialist in Shobra General Hospital, Ms. Sousou Kamel El Nagar -Head Nurse in Shobra General Hospital, - Dr. Hesham Fouad - Head of Hemodialysis Unit in Specialized Damietta Hospital, Dr. Samah Sabry - Nephrology Specialist in Specialized Damietta Hospital, Dr. Ilham El Ghobashy - Nephrology Specialist in Specialized Damietta Hospital, Dr. Laila Nader - Nephrology Specialist, Dr. Hala El Shemy - Nephrology Resident in Specialized Damietta Hospital, - Ms. Nesrine Montaser - Head of Hemodialysis Unit in Specialized Damietta Hospital, Ms. Doaa Abo Al Ftoh - Staff nurse in Hemodialysis Unit in Specialized Damietta Hospital – Dr. Ahmed Tarek Eid Ahmed - Head of Hemodialysis Unit in El Mahlla General Hospital and Internal Medicine Consultant, Dr. Fawqia Hosny Ismail Al Dahtory - Nephrology Specialist in El Mahlla General Hospital, Dr. Ahmed El Sherkawy - Nephrology Specialist in El Mahlla General Hospital, Hanan Nagah, Veterinarian Student, Soha Ali - Pharmacy Student, Heba Magdy El Bahnasawy - Dentistry Student, Menna Magdy El Bahnasawy - Medicine Student. Mr. Rabia Ramadan
Conflict of interest: None declared.
| References|| |
Egyptian Ministry of Health Registry (June 2016, personal MOH Registry, Personal Communication. June, 2016.
Emami-Naini A, Roomizadeh P, Baradaran A, Abedini A, Abtahi M. Ramadan fasting and patients with renal diseases: A mini review of the literature. J Res Med Sci 2013;18:711-6.
Imtiaz S, Salman B, Dhrolia MF, Nasir K, Abbas HN, Ahmad A. Clinical and biochemical parameters of hemodialysis patients before and during Islamic month of Ramadan. Iran J Kidney Dis 2016;10:75-8.
Alshamsi S, Binsaleh F, Hejaili F, et al. Changes in biochemical, hemodynamic, and dialysis adherence parameters in hemodialysis patients during Ramadan. Hemodial Int 2016; 20:270-6.
Mollaoglu M, Candan F, Mollaoglu M. Illness perception and hopelessness in hemodialysis. Arch Clin Nephrol 2016;2:44-8.
Berlim MT, Mattevi BS, Duarte AP, Thomé FS, Barros EJ, Fleck MP. Quality of life and depressive symptoms in patients with major depression and end-stage renal disease: A matched-pair study. J Psychosom Res 2006; 61:731-4.
Biçer S, Bayat M. Hope-hopelessness and social support levels of people taking dialysis treatment. Fırat Sağlık Hizmetleri Derg 2012; 7:8-21.
Hassanein M, Al-Arouj M, Hamdy O, et al. Diabetes and Ramadan: Practical guidelines. Diabetes Res Clin Pract 2017;126:303-16.
Chamsi-Pasha H, Ahmed WH. The effect of fasting in Ramadan on patients with heart disease. Saudi Med J 2004;25:47-51.
Al Suwaidi J, Zubaid M, Al-Mahmeed WA, et al. Impact of fasting in Ramadan in patients with cardiac disease. Saudi Med J 2005;26: 1579-83.
Salti I, Bénard E, Detournay B, C, et al. A population-based study of diabetes and its characteristics during the fasting month of Ramadan in 13 countries: Results of the epidemiology of diabetes and Ramadan 1422/2001 (EPIDIAR) study. Diabetes Care 2004;27:2306-11.
Sedaghat MR, Askarizadeh SF, Heravian J, Rakhshandadi T, Nematy M, Mahmoodi Z, et al. The effects of Islamic fasting on blood hematological-biochemical parameters. J Fasting Health 2017;5:56-62.
Goodkin DA, Bragg-Gresham JL, Koenig KG, et al. Association of comorbid conditions and mortality in hemodialysis patients in Europe, Japan, and the United States: The dialysis outcomes and practice patterns study (DOPPS). J Am Soc Nephrol 2003;14:3270-7.
Mansoura Nephrology and Dialysis Unit (MNDU), Mansoura Faculty of Medicine, Mansoura
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]
| Article Access Statistics|
| Viewed||245 |
| Printed||0 |
| Emailed||0 |
| PDF Downloaded||66 |
| Comments ||[Add] |