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==Overview==
==Overview==
The incidence of meningioma is approximately 7.62 per 100,000 individuals in the United States.<ref name="pmid25872752">{{cite journal| author=Dolecek TA, Dressler EV, Thakkar JP, Liu M, Al-Qaisi A, Villano JL| title=Epidemiology of meningiomas post-Public Law 107-206: The Benign Brain Tumor Cancer Registries Amendment Act. | journal=Cancer | year= 2015 | volume= 121 | issue= 14 | pages= 2400-10 | pmid=25872752 | doi=10.1002/cncr.29379 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25872752  }} </ref> The prevalence of meningioma was estimated to be 97.5 cases per 100,000 individuals in the United States.<ref name="pmid20821343">{{cite journal| author=Wiemels J, Wrensch M, Claus EB| title=Epidemiology and etiology of meningioma. | journal=J Neurooncol | year= 2010 | volume= 99 | issue= 3 | pages= 307-14 | pmid=20821343 | doi=10.1007/s11060-010-0386-3 | pmc=PMC2945461 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20821343  }} </ref> Meningiomas may appear at any age, but are most commonly noticed among patients older than 50 years of age.<ref name="wiki">Meningioma. Wikipedia(2015) https://en.wikipedia.org/wiki/Meningioma#cite_note-pmid7731706-9 Accessed on September, 25th 2015</ref> Females are more commonly affected with meningiomas than males.<ref name="pmid20821343">{{cite journal| author=Wiemels J, Wrensch M, Claus EB| title=Epidemiology and etiology of meningioma. | journal=J Neurooncol | year= 2010 | volume= 99 | issue= 3 | pages= 307-14 | pmid=20821343 | doi=10.1007/s11060-010-0386-3 | pmc=PMC2945461 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20821343  }} </ref> Meningioma usually affects individuals of the African American race. Caucasian and Latin American individuals are less likely to develop meningioma.<ref name="pmid20821343">{{cite journal| author=Wiemels J, Wrensch M, Claus EB| title=Epidemiology and etiology of meningioma. | journal=J Neurooncol | year= 2010 | volume= 99 | issue= 3 | pages= 307-14 | pmid=20821343 | doi=10.1007/s11060-010-0386-3 | pmc=PMC2945461 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20821343  }} </ref>
The prevalence of meningioma is estimated to be 97.5 cases per 100,000 individuals in the United States. The incidence of meningioma is approximately 7.62 per 100,000 individuals in the United States. Meningiomas may appear at any age, but are most commonly noticed among patients older than 50 years of age. Females are more commonly affected with meningiomas than males, with a ratio of about 2:1. Meningioma usually affects individuals of the African American race. Caucasian and Latin American individuals are less likely to develop meningioma.


==Epidemiology and Demographics==
==Epidemiology and Demographics==
===Incidence===
* The incidence of meningiomas is approximately 7.62 per 100,000 individuals in the United States.<ref name="pmid25872752">{{cite journal| author=Dolecek TA, Dressler EV, Thakkar JP, Liu M, Al-Qaisi A, Villano JL| title=Epidemiology of meningiomas post-Public Law 107-206: The Benign Brain Tumor Cancer Registries Amendment Act. | journal=Cancer | year= 2015 | volume= 121 | issue= 14 | pages= 2400-10 | pmid=25872752 | doi=10.1002/cncr.29379 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25872752  }} </ref>
* The advent of modern sophisticated imaging studies tripled the incidence of asymptomatic meningiomas.<ref name="wiki">Meningioma. Wikipedia(2015) https://en.wikipedia.org/wiki/Meningioma#cite_note-pmid7731706-9 Accessed on September, 25th 2015</ref>


===Prevalence===
===Prevalence===
* The prevalence of meningioma was estimated to be 97.5 cases per 100,000 individuals in the United States.<ref name="pmid20821343">{{cite journal| author=Wiemels J, Wrensch M, Claus EB| title=Epidemiology and etiology of meningioma. | journal=J Neurooncol | year= 2010 | volume= 99 | issue= 3 | pages= 307-14 | pmid=20821343 | doi=10.1007/s11060-010-0386-3 | pmc=PMC2945461 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20821343  }} </ref>
* The prevalence of meningioma is estimated to be 97.5 cases per 100,000 individuals in the United States. There are over 170,000 diagnosed cases in the United States.<ref name="pmid20821343">{{cite journal| author=Wiemels J, Wrensch M, Claus EB| title=Epidemiology and etiology of meningioma. | journal=J Neurooncol | year= 2010 | volume= 99 | issue= 3 | pages= 307-14 | pmid=20821343 | doi=10.1007/s11060-010-0386-3 | pmc=PMC2945461 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20821343  }} </ref>
* It was the most reported primary [[brain]] and [[central nervous system]] [[tumor]] in the Unites States between 2002 and 2006. It accounted for about 33.8% of the tumors reported, making it the most frequently diagnosed [[brain tumor]].<ref name="pmid20821343">{{cite journal| author=Wiemels J, Wrensch M, Claus EB| title=Epidemiology and etiology of meningioma. | journal=J Neurooncol | year= 2010 | volume= 99 | issue= 3 | pages= 307-14 | pmid=20821343 | doi=10.1007/s11060-010-0386-3 | pmc=2945461 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20821343  }} </ref>  
* Meningioma is the second most common primary [[brain tumor]] worldwide.<ref name="pmid21955199">{{cite journal| author=Chamberlain MC, Barnholtz-Sloan JS| title=Medical treatment of recurrent meningiomas. | journal=Expert Rev Neurother | year= 2011 | volume= 11 | issue= 10 | pages= 1425-32 | pmid=21955199 | doi=10.1586/ern.11.38 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21955199  }} </ref>
* Meningioma is the second most common primary [[brain tumor]] worldwide.<ref name="pmid21955199">{{cite journal| author=Chamberlain MC, Barnholtz-Sloan JS| title=Medical treatment of recurrent meningiomas. | journal=Expert Rev Neurother | year= 2011 | volume= 11 | issue= 10 | pages= 1425-32 | pmid=21955199 | doi=10.1586/ern.11.38 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21955199  }} </ref>
* Meningioma accounts for approximately 1 out of 3 primary [[brain]] and [[spinal cord]] [[tumor]]s.<ref name="C">Meningioma. Canadian Cancer Society http://www.cancer.ca/en/cancer-information/cancer-type/brain-spinal/brain-and-spinal-tumours/meningioma/?region=mb September, 25th 2015</ref>
 
* The prevalence of meningioma was estimated to be around 170,000 individuals in the United States.<ref name="pmid20821343">{{cite journal| author=Wiemels J, Wrensch M, Claus EB| title=Epidemiology and etiology of meningioma. | journal=J Neurooncol | year= 2010 | volume= 99 | issue= 3 | pages= 307-14 | pmid=20821343 | doi=10.1007/s11060-010-0386-3 | pmc=PMC2945461 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20821343 }} </ref>
===Incidence===
* [[Benign]] meningiomas account for approximately 70% of all meningioma cases.<ref name="C">Meningioma. Canadian Cancer Society http://www.cancer.ca/en/cancer-information/cancer-type/brain-spinal/brain-and-spinal-tumours/meningioma/?region=mb September, 25th 2015</ref>
* The incidence of meningiomas annually is approximately 7.62 per 100,000 individuals in the United States. The incidence of [[benign]] meningiomas is about 7.18, about 0.32 for borderline [[malignant]] meningiomas, and about 0.12 for [[malignant]] meningiomas.<ref name="pmid25872752">{{cite journal| author=Dolecek TA, Dressler EV, Thakkar JP, Liu M, Al-Qaisi A, Villano JL| title=Epidemiology of meningiomas post-Public Law 107-206: The Benign Brain Tumor Cancer Registries Amendment Act. | journal=Cancer | year= 2015 | volume= 121 | issue= 14 | pages= 2400-10 | pmid=25872752 | doi=10.1002/cncr.29379 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25872752 }} </ref>
* Atypical meningiomas account for approximately 15%–25% of all meningioma cases.<ref name="C">Meningioma. Canadian Cancer Society http://www.cancer.ca/en/cancer-information/cancer-type/brain-spinal/brain-and-spinal-tumours/meningioma/?region=mb September, 25th 2015</ref>
* [[Anaplastic]] or [[malignant]] meningiomas account for about 1%–3% of all meningioma cases.<ref name="C">Meningioma. Canadian Cancer Society http://www.cancer.ca/en/cancer-information/cancer-type/brain-spinal/brain-and-spinal-tumours/meningioma/?region=mb September, 25th 2015</ref>


===Age===
===Age===
* Meningiomas may appear at any age, but are most commonly noticed among patients older than 50 years of age.<ref name="wiki">Meningioma. Wikipedia(2015) https://en.wikipedia.org/wiki/Meningioma#cite_note-pmid7731706-9 Accessed on September, 25th 2015</ref>  
* Meningiomas can occur at any age but is mostly seen with advancing age. <ref name="pmid25872752">{{cite journal| author=Dolecek TA, Dressler EV, Thakkar JP, Liu M, Al-Qaisi A, Villano JL| title=Epidemiology of meningiomas post-Public Law 107-206: The Benign Brain Tumor Cancer Registries Amendment Act. | journal=Cancer | year= 2015 | volume= 121 | issue= 14 | pages= 2400-10 | pmid=25872752 | doi=10.1002/cncr.29379 | pmc=5549267 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25872752  }} </ref>
* Meningiomas are uncommon among patients before the age of 40 and should raise suspicion of [[neurofibromatosis type 2]] (NF2) syndrome when found among young patients.<ref name="radio">Meningeoma. Radiopaedia(2015)http://radiopaedia.org/articles/meningioma Accessed on September, 25th 2015</ref>
* It is commonly seen between the ages of 40 to 60 and is more common in [[postmenopausal]] women.<ref name="pmid29492130">{{cite journal| author=Gurcay AG, Bozkurt I, Senturk S, Kazanci A, Gurcan O, Turkoglu OF et al.| title=Diagnosis, Treatment, and Management Strategy of Meningioma during Pregnancy. | journal=Asian J Neurosurg | year= 2018 | volume= 13 | issue= 1 | pages= 86-89 | pmid=29492130 | doi=10.4103/1793-5482.181115 | pmc=5820904 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29492130  }} </ref>
* In childhood and adolescence, meningiomas account for about 1.5% of [[Brain tumor|brain tumors]].<ref name="pmid30740161">{{cite journal| author=Sumkovski R, Micunovic M, Kocevski I, Ilievski B, Petrov I| title=Surgical Treatment of Meningiomas - Outcome Associated With Type of Resection, Recurrence, Karnofsky Performance Score, Mitotic Count. | journal=Open Access Maced J Med Sci | year= 2019 | volume= 7 | issue= 1 | pages= 56-64 | pmid=30740161 | doi=10.3889/oamjms.2018.503 | pmc=6352459 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30740161  }} </ref>


===Gender===
===Gender===
* Females are more commonly affected with meningiomas than males.<ref name="pmid20821343">{{cite journal| author=Wiemels J, Wrensch M, Claus EB| title=Epidemiology and etiology of meningioma. | journal=J Neurooncol | year= 2010 | volume= 99 | issue= 3 | pages= 307-14 | pmid=20821343 | doi=10.1007/s11060-010-0386-3 | pmc=PMC2945461 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20821343  }} </ref>
* Females are more commonly affected with meningiomas than males.<ref name="pmid20821343">{{cite journal| author=Wiemels J, Wrensch M, Claus EB| title=Epidemiology and etiology of meningioma. | journal=J Neurooncol | year= 2010 | volume= 99 | issue= 3 | pages= 307-14 | pmid=20821343 | doi=10.1007/s11060-010-0386-3 | pmc=PMC2945461 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20821343  }} </ref>
* The female to male ratio is approximately 2 to 1.<ref name="pmid20821343">{{cite journal| author=Wiemels J, Wrensch M, Claus EB| title=Epidemiology and etiology of meningioma. | journal=J Neurooncol | year= 2010 | volume= 99 | issue= 3 | pages= 307-14 | pmid=20821343 | doi=10.1007/s11060-010-0386-3 | pmc=PMC2945461 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20821343 }} </ref>
* The female to male ratio is approximately 2 to 1.
* The incidence of meningioma among females is approximately 10.22 per 100,000 individuals in the United States.<ref name="pmid25872752">{{cite journal| author=Dolecek TA, Dressler EV, Thakkar JP, Liu M, Al-Qaisi A, Villano JL| title=Epidemiology of meningiomas post-Public Law 107-206: The Benign Brain Tumor Cancer Registries Amendment Act. | journal=Cancer | year= 2015 | volume= 121 | issue= 14 | pages= 2400-10 | pmid=25872752 | doi=10.1002/cncr.29379 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25872752 }} </ref>
* The incidence of meningioma among females is approximately 8.36 per 100,000 individuals in the United States, with that of males being 3.61 per 100,000 individuals.<ref name="pmid20821343">Wiemels J, Wrensch M, Claus EB (2010) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=20821343 Epidemiology and etiology of meningioma.] ''J Neurooncol'' 99 (3):307-14. [http://dx.doi.org/10.1007/s11060-010-0386-3 DOI:10.1007/s11060-010-0386-3] PMID: [https://pubmed.gov/20821343 20821343]</ref>
* The incidence of meningioma among males is approximately 4.85 per 100,000 individuals in the United States.<ref name="pmid25872752">{{cite journal| author=Dolecek TA, Dressler EV, Thakkar JP, Liu M, Al-Qaisi A, Villano JL| title=Epidemiology of meningiomas post-Public Law 107-206: The Benign Brain Tumor Cancer Registries Amendment Act. | journal=Cancer | year= 2015 | volume= 121 | issue= 14 | pages= 2400-10 | pmid=25872752 | doi=10.1002/cncr.29379 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25872752  }} </ref>
* The female to male ratio of meningiomas may be inverted among affected patients who are younger than 15 years of age.<ref name="pmid20821343">{{cite journal| author=Wiemels J, Wrensch M, Claus EB| title=Epidemiology and etiology of meningioma. | journal=J Neurooncol | year= 2010 | volume= 99 | issue= 3 | pages= 307-14 | pmid=20821343 | doi=10.1007/s11060-010-0386-3 | pmc=PMC2945461 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20821343 }} </ref>
* The female to male ratio of meningiomas may be inverted among patients who are younger than 15 years of age.<ref name="pmid20821343">{{cite journal| author=Wiemels J, Wrensch M, Claus EB| title=Epidemiology and etiology of meningioma. | journal=J Neurooncol | year= 2010 | volume= 99 | issue= 3 | pages= 307-14 | pmid=20821343 | doi=10.1007/s11060-010-0386-3 | pmc=PMC2945461 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20821343 }} </ref>
* Atypical and malignant meningiomas have a slight male predominace.<ref name="pmid20821343">Wiemels J, Wrensch M, Claus EB (2010) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=20821343 Epidemiology and etiology of meningioma.] ''J Neurooncol'' 99 (3):307-14. [http://dx.doi.org/10.1007/s11060-010-0386-3 DOI:10.1007/s11060-010-0386-3] PMID: [https://pubmed.gov/20821343 20821343]</ref>


===Race===
===Race===
* Meningioma usually affects individuals of the African American race. Caucasian and Latin American individuals are less likely to develop meningioma.<ref name="pmid20821343">{{cite journal| author=Wiemels J, Wrensch M, Claus EB| title=Epidemiology and etiology of meningioma. | journal=J Neurooncol | year= 2010 | volume= 99 | issue= 3 | pages= 307-14 | pmid=20821343 | doi=10.1007/s11060-010-0386-3 | pmc=PMC2945461 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20821343  }} </ref>
* Meningioma usually affects individuals of the black race. Caucasian and Latin American individuals are less likely to develop meningioma.<ref name="pmid20821343">{{cite journal| author=Wiemels J, Wrensch M, Claus EB| title=Epidemiology and etiology of meningioma. | journal=J Neurooncol | year= 2010 | volume= 99 | issue= 3 | pages= 307-14 | pmid=20821343 | doi=10.1007/s11060-010-0386-3 | pmc=PMC2945461 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20821343  }} </ref>


==References==
==References==


{{Reflist|2}}
{{Reflist|2}}


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Latest revision as of 14:31, 10 September 2019

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Ifeoma Odukwe, M.D. [2] Haytham Allaham, M.D. [3]

Overview

The prevalence of meningioma is estimated to be 97.5 cases per 100,000 individuals in the United States. The incidence of meningioma is approximately 7.62 per 100,000 individuals in the United States. Meningiomas may appear at any age, but are most commonly noticed among patients older than 50 years of age. Females are more commonly affected with meningiomas than males, with a ratio of about 2:1. Meningioma usually affects individuals of the African American race. Caucasian and Latin American individuals are less likely to develop meningioma.

Epidemiology and Demographics

Prevalence

  • The prevalence of meningioma is estimated to be 97.5 cases per 100,000 individuals in the United States. There are over 170,000 diagnosed cases in the United States.[1]
  • It was the most reported primary brain and central nervous system tumor in the Unites States between 2002 and 2006. It accounted for about 33.8% of the tumors reported, making it the most frequently diagnosed brain tumor.[1]
  • Meningioma is the second most common primary brain tumor worldwide.[2]

Incidence

  • The incidence of meningiomas annually is approximately 7.62 per 100,000 individuals in the United States. The incidence of benign meningiomas is about 7.18, about 0.32 for borderline malignant meningiomas, and about 0.12 for malignant meningiomas.[3]

Age

  • Meningiomas can occur at any age but is mostly seen with advancing age. [3]
  • It is commonly seen between the ages of 40 to 60 and is more common in postmenopausal women.[4]
  • In childhood and adolescence, meningiomas account for about 1.5% of brain tumors.[5]

Gender

  • Females are more commonly affected with meningiomas than males.[1]
  • The female to male ratio is approximately 2 to 1.
  • The incidence of meningioma among females is approximately 8.36 per 100,000 individuals in the United States, with that of males being 3.61 per 100,000 individuals.[1]
  • The female to male ratio of meningiomas may be inverted among affected patients who are younger than 15 years of age.[1]
  • Atypical and malignant meningiomas have a slight male predominace.[1]

Race

  • Meningioma usually affects individuals of the black race. Caucasian and Latin American individuals are less likely to develop meningioma.[1]

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Wiemels J, Wrensch M, Claus EB (2010). "Epidemiology and etiology of meningioma". J Neurooncol. 99 (3): 307–14. doi:10.1007/s11060-010-0386-3. PMC 2945461. PMID 20821343.
  2. ↑ Chamberlain MC, Barnholtz-Sloan JS (2011). "Medical treatment of recurrent meningiomas". Expert Rev Neurother. 11 (10): 1425–32. doi:10.1586/ern.11.38. PMID 21955199.
  3. ↑ 3.0 3.1 Dolecek TA, Dressler EV, Thakkar JP, Liu M, Al-Qaisi A, Villano JL (2015). "Epidemiology of meningiomas post-Public Law 107-206: The Benign Brain Tumor Cancer Registries Amendment Act". Cancer. 121 (14): 2400–10. doi:10.1002/cncr.29379. PMID 25872752.
  4. ↑ Gurcay AG, Bozkurt I, Senturk S, Kazanci A, Gurcan O, Turkoglu OF; et al. (2018). "Diagnosis, Treatment, and Management Strategy of Meningioma during Pregnancy". Asian J Neurosurg. 13 (1): 86–89. doi:10.4103/1793-5482.181115. PMC 5820904. PMID 29492130.
  5. ↑ Sumkovski R, Micunovic M, Kocevski I, Ilievski B, Petrov I (2019). "Surgical Treatment of Meningiomas - Outcome Associated With Type of Resection, Recurrence, Karnofsky Performance Score, Mitotic Count". Open Access Maced J Med Sci. 7 (1): 56–64. doi:10.3889/oamjms.2018.503. PMC 6352459. PMID 30740161.
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