Turkiye Klinikleri Journal of Internal Medicine

.: ORIGINAL RESEARCH
Evaluation of Epicardial Adipose Tissue Thickness and Proinflammatory Cytokines in Subclinical Hypothyroidism: A Case Control Study
Subklinik Hipotiroidide Epikardiyal Yağ Doku Kalınlığı ve Proinflamatuar Sitokinlerin Değerlendirilmesi: Bir Vaka Kontrol Çalışması
Gözde TAHTACIa, Mehmet Ayhan KARAKOÇb
aDivision of Medical Oncology, Gazi University Faculty of Medicine, Ankara, Türkiye
bDivision of Endocrinology and Metabolism, Gazi University Faculty of Medicine, Ankara, Türkiye
Turkiye Klinikleri J Intern Med. 2022;7(2/3):45-50
doi: 10.5336/intermed.2022-89994
Article Language: EN
Full Text
ABSTRACT
 Objective: Epicardial adipose tissue (EAT) is an adipose tissue located between the myocardial surface and the visceral layer of the pericardium. Epicardial adipose tissue thickness (EATT) is a sign of atherosclerosis. It has been reported that EATT is increased in patients with subclinical hypothyroidism (SCH). It is suggested that EAT may cause coronary atherosclerosis through paracrine and vasocrine pathways mediated by adipokines / cytokines. In this study, it was aimed to evaluate the relationship of EATT in SCH with proinflammatory cytokines (interleukin-6 (IL-6), highly sensitive C-reactive protein (hsCRP), monocyte chemo attractant protein-1 (MCP-1) and tumor necrosis factor-alpha (TNF-alpha)). Material and Methods: A total of 32 cases of SCH and 27 healthy volunteers were prospectively included in the study. EATT were measured by echocardiography. IL-6, hsCRP, MCP-1 and TNF-alpha were measured through simultaneously taken serum samples. Results: EATT was significantly higher in SCH compared to the control group (p=0.05). Groups were similar in terms of age, BMI, totalcholesterol, LDL-cholesterol levels; but only HDL-cholesterol was found to be significantly higher in SCH group (p=0.034). There was no significant difference between the SCH and the control group in terms of IL-6, hsCRP, MCP-1 and TNF-alpha. Conclusion: EATT was found to be increased in SCH. But, serum levels of proinflammatory cytokines were similar between groups. In the SCH group, there was no relationship between EATT and proinflammatory cytokines. Although EATT is an indicator of atherosclerosis, it may have different control mechanisms in SCH in terms of proinflammatory bioactive molecule synthesis and secretion.

Keywords: Subclinical hypothyroidism; epicardial adipose tissue; monocyte chemo attractant protein-1; tumor necrosis factor-alpha
ÖZET
 Amaç: Epikardiyal yağ dokusu (EYD), miyokardiyal yüzey ileperikardın visseral tabakası arasında yer alan bir yağ dokusudur. Epikardiyal yağ doku kalınlığı (EYDK) aterosklerozun belirteçlerinden biridir. Subklinik hipotiroidili (SKH) hastalarda, EYDK'nin arttığı bildirilmektedir. EYD'nin adipokin/ sitokin aracılı parakrin ve vazokrin yolaklar ile koroner ateroskleroza neden olabileceği öne sürülmektedir. Ancak SKH'de proinflamatuar sitokinler ile EYDK'nin ilişkisi net değildir. Bu çalışmada, SKH'de EYDK'nin proinflamatuar sitokinler [interlökin (IL-6), yüksek hassasiyetli C-reaktif protein (high sensitivity C-reactive protein 'hs-CRP'), monosit kemoatraktan protein-1 (monocyte chemo attractant protein-1 'MCP-1') ve tümö rnekrozis faktöralfa (TNF-α)] ile ilişkisinin değerlendirilmesi amaçlandı. Gereç ve Yöntemler: SKH tanılı 32 olgu ve 27 sağlıklı gönüllü prospektif olarak çalışmaya dâhil edildi. Olguların EYDK'lari ekokardiyografiile ölçüldü. Eş zamanlı alınan serum örneklerinde IL-6, hs- CRP, MCP-1 ve TNF-α düzeyleri ölçüldü. Bulgular: SKH'li olgularda, EYDK kontrol grubuna göre anlamlı yüksekti (p=0,05). Gruplar yaş, beden kitle indeksi, total kolesterol, düşük yoğunluklu lipoprotein kolesterol düzeyleri açısından benzerdi; ancak yüksek yoğunluklu lipoprotein kolesterol SKH grubunda anlamlı olarak yüksek bulundu (p=0,034). Hasta grubu ve kontrol grubu arasında IL-6, hs-CRP, MCP-1 ve TNF-α açısından anlamlı farklılık saptanmadı. Sonuç: SKH olgularında, EYDK artmış olarak saptandı. Karşıt olarak serum proinflamatuar sitokinlerin düzeyleri kontrol grubundan farklı değildi. Proinflamatuar sitokinlerle EYDK arasında anlamlı ilişki bulunamadı. EYDK, aterosklerozun bir göstergesi olmasına rağmen proinflamatuar biyoaktif molekül sentezi ve salgılanması açısından SKH durumunda farklı kontrol mekanizmalarına sahip olabilir.

Anahtar Kelimeler: Subklinik hipotiroidi; epikardiyal adipoz doku; monosit kemoatraktan protein-1; tümör nekrozis faktör-alfa
REFERENCES:
  1. Cooper DS. Clinical practice. Subclinical hypothyroidism. N Engl J Med. 2001;345(4):260-5. [Crossref]  [PubMed] 
  2. Moon S, Kong SH, Choi HS, Hwangbo Y, Lee MK, Moon JH, et al. Relation of subclinical hypothyroidism is associated with cardiovascular events and all-cause mortality in adults with high cardiovascular risk. Am J Cardiol. 2018;122(4):571-7. [Crossref]  [PubMed] 
  3. Moon S, Kim MJ, Yu JM, Yoo HJ, Park YJ. Subclinical hypothyroidism and the risk of cardiovascular disease and all-cause mortality: a meta-analysis of prospective cohort studies. Thyroid. 2018;28(9):1101-10. [Crossref]  [PubMed] 
  4. Sun J, Yao L, Fang Y, Yang R, Chen Y, Yang K, et al. Relationship between subclinical thyroid dysfunction and the risk of cardiovascular outcomes: a systematic review and meta-analysis of prospective cohort studies. Int J Endocrinol. 2017;2017:8130796. [Crossref]  [PubMed]  [PMC] 
  5. Kang YE, Kim JM, Joung KH, Lee JH, You BR, Choi MJ, et al. The roles of adipokines, proinflammatory cytokines, and adipose tissue macrophages in obesity-associated ınsulin resistance in modest obesity and early metabolic dysfunction. PLoS One. 2016;11(4):e0154003. [Crossref]  [PubMed]  [PMC] 
  6. Iozzo P. Myocardial, perivascular, and epicardial fat. Diabetes Care. 2011;34 Suppl 2(Suppl 2):S371-9. [Crossref]  [PubMed]  [PMC] 
  7. Sacks HS, Fain JN. Human epicardial adipose tissue: a review. Am Heart J. 2007;153(6):907-17. [Crossref]  [PubMed] 
  8. Nagy E, Jermendy AL, Merkely B, Maurovich-Horvat P. Clinical importance of epicardial adipose tissue. Arch Med Sci. 2017;13(4):864-74. [Crossref]  [PubMed]  [PMC] 
  9. Korkmaz L, Sahin S, Akyuz AR, Ziyrek M, Anaforoglu I, Kose M, et al. Epicardial adipose tissue increased in patients with newly diagnosed subclinical hypothyroidism. Med Princ Pract. 2013;22(1):42-6. [Crossref]  [PubMed]  [PMC] 
  10. Unubol M, Eryilmaz U, Guney E, Akgullu C, Kurt Omurlu I. Epicardial adipose tissue in patients with subclinical hypothyroidism. Minerva Endocrinol. 2014;39(2):135-40. [PubMed] 
  11. Balta S, Demırkol S, Kucuk U, Arslan Z, Unlu M, Yesil FG. Epicardial adipose tissue should be evaluated with other inflammatory markers in patients with subclinical hypothyroidism. Med Princ Pract. 2013;22(6):603. [Crossref]  [PubMed]  [PMC] 
  12. Serter R, Demirbas B, Korukluoglu B, Culha C, Cakal E, Aral Y. The effect of L-thyroxine replacement therapy on lipid based cardiovascular risk in subclinical hypothyroidism. J Endocrinol Invest. 2004;27(10):897-903. [Crossref]  [PubMed] 
  13. Aydogdu A, Karakas EY, Erkus E, Altıparmak İH, Savık E, Ulas T, et al. Epicardial fat thickness and oxidative stress parameters in patients with subclinical hypothyroidism. Arch Med Sci. 2017;13(2):383-9. [Crossref]  [PubMed]  [PMC] 
  14. Mattace-Raso FU, van der Cammen TJ, Hofman A, van Popele NM, Bos ML, Schalekamp MA, et al. Arterial stiffness and risk of coronary heart disease and stroke: the Rotterdam Study. Circulation. 2006;113(5):657-63. [Crossref]  [PubMed] 
  15. Yao K, Zhao T, Zeng L, Yang J, Liu Y, He Q, et al. Non-invasive markers of cardiovascular risk in patients with subclinical hypothyroidism: A systematic review and meta-analysis of 27 case control studies. Sci Rep. 2018;8(1):4579. [Crossref]  [PubMed]  [PMC] 
  16. Rodondi N, den Elzen WP, Bauer DC, Cappola AR, Razvi S, Walsh JP, et al; Thyroid Studies Collaboration. Subclinical hypothyroidism and the risk of coronary heart disease and mortality. JAMA. 2010;304(12):1365-74. [Crossref]  [PubMed]  [PMC] 
  17. Collet TH, Bauer DC, Cappola AR, Asvold BO, Weiler S, Vittinghoff E, et al; Thyroid Studies Collaboration. Thyroid antibody status, subclinical hypothyroidism, and the risk of coronary heart disease: an individual participant data analysis. J Clin Endocrinol Metab. 2014;99(9):3353-62. [Crossref]  [PubMed]  [PMC] 
  18. Lee Y, Lim YH, Shin JH, Park J, Shin J. Impact of subclinical hypothyroidism on clinical outcomes following percutaneous coronary intervention. Int J Cardiol. 2018;253:155-60. [Crossref]  [PubMed] 
  19. Blum MR, Gencer B, Adam L, Feller M, Collet TH, da Costa BR, et al. Impact of thyroid hormone therapy on atherosclerosis in the elderly with subclinical hypothyroidism: a randomized trial. J Clin Endocrinol Metab. 2018;103(8):2988-97. [Crossref]  [PubMed] 
  20. Seo C, Kim S, Lee M, Cha MU, Kim H, Park S, et al. Thyroid hormone replacement reduces the risk of cardiovascular diseases in diabetic nephropathy patients with subclinical hypothyroidism. Endocr Pract. 2018;24(3):265-72. [Crossref]  [PubMed] 
  21. Kanaya AM, Harris F, Volpato S, Pérez-Stable EJ, Harris T, Bauer DC. Association between thyroid dysfunction and total cholesterol level in an older biracial population: the health, aging and body composition study. Arch Intern Med. 2002;162(7):773-9. [Crossref]  [PubMed] 
  22. Bauer DC, Ettinger B, Browner WS. Thyroid functions and serum lipids in older women: a population-based study. Am J Med. 1998;104(6):546-51. [Crossref]  [PubMed] 
  23. Imaizumi M, Akahoshi M, Ichimaru S, Nakashima E, Hida A, Soda M, et al. Risk for ischemic heart disease and all-cause mortality in subclinical hypothyroidism. J Clin Endocrinol Metab. 2004;89(7):3365-70. [Crossref]  [PubMed] 
  24. Iacobellis G, Bianco AC. Epicardial adipose tissue: emerging physiological, pathophysiological and clinical features. Trends Endocrinol Metab. 2011;22(11):450-7. [Crossref]  [PubMed]  [PMC] 
  25. Xu Y, Cheng X, Hong K, Huang C, Wan L. How to interpret epicardial adipose tissue as a cause of coronary artery disease: a meta-analysis. Coron Artery Dis. 2012;23(4):227-33. [Crossref]  [PubMed] 
  26. Silaghi A, Piercecchi-Marti MD, Grino M, Leonetti G, Alessi MC, Clement K, et al. Epicardial adipose tissue extent: relationship with age, body fat distribution, and coronaropathy. Obesity (Silver Spring). 2008;16(11):2424-30. [Crossref]  [PubMed] 
  27. Eiras S, Teijeira-Fernández E, Salgado-Somoza A, Couso E, García-Caballero T, Sierra J, et al. Relationship between epicardial adipose tissue adipocyte size and MCP-1 expression. Cytokine. 2010;51(2):207-12. [Crossref]  [PubMed] 
  28. Kokkotou E, Marafelia P, Mantzos EI, Tritos NA. Serum monocyte chemoattractant protein-1 is increased in chronic autoimmune thyroiditis. Metabolism. 2002;51(11):1489-93. [Crossref]  [PubMed] 

.: Up To Date

.: Process List

Login

 Forgot your password?

 New Registration  

Contact

Ortadoğu Reklam Tanıtım Yayıncılık Turizm Eğitim İnşaat Sanayi ve Ticaret A.Ş.

.: Address

Turkocagi Caddesi No:30 06520 Balgat / ANKARA
Phone: +90 312 286 56 56
Fax: +90 312 220 04 70
E-mail: info@turkiyeklinikleri.com

.: Manuscript Editing Department

Phone: +90 312 286 56 56/ 2
E-mail: yaziisleri@turkiyeklinikleri.com

.: English Language Redaction

Phone: +90 312 286 56 56/ 145
E-mail: tkyayindestek@turkiyeklinikleri.com

.: Marketing Sales-Project Department

Phone: +90 312 286 56 56/ 142
E-mail: reklam@turkiyeklinikleri.com

.: Subscription and Public Relations Department

Phone: +90 312 286 56 56/ 118
E-mail: abone@turkiyeklinikleri.com

.: Customer Services

Phone: +90 312 286 56 56/ 118
E-mail: satisdestek@turkiyeklinikleri.com

1. TERMS OF USE

1.1. To use the web pages with http://www.turkiyeklinikleri.com domain name or the websites reached through the sub domain names attached to the domain name (They will be collectively referred as "SITE"), please read the conditions below. If you do not accept these terms, please cease to use the "SITE." "SITE" owner reserves the right to change the information on the website, forms, contents, the "SITE," "SITE" terms of use anytime they want.

1.2. The owner of the "SITE" is Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. (From now on it is going to be referred as "Turkiye Klinikleri", shortly) and it resides at Turkocagi cad. No:30, 06520 Balgat Ankara. The services in the "SITE" are provided by "Turkiye Klinikleri."

1.3. Anyone accessing the "SITE" with or without a fee whether they are a natural person or a legal identity is considered to agree these terms of use. In this contract hereby, "Turkiye Klinikleri" may change the stated terms anytime. These changes will be published in the "SITE" periodically and they will be valid when they are published. Any natural person or legal identity benefiting from and reaching to the "SITE" are considered to be agreed to any change on hereby contract terms done by "Turkiye Klinikleri."

1.4. The "Terms of Use" hereby is published in the website with the last change on March 30th 2014 and the "SITE" is activated by enabling the access to everyone. The "Terms of Use" hereby is also a part of the any "USER Contract" was and/or will be done with the users using "Turkiye Klinikleri" services with or without a fee an inseparable.

2. DEFINITIONS

2.1. "SITE": A website offering different kind of services and context with a certain frame determined by "Turkiye Klinikleri" and it is accessible on-line on http://www.turkiyeklinikleri.com domain name and/or subdomains connected to the domain name.

2.2. USER: A natural person or a legal identity accessing to the "SITE" through online settings.

2.3. LINK: A link enabling to access to another website through the "SITE", the files, the context or through another website to the "SITE", the files and the context.

2.4. CONTEXT: Any visual, literary and auditory images published in the "Turkiye Klinikleri", "SITE" and/or any website or any accessible information, file, picture, number/figures, price, etc.

2.5. "USER CONTRACT": An electronically signed contract between a natural or a legal identity benefiting from special services "Turkiye Klinikleri" will provide and "Turkiye Klinikleri".

3. SCOPE OF THE SERVICES

3.1. "Turkiye Klinikleri" is completely free to determine the scope and quality of the services via the "SITE".

3.2. To benefit the services of "Turkiye Klinikleri" "SITE", the "USER" must deliver the features that will be specified by "Turkiye Klinikleri". "Turkiye Klinikleri" may change this necessity any time single-sided.

3.3. Not for a limited number, the services "Turkiye Klinikleri" will provide through the "SITE" for a certain price or for free are;

- Providing scientific articles, books and informative publications for health industry.

- Providing structural, statistical and editorial support to article preparation stage for scientific journals.

4. GENERAL PROVISIONS

4.1. "Turkiye Klinikleri" is completely free to determine which of the services and contents provided in the "SITE" will be charged.

4.2. People benefiting from the services provided by "Turkiye Klinikleri" and using the website can use the "SITE" only according to the law and only for personal reasons. Users have the criminal and civil liability for every process and action they take in the "SITE". Every USER agrees, declares and undertakes that they will not proceed by any function or action infringement of rights of "Turkiye Klinikleri"s and/or other third parties', they are the exclusive right holder on usage, processing, storage, made public and revealing any written, visual or auditory information reported to Turkiye Klinikleri" and/or "SITE" to the third parties. "USER" agrees and undertakes that s/he will not duplicate, copy, distribute, process, the pictures, text, visual and auditory images, video clips, files, databases, catalogs and lists within the "SITE", s/he will not be using these actions or with other ways to compete with "Turkiye Klinikleri", directly or indirectly.

4.3. The services provided and the context published within the "SITE" by third parties is not under the responsibility of "Turkiye Klinikleri", institutions collaborated with "Turkiye Klinikleri", "Turkiye Klinikleri" employee and directors, "Turkiye Klinikleri" authorized salespeople. Commitment to accuracy and legality of the published information, context, visual and auditory images provided by any third party are under the full responsibility of the third party. "Turkiye Klinikleri" does not promise and guarantee the safety, accuracy and legality of the services and context provided by a third party.

4.4. "USER"s cannot act against "Turkiye Klinikleri", other "USER"s and third parties by using the "SITE". "Turkiye Klinikleri" has no direct and/or indirect responsibility for any damage a third party suffered or will suffer regarding "USER"s actions on the "SITE" against the rules of the hereby "Terms of Use" and the law.

4.5. "USER"s accept and undertake that the information and context they provided to the "SITE" are accurate and legal. "Turkiye Klinikleri" is not liable and responsible for promising and guaranteeing the verification of the information and context transmitted to "Turkiye Klinikleri" by the "USER"s, or uploaded, changed and provided through the "SITE" by them and whether these information are safe, accurate and legal.

4.6. "USER"s agree and undertake that they will not perform any action leading to unfair competition, weakening the personal and commercial credit of "Turkiye Klinikleri" and a third party,  encroaching and attacking on personal rights within the "SITE" in accordance with the Turkish Commercial Code Law.

4.7. "Turkiye Klinikleri" reserves the right to change the services and the context within the "SITE"  anytime. "Turkiye Klinikleri" may use this right without any notification and timelessly. "USER"s have to make the changes and/or corrections "Turkiye Klinikleri" required immediately. Any changes and/or corrections that are required by "Turkiye Klinikleri", may be made by "Turkiye Klinikleri" when needed. Any harm, criminal and civil liability resulted or will result from changes and/or corrections required by "Turkiye Klinikleri" and were not made on time by the "USER"s belongs completely to the users.

4.8. "Turkiye Klinikleri" may give links through the "SITE" to other websites and/or "CONTEXT"s and/or folders that are outside of their control and owned and run by third parties. These links are provided for ease of reference only and do not hold qualification for support the respective web SITE or the admin or declaration or guarantee for the information inside. "Turkiye Klinikleri" does not hold any responsibility over the web-sites connected through the links on the "SITE", folders and context, the services or products on the websites provided through these links or their context.

4.9. "Turkiye Klinikleri" may use the information provided to them by the "USERS" through the "SITE" in line with the terms of the "PRIVACY POLICY" and "USER CONTRACT". It may process the information or classify and save them on a database. "Turkiye Klinikleri" may also use the USER's or visitor's identity, address, e-mail address, phone number, IP number, which sections of the "SITE" they visited, domain type, browser type, date and time information to provide statistical evaluation and customized services.

5. PROPRIETARY RIGHTS

5.1. The information accessed through this "SITE" or provided by the users legally and all the elements (including but not limited to design, text, image, html code and other codes) of the "SITE" (all of them will be called as studies tied to "Turkiye Klinikleri"s copyrights) belongs to "Turkiye Klinikleri". Users do not have the right to resell, process, share, distribute, display or give someone permission to access or to use the "Turkiye Klinikleri" services, "Turkiye Klinikleri" information and the products under copyright protection by "Turkiye Klinikleri". Within hereby "Terms of Use" unless explicitly permitted by "Turkiye Klinikleri" nobody can reproduce, process, distribute or produce or prepare any study from those under "Turkiye Klinikleri" copyright protection.

5.2. Within hereby "Terms of Use", "Turkiye Klinikleri" reserves the rights for "Turkiye Klinikleri" services, "Turkiye Klinikleri" information, the products associated with "Turkiye Klinikleri" copyrights, "Turkiye Klinikleri" trademarks, "Turkiye Klinikleri" trade looks or its all rights for other entity and information it has through this website unless it is explicitly authorized by "Turkiye Klinikleri".

6. CHANGES IN THE TERMS OF USE

"Turkiye Klinikleri" in its sole discretion may change the hereby "Terms of Use" anytime announcing within the "SITE". The changed terms of the hereby "Terms of Use" will become valid when they are announced. Hereby "Terms of Use" cannot be changed by unilateral declarations of users.

7. FORCE MAJEURE

"Turkiye Klinikleri" is not responsible for executing late or never of this hereby "Terms of Use", privacy policy and "USER Contract" in any situation legally taken into account as force majeure. Being late or failure of performance or non-defaulting of this and similar cases like this will not be the case from the viewpoint of "Turkiye Klinikleri", and "Turkiye Klinikleri" will not have any damage liability for these situations. "Force majeure" term will be regarded as outside of the concerned party's reasonable control and any situation that "Turkiye Klinikleri" cannot prevent even though it shows due diligence. Also, force majeure situations include but not limited to natural disasters, rebellion, war, strike, communication problems, infrastructure and internet failure, power cut and bad weather conditions.

8. LAW AND AUTHORISATION TO FOLLOW

Turkish Law will be applied in practicing, interpreting the hereby "Terms of Use" and managing the emerging legal relationships within this "Terms of Use" in case of finding element of foreignness, except for the rules of Turkish conflict of laws. Ankara Courts and Enforcement Offices are entitled in any controversy happened or may happen due to hereby contract.

9. CLOSING AND AGREEMENT

Hereby "Terms of Use" come into force when announced in the "SITE" by "Turkiye Klinikleri". The users are regarded to agree to hereby contract terms by using the "SITE". "Turkiye Klinikleri" may change the contract terms and the changes will be come into force by specifying the version number and the date of change on time it is published in the "SITE".

 

30.03.2014

Privacy Policy

We recommend you to read the terms of use below before you visit our website. In case you agree these terms, following our rules will be to your favor. Please read our Terms of Use thoroughly.

www.turkiyeklinikleri.com website belongs to Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. and is designed in order to inform physicians in the field of health

www.turkiyeklinikleri.com cannot reach to user’s identity, address, service providers or other information. The users may send this information to the website through forms if they would like to. However, www.turkiyeklinikleri.com may collect your hardware and software information. The information consists of your IP address, browser type, operating system, domain name, access time, and related websites. www.turkiyeklinikleri.com cannot sell the provided user information (your name, e-mail address, home and work address, phone number) to the third parties, publish it publicly, or keep it in the website. Gathered information has a directing feature to be a source for the website’s visitor profile, reporting and promotion of the services.

www.turkiyeklinikleri.com uses the taken information:

-To enhance, improve and maintain the quality of the website

-To generate visitor’s profile and statistical data

-To determine the tendency of the visitors on using our website

-To send print publications/correspondences

-To send press releases or notifications through e-mail

-To generate a list for an event or competition

By using www.turkiyeklinikleri.com you are considered to agree that;

-Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. cannot be hold responsible for any user’s illegal and immoral behavior,

-Terms of use may change from time to time,

-It is not responsible for other websites’ contents it cannot control or the harms they may cause although it uses the connection they provided.

Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. may block the website to users in the following events:

-Information with wrong, incomplete, deceiving or immoral expressions is recorded to the website,

-Proclamation, advertisement, announcement, libelous expressions are used against natural person or legal identity,

-During various attacks to the website,

-Disruption of the website because of a virus.

Written, visual and audible materials of the website, including the code and the software are under protection by legal legislation.

Without the written consent of Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. the information on the website cannot be downloaded, changed, reproduced, copied, republished, posted or distributed.

All rights of the software and the design of the website belong to Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc.

Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. will be pleased to hear your comments about our terms of use. Please share the subjects you think may enrich our website or if there is any problem regarding our website.

info@turkiyeklinikleri.com