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Shepherd JA, Shiozawa A, Schild AL, Singh D, Mancuso SA. Retrospective text and qualitative analyses of patient experience and management of vasomotor symptoms due to menopause: voices from the PatientsLikeMe community. Menopause 2024; 31:789-795. [PMID: 38980735 PMCID: PMC11469626 DOI: 10.1097/gme.0000000000002391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 04/08/2024] [Indexed: 07/11/2024]
Abstract
OBJECTIVE Vasomotor symptoms (VMS) due to menopause cause substantial burden and distress. Some women join online communities to share experiences and treatment outcomes through peer-to-peer interactions. This study describes women's experiences with VMS and symptom management on the PatientsLikeMe online support group. METHODS Mixed-methods research included women aged 40 to 65 years in the PatientsLikeMe community who were recruited using convenience sampling. Text from online posts by members was analyzed retrospectively using natural language processing. Relevant data, including numbers and percentages of women and frequencies of mentions, were summarized descriptively. Qualitative semistructured interviews were conducted; data, notes, and recordings were transcribed and deidentified and thematic analyses were performed. RESULTS Demographic information was available from 1,614 accounts included in retrospective text analyses. Women had a mean age of 56.7 years; most were White (87.8%) and not Hispanic/Latino (90.2%). Hot flashes and night sweats were most commonly mentioned symptoms (n = 146). Of 16 women who were interviewed, 14 met the inclusion criteria, and their responses were included in the analysis. VMS impacted life quality in terms of physical (43%) and mental well-being (36%), social activities (21%), and productivity (14%). Symptom management included temperature regulation (43%), lifestyle changes (36%), over-the-counter Estroven (29%), hormone therapy (21%), and contraceptives (21%). Half of the women were surprised by symptom intensity and duration; many felt unheard by their healthcare providers. CONCLUSIONS VMS have a substantial negative impact on multiple aspects of women's life. Management strategies for these symptoms vary widely, and many women feel unprepared for navigating the complex challenges of menopause.
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Claes M, Tuts L, Robijns J, Mulders K, Van De Werf E, Bulens P, Mebis J. Cancer therapy-related vaginal toxicity: its prevalence and assessment methods-a systematic review. J Cancer Surviv 2024:10.1007/s11764-024-01553-y. [PMID: 38383907 DOI: 10.1007/s11764-024-01553-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 02/13/2024] [Indexed: 02/23/2024]
Abstract
PURPOSE In 2020, almost 9 million women were diagnosed with cancer worldwide. Despite advancements in cancer treatment strategies, patients still suffer from acute and long-term side effects. This systematic review aims to evaluate the most frequently reported adverse effects in the genitourinary system and compare them across cancer types, treatment modalities, and evaluation methods. METHODS Pubmed Central, SCOPUS, and Cochrane Library were searched following the PRISMA guidelines to identify all prospective and retrospective observational cohort studies and randomized controlled trials assessing vaginal side effects of adult female cancer patients. The study quality was evaluated using The Newcastle-Ottawa Scale or the Risk of Bias 2 tool, as appropriate. RESULTS The most prevalent population was breast cancer patients, followed by gynaecological cancer patients. Overall, the focus was on vaginal dryness, while vaginal stenosis was the primary outcome in gynaecological cancer patients. Significant discrepancies were found in the frequency and severity of the reported adverse events. Most studies in this review evaluated side effects using patient-reported outcome measures (PROMs). CONCLUSIONS Genitourinary syndrome of menopause following cancer treatment is most frequently documented in breast and gynaecological cancer patients, often focussing on vaginal dryness and vaginal stenosis based on PROMs. This review provides a complete overview of the literature, but more high-quality clinical trials are necessary to draw firm conclusions on acute and chronic vaginal toxicity following cancer treatment. IMPLICATIONS FOR CANCER SURVIVORS This review could help improve the current preventive and curative management options for genitourinary complications, thereby increasing the patient's QoL and sexual functioning.
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Affiliation(s)
- Marithé Claes
- Faculty of Medicine and Life Sciences, Hasselt University, Martelarenlaan 42, 3500, Hasselt, Belgium.
- LCRC, Hasselt, Belgium.
- Dept. Medical Oncology, Jessa Hospital, Salvatorstraat 20, 3500, Hasselt, Belgium.
- Dept. Jessa & Science, Jessa Hospital, Salvatorstraat 20, 3500, Hasselt, Belgium.
| | - L Tuts
- Faculty of Medicine and Life Sciences, Hasselt University, Martelarenlaan 42, 3500, Hasselt, Belgium
- LCRC, Hasselt, Belgium
- Dept. Medical Oncology, Jessa Hospital, Salvatorstraat 20, 3500, Hasselt, Belgium
- Dept. Jessa & Science, Jessa Hospital, Salvatorstraat 20, 3500, Hasselt, Belgium
| | - J Robijns
- Faculty of Medicine and Life Sciences, Hasselt University, Martelarenlaan 42, 3500, Hasselt, Belgium
- LCRC, Hasselt, Belgium
- Dept. Medical Oncology, Jessa Hospital, Salvatorstraat 20, 3500, Hasselt, Belgium
- Dept. Jessa & Science, Jessa Hospital, Salvatorstraat 20, 3500, Hasselt, Belgium
| | - K Mulders
- LCRC, Hasselt, Belgium
- Dept. Medical Oncology, Jessa Hospital, Salvatorstraat 20, 3500, Hasselt, Belgium
- Dept. Jessa & Science, Jessa Hospital, Salvatorstraat 20, 3500, Hasselt, Belgium
| | - E Van De Werf
- LCRC, Hasselt, Belgium
- Dept. Radiation Oncology, Jessa Hospital, Salvatorstraat 20, 3500, Hasselt, Belgium
- Dept. Jessa & Science, Jessa Hospital, Salvatorstraat 20, 3500, Hasselt, Belgium
- Dept. Radiation Oncology, Ziekenhuis Oost-Limburg, Synaps Park 1, 3600, Genk, Belgium
- Dept. Future Health, Ziekenhuis Oost-Limburg, Synaps Park 1, 3600, Genk, Belgium
| | - P Bulens
- LCRC, Hasselt, Belgium
- Dept. Radiation Oncology, Jessa Hospital, Salvatorstraat 20, 3500, Hasselt, Belgium
- Dept. Jessa & Science, Jessa Hospital, Salvatorstraat 20, 3500, Hasselt, Belgium
- Dept. Radiation Oncology, Ziekenhuis Oost-Limburg, Synaps Park 1, 3600, Genk, Belgium
- Dept. Future Health, Ziekenhuis Oost-Limburg, Synaps Park 1, 3600, Genk, Belgium
| | - J Mebis
- Faculty of Medicine and Life Sciences, Hasselt University, Martelarenlaan 42, 3500, Hasselt, Belgium
- LCRC, Hasselt, Belgium
- Dept. Medical Oncology, Jessa Hospital, Salvatorstraat 20, 3500, Hasselt, Belgium
- Dept. Jessa & Science, Jessa Hospital, Salvatorstraat 20, 3500, Hasselt, Belgium
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Chang SY, Huang CC, Fan YH, Wu PW, Lee TJ, Chang PH, Huang CC. Identifying the Risk Factors for Orbital Complications in Isolated Sphenoid Rhinosinusitis. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:128. [PMID: 38256389 PMCID: PMC10818769 DOI: 10.3390/medicina60010128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 01/06/2024] [Accepted: 01/09/2024] [Indexed: 01/24/2024]
Abstract
Background and Objectives: Isolated sphenoid rhinosinusitis may have devastating consequences such as orbital complications due to its anatomical contiguity with vital structures. This study aimed to identify patients with isolated sphenoid inflammatory diseases at high risk for developing orbital complications and requiring aggressive management through investigation of the clinical and computed tomography (CT) characteristics of patients with isolated sphenoid rhinosinusitis. Materials and Methods: The medical records of patients who underwent endoscopic sinus surgery between 2005 and 2022 were retrospectively reviewed. Patients with isolated sphenoid rhinosinusitis were identified based on a manual review of the clinical and histopathological findings. Participants' clinical and CT features were reviewed. Results: Among the 118 patients with isolated sphenoid rhinosinusitis, 15 (12.7%) developed orbital complications, including diplopia, extraocular motility limitation, ptosis, and visual impairment. Headaches and facial pain occurred significantly more frequently in patients with orbital complications than in those without orbital complications (p < 0.001). Patients with diabetes mellitus or malignant neoplasms were more likely to develop orbital complications than those without these comorbidities (p < 0.05). Bony dehiscence on CT images was significantly more common in patients with orbital complications than in those without. In the regression analysis, diabetes mellitus (OR, 4.62), malignant neoplasm (OR, 4.32), and bony dehiscence (OR, 4.87) were significant predictors of orbital complications (p < 0.05). Conclusions: Headaches and facial pain are the most common symptoms of isolated sphenoid rhinosinusitis. Orbital complications of isolated sphenoid rhinosinusitis are more common in patients with comorbidities such as diabetes mellitus or malignancy or in those with bony dehiscence on CT images.
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Affiliation(s)
- Shiaw-Yu Chang
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan 333, Taiwan; (S.-Y.C.); (C.-C.H.); (Y.-H.F.); (P.-W.W.); (T.-J.L.); (P.-H.C.)
| | - Chi-Che Huang
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan 333, Taiwan; (S.-Y.C.); (C.-C.H.); (Y.-H.F.); (P.-W.W.); (T.-J.L.); (P.-H.C.)
- School of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Yu-Hsi Fan
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan 333, Taiwan; (S.-Y.C.); (C.-C.H.); (Y.-H.F.); (P.-W.W.); (T.-J.L.); (P.-H.C.)
| | - Pei-Wen Wu
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan 333, Taiwan; (S.-Y.C.); (C.-C.H.); (Y.-H.F.); (P.-W.W.); (T.-J.L.); (P.-H.C.)
- School of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Ta-Jen Lee
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan 333, Taiwan; (S.-Y.C.); (C.-C.H.); (Y.-H.F.); (P.-W.W.); (T.-J.L.); (P.-H.C.)
- School of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Department of Otolaryngology, Xiamen Chang Gung Hospital, Xiamen 361028, China
| | - Po-Hung Chang
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan 333, Taiwan; (S.-Y.C.); (C.-C.H.); (Y.-H.F.); (P.-W.W.); (T.-J.L.); (P.-H.C.)
| | - Chien-Chia Huang
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan 333, Taiwan; (S.-Y.C.); (C.-C.H.); (Y.-H.F.); (P.-W.W.); (T.-J.L.); (P.-H.C.)
- School of Medicine, Chang Gung University, Taoyuan 333, Taiwan
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Zilski N, Speiser D, Bartley J, Roehle R, Blohmer JU, Keilholz U, Goerling U. Quality of life after risk-reducing salpingo-oophorectomy in women with a pathogenic BRCA variant. J Sex Med 2023; 21:33-39. [PMID: 37973412 DOI: 10.1093/jsxmed/qdad143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/27/2023] [Accepted: 10/09/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Risk-reducing salpingo-oophorectomy (RRSO) is recommended to women with a pathogenic BRCA variant, but as a main side effect, RRSO could lead to an early onset of menopause. AIM To evaluate the impact of RRSO and preoperative menopausal status on menopausal symptoms, sexual functioning, and quality of life (QOL). METHODS The study was conducted between November 2019 and April 2020. Women were included who tested positive for a pathogenic BRCA1/2 variant between 2015 and 2018. Depression levels, QOL, and global health status were measured and compared with those of women who opted against RRSO. Furthermore, women who underwent RRSO treatment were asked to report menopausal complaints that they experienced at 1 month postsurgery and any current complaints. OUTCOMES RRSO had no significant impact on QOL, but women who were premenopausal at the time of surgery reported more sexual complaints than postmenopausal women. RESULTS In total, 134 carriers of a BRCA mutation were included: 90 (67%) underwent RRSO and 44 (33%) did not. At the time of the survey, neither the control nor experimental group experienced significant changes in QOL (b = -0.18, P = .59). Women who underwent RRSO reported a significantly lower global health status (b = -0.66, P = .05). Women who were premenopausal at the time of surgery were bothered more by sexual symptoms (b = 0.91, P = .19) but experienced fewer vasomotor complaints (b = -1.09, P = .13) than women who were postmenopausal at the time of RRSO. CLINICAL IMPLICATIONS The decrease of sexual functioning after RRSO should be an integral part of preoperative counseling because it is important for BRCA carriers, especially for premenopausal women. STRENGTHS AND LIMITATIONS Some strengths of the present study were the long follow-up, a high response rate, and the existence of a control group, whereas defining menopausal status by last menstrual bleeding and self-report of data (eg, breast cancer history) increased the risk of errors. CONCLUSION Our study indicated that women who underwent RRSO experienced no difference in QOL when compared with women without RRSO and that patients with premenopausal status seemed to be at higher risk to experience sexual complaints after surgery.
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Affiliation(s)
- Nicole Zilski
- Hereditary Breast and Ovarian Cancer Center, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
- Department of Gynecology, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Dorothee Speiser
- Hereditary Breast and Ovarian Cancer Center, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
- Department of Gynecology, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Julia Bartley
- Department of Gynecology, Universitätsklinikum Magdeburg, 39108 Magdeburg, Germany
- TFP Fertility Berlin, 10117 Berlin, Germany
| | - Robert Roehle
- Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
- Clinical Study Center, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
- Berlin Institute of Health, 10178, Berlin, Germany
| | - Jens-Uwe Blohmer
- Department of Gynecology, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Ulrich Keilholz
- Comprehensive Cancer Center, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Ute Goerling
- Comprehensive Cancer Center, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
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Fan YH, Shih KY, Wu PW, Huang YL, Lee TJ, Huang CC, Chang PH, Huang CC. Predicting the Probability of the Incidence of Maxillary Sinus Fungus Ball in Patients Using Nomogram Models. Diagnostics (Basel) 2023; 13:3156. [PMID: 37835900 PMCID: PMC10572425 DOI: 10.3390/diagnostics13193156] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/06/2023] [Accepted: 10/02/2023] [Indexed: 10/15/2023] Open
Abstract
Maxillary sinus fungal ball (MSFB) is the most common type of non-invasive fungal rhinosinusitis. Since MSFB requires a unique treatment strategy and is associated with potentially severe complications, timely and precise diagnosis is crucial. Computed tomography (CT) is the first-line imaging tool for evaluating chronic rhinosinusitis. Accordingly, we aimed to investigate the clinical and CT imaging characteristics of MSFB. We retrospectively enrolled 97 patients with unilateral MSFB and 158 with unilateral non-fungal maxillary rhinosinusitis. The clinical characteristics, laboratory data, and CT imaging features of participants were evaluated. Older age, female sex, lower white blood cell and neutrophil counts, and CT imaging features (including an irregular surface, erosion of the medial sinus wall, sclerosis of the lateral sinus wall, and intralesional hyperdensity) were significantly associated with MSFB. The presence of adjacent maxillary odontogenic pathology was associated with a decreased likelihood of the incidence of MSFB in unilateral maxillary rhinosinusitis. Separate nomograms were created for patients, without and with the use of CT scan, to predict the probabilities of MSFB in patients with unilateral maxillary rhinosinusitis. We proposed two nomograms based on the clinical and CT characteristics of patients with MSFB. These could serve as evaluation tools to assist clinicians in determining the need for undergoing CT and facilitate the accurate and timely diagnosis of MSFB.
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Affiliation(s)
- Yu-Hsi Fan
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 333, Taiwan (P.-W.W.); (T.-J.L.); (C.-C.H.); (P.-H.C.)
| | - Kai-Yi Shih
- School of Traditional Chinese Medicine, Chang Gung University, Taoyuan 333, Taiwan;
| | - Pei-Wen Wu
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 333, Taiwan (P.-W.W.); (T.-J.L.); (C.-C.H.); (P.-H.C.)
- School of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Yen-Lin Huang
- Department of Anatomic Pathology, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 333, Taiwan;
- School of Medicine, National Tsing-Hua University, Hsinchu 300, Taiwan
- Institute of Stem Cell and Translational Cancer Research, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Ta-Jen Lee
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 333, Taiwan (P.-W.W.); (T.-J.L.); (C.-C.H.); (P.-H.C.)
- School of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Department of Otolaryngology, Xiamen Chang Gung Hospital, Xiamen 361028, China
| | - Chi-Che Huang
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 333, Taiwan (P.-W.W.); (T.-J.L.); (C.-C.H.); (P.-H.C.)
- School of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Po-Hung Chang
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 333, Taiwan (P.-W.W.); (T.-J.L.); (C.-C.H.); (P.-H.C.)
| | - Chien-Chia Huang
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 333, Taiwan (P.-W.W.); (T.-J.L.); (C.-C.H.); (P.-H.C.)
- School of Medicine, Chang Gung University, Taoyuan 333, Taiwan
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Wu PW, Lee TJ, Yang SW, Huang Y, Lee YS, Ho CF, Huang CC. Differences in clinical and imaging presentation of maxillary sinus fungus ball with and without intralesional hyperdensity. Sci Rep 2021; 11:23945. [PMID: 34907314 PMCID: PMC8671531 DOI: 10.1038/s41598-021-03507-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 12/01/2021] [Indexed: 11/09/2022] Open
Abstract
Maxillary sinus fungal balls (MSFBs) mostly occur in older individuals and demonstrate female predominance. Early diagnosis is important to avoid treatment delays. Intralesional hyperdensity (IH) indicates the presence of heavy metal deposition within fungal hyphae and has been the most specific characteristic of MSFB on computed tomography (CT). For those without IH on CT, the diagnosis of MSFB remains challenging. This study aimed to characterize clinical presentation of MSFB with and without IH and to study factors contributing to MSFB with no IH formation. We retrospectively identified 588 patients with MSFB. The clinical characteristics and CT findings were reviewed. Patients with unilateral MSFB had a mean age of 57.4 years and demonstrated female predominance (64.63%). The female-to-male ratio was highest at 51–60 years (2.02) and rose to 2.60 in MSFB with IH only. Compared to those with IH, MSFB without IH was significantly more common in males (OR = 2.49), in those with diabetes mellitus (DM) (OR = 1.87), adjacent maxillary odontogenic pathology (OR = 1.75). Complete opacification on CT was less common in MSFB without IH (OR = 0.60). Patients with MSFB without IH were more likely to have DM, no female predominance, adjacent maxillary odontogenic pathology, and partial opacification of the sinus, compared to those with IH. These may be helpful in better understanding of the formation of MSFBs without IH, early identification of them and prevention of post-operative recurrence.
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Affiliation(s)
- Pei-Wen Wu
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, No. 5, Fu-Shin Street, Kweishan, Taoyuan, 333, Taiwan, ROC.,Department of Otolaryngology-Head and Neck Surgery, Chang Gung Memorial Hospital and Chang Gung University, Keelung, Taiwan, ROC
| | - Ta-Jen Lee
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, No. 5, Fu-Shin Street, Kweishan, Taoyuan, 333, Taiwan, ROC.,School of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC.,Xiamen Chang Gung Hospital, Xiamen, People's Republic of China
| | - Shih-Wei Yang
- Department of Otolaryngology-Head and Neck Surgery, Chang Gung Memorial Hospital and Chang Gung University, Keelung, Taiwan, ROC.,School of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC
| | - Yenlin Huang
- Department of Anatomic Pathology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan, ROC
| | - Yun-Shien Lee
- Department of Biotechnology, Ming Chuan University, Taoyuan, Taiwan, ROC.,Genomic Medicine Research Core Laboratory, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan, ROC
| | - Che-Fang Ho
- Department of Otolaryngology-Head and Neck Surgery, Chang Gung Memorial Hospital and Chang Gung University, Keelung, Taiwan, ROC
| | - Chien-Chia Huang
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, No. 5, Fu-Shin Street, Kweishan, Taoyuan, 333, Taiwan, ROC. .,School of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC. .,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC.
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