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Li Y, Li Q, Zhao G, Zhang H, Zhong H, Zeng Y. Nalbuphine in Pediatric Emergence Agitation Following Cochlear Implantation: A Randomized Trial. Drug Des Devel Ther 2024; 18:2837-2845. [PMID: 39006192 PMCID: PMC11244056 DOI: 10.2147/dddt.s451089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 04/30/2024] [Indexed: 07/16/2024] Open
Abstract
Background To investigate the effects of nalbuphine on emergency agitation (EA), which affects up to 80% of the children following otolaryngology procedures, in children undergoing cochlear implantation. Methods A prospective double-blinded randomized controlled clinical trial was conducted between November 2020 and October 2022. Eligible children, aged 6 months to 3 years old, were randomly assigned to either 0.1 mg/kg, 0.15 mg/kg, 0.2 mg/kg nalbuphine or 0.9% saline groups. EA was defined by the Pediatric Anesthesia Emergence Delirium (PAED) score ≥10. Extubation time, post-anesthesia care unit (PACU) length of stay, severe EA (PAED ≥ 15), peak PAED score, the Faces, Legs, Activity, Cry, and Consolability (FLACC) scale, Ramsay sedation score, and adverse events were also recorded. Results A total of 104 children were enrolled, with 26 children in each group. Nalbuphine significantly reduced the EA occurrence from 73.1% in the saline group to 38.5%, 30.8%, and 26.9% in the 0.1 mg/kg, 0.15 mg/kg, and 0.2 mg/kg nalbuphine groups, respectively (P < 0.001), without affecting the extubation time and PACU length of stay. More children (34.6%) in the 0.9% saline group experienced severe EA. Higher dose nalbuphine (0.15 mg/kg, 0.2 mg/kg) showed lower peak PAED score, better analgesia and sedation effect compared with 0.1 mg/kg nalbuphine and saline groups. However, 0.2mg/kg nalbuphine caused undesired over-sedation in two (7.7%) children. No other adverse events were reported. Conclusion Young children undergoing cochlear implantation surgery were at a high risk of EA and postoperative pain, while 0.2 mg/kg nalbuphine might be an ideal candidate for EA and pain prevention when used under close monitoring. Trial Registration ChiCTR2000040407.
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Affiliation(s)
- Yan Li
- Department of Anesthesia and Perioperative Medicine, Xijing Hospital, the Fourth Military Medical University, Xi’an, 710000, People’s Republic of China
| | - Qi Li
- Department of Anesthesia and Perioperative Medicine, Xijing Hospital, the Fourth Military Medical University, Xi’an, 710000, People’s Republic of China
| | - Guangchao Zhao
- Department of Anesthesia and Perioperative Medicine, Xijing Hospital, the Fourth Military Medical University, Xi’an, 710000, People’s Republic of China
| | - Haopeng Zhang
- Department of Anesthesia and Perioperative Medicine, Xijing Hospital, the Fourth Military Medical University, Xi’an, 710000, People’s Republic of China
| | - Haixing Zhong
- Department of Anesthesia and Perioperative Medicine, Xijing Hospital, the Fourth Military Medical University, Xi’an, 710000, People’s Republic of China
| | - Yi Zeng
- Department of Anesthesia and Perioperative Medicine, Xijing Hospital, the Fourth Military Medical University, Xi’an, 710000, People’s Republic of China
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Lütze C, Weber TP, Lücke T, Gude P, Georgevici AI. Incidence of emergence delirium after homeostasis-guided pediatric anesthesia for ear-nose-throat surgery. Minerva Anestesiol 2024; 90:644-653. [PMID: 39021140 DOI: 10.23736/s0375-9393.24.17847-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
BACKGROUND Emergence delirium is a complication of pediatric anesthesia during the early recovery period. Children undergoing ear, nose, and throat surgery are at high risk. The Pediatric Assessment of Emergence Delirium (PAED) scale is used for diagnosis and founded to specify the degree of emergence delirium. However, there is no consensus regarding a threshold value for emergence delirium diagnosis. Homeostasis-guided pediatric general anesthesia aims to maintain physiological parameters within normal ranges. In this prospective, observational study we evaluated the incidence of emergence delirium in children undergoing elective ear, nose, and throat surgery under standardized homeostasis-guided general anesthesia. Secondarily, we identified risk factors associated with an increased PAED score. METHODS In children aged 0-6 years, we collected data from standard monitoring, depth of anesthesia, and preoperative glucose and ketone body levels. These variables were studied as risk or protective factors for increased PAED >0 scores using multivariate logistic regression. RESULTS Of the 105 children analyzed, only five children (4.7%) had emergence delirium according to a threshold PAED score ≥10, while 37 children (35%) had PAED scores >0. Statistical analysis of the PAED outcome identified two significant positive associations with pain (P<0.001) and preoperative blood glucose levels (P=0.006) and one negative association with preoperative ketone body levels (P<0.001). CONCLUSIONS Our cohort observed a lower incidence of emergence delirium than in the literature. Higher pain intensity and lower blood glucose levels were risk factors for PAED > 0, whereas preoperative ketone body levels were protective.
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Affiliation(s)
- Christian Lütze
- Department of Anesthesiology, St. Josef and St. Elisabeth Hospital, Ruhr University Bochum, Bochum, Germany -
| | - Thomas P Weber
- Department of Anesthesiology, St. Josef and St. Elisabeth Hospital, Ruhr University Bochum, Bochum, Germany
| | - Thomas Lücke
- University Children's Hospital, St. Josef and St. Elisabeth Hospital, Ruhr University Bochum, Bochum, Germany
| | - Philipp Gude
- Department of Anesthesiology, St. Josef and St. Elisabeth Hospital, Ruhr University Bochum, Bochum, Germany
| | - Adrian-Iustin Georgevici
- Department of Anesthesiology, St. Josef and St. Elisabeth Hospital, Ruhr University Bochum, Bochum, Germany
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Henry E, Chen-Lim ML. Does Postanesthesia Forced-Air Warming Affect Emergence Delirium in Pediatric Patients Receiving Daily Anesthesia? J Perianesth Nurs 2024:S1089-9472(24)00041-8. [PMID: 38852105 DOI: 10.1016/j.jopan.2024.01.021] [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: 09/15/2023] [Revised: 01/13/2024] [Accepted: 01/24/2024] [Indexed: 06/10/2024]
Abstract
PURPOSE To determine if postanesthesia forced-air warming as a nonpharmacologic intervention for emergence delirium (ED)/emergence agitation (EA) decreased the incidence and severity of ED in children aged 18 months to 6 years old. DESIGN Prospective nonrandomized controlled trial. METHODS Participants included children aged 18 months to 6 years old receiving general anesthesia within a radiation oncology setting. Status of ED/EA was based on the participants' Pediatric Anesthesia Emergence Delirium (PAED) scale score (two consecutive scores greater than 10 out of 20) or inconsolable agitation behaviors post computed tomography simulation (day 0). Interrater reliability was conducted among the center's perianesthesia care nurses. Participants who scored positive for ED/EA received a forced-air warming blanket for the remainder of treatment with data collection 1 to 14 days postanesthesia. Non-ED/EA participants were followed for 14 days and provided forced-air warming if ED/EA occurred. Data consisted of daily PAED scores and self- or parent-report on the anxiety scale. If the participants received forced-air warming, nurses' clinical observations and parent satisfaction surveys were collected 3 times during the 14-day study period. FINDINGS A total of 59 participants completed the study (mean age 3.43 years; 60% male; 63% non-Hispanic White); 16 were identified with ED or EA (mean age 3.56 years; 50% male; 69% non-Hispanic White) with an incidence rate of 28%. For the 16 participants with ED/EA, the primary diagnosis consisted of solid tumors and an American Society of Anesthesia Classification III to IV. Prior to the forced-air warming intervention, all 16 participants exhibited inconsolable ED/EA behaviors, including 8 who had PAED scores greater than 10. ED/EA behaviors expressed included inconsolability, confusion, thrashing, and combativeness. Within the 14-day period, 3 participants received forced-air warming on day 1, while the other 13 received an average of 4.23 days of treatment (range 1 to 11 days; mode 1 day; median 4 days). Comparison of PAED scores pre (mean 4.4) and post (mean 1.8) indicated that the use of forced-air warming was statistically significant (P = .001). ED/EA behaviors and PAED scores after the forced-air warming period decreased in all but one participant. Some agitation behaviors were not captured within the PAED score. CONCLUSIONS Forced-air warming impacted PAED scores and agitation behaviors for studied participants, offering a safe, nonpharmacological nursing intervention that may be an effective tool for helping to manage this baffling condition.
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Affiliation(s)
- Elizabeth Henry
- Children's Hospital of Philadelphia, Philadelphia, PA; Hospital of the University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, PA.
| | - Mei Lin Chen-Lim
- Children's Hospital of Philadelphia, Philadelphia, PA; Thomas Jefferson University, College of Nursing, Philadelphia, PA; Center for Pediatric Nursing Research & Evidence-Based Practice, Children's Hospital of Philadelphia, Philadelphia, PA
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Li J, Zhu H, Wang Y, Chen J, He K, Wang S. Remifentanil is Superior to Propofol for Treating Emergence Agitation in Adults After General Anesthesia. Drug Des Devel Ther 2024; 18:341-350. [PMID: 38344258 PMCID: PMC10859049 DOI: 10.2147/dddt.s433155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 01/25/2024] [Indexed: 02/15/2024] Open
Abstract
Background Emergence agitation (EA) is one of the most common complications in clinical general anesthesia during recovery in adults. Remifentanil and propofol can reduce the incidence of EA, but with no randomized controlled trial to evaluate their effectiveness for treating EA. This study aims to compare the effectiveness of remifentanil and propofol for treating EA following general anesthesia. Patients and methods Among 152 randomized patients with a mean of 49.5 years, and 99 (65.1%) of them being male, 149 were divided into two groups for subsequent analysis. The remifentanil group (Group R, n = 74) received a 0.5μg kg-1 remifentanil infusion followed by a 0.05μg kg-1 min-1 infusion until 15 minutes, after the onset of agitation. The propofol group (Group P, n = 75) received a 1mg kg-1 propofol infusion once agitation occurred. Emergence agitation was assessed using the Riker Sedation Agitation Score, with a score of ≥5 defining emergence agitation. During the post-anesthesia care unit (PACU), the recurrence of emergence agitation, time to extubation, and discharge from PACU were evaluated. Results The incidence of reoccurring emergence agitation was lower in Group R (29.7%) compared with Group P (49.3%), with an odds ratio of 0.44 (95% CI 0.22-0.85; P=0.014). The time to extubation was shorter in Group R (mean 12min, range 8-15 min) compared with Group P (mean 17min, range 13-21 min) (P<0.001), as was the time discharge from the PACU (mean 30.5 min, range 25-40 min) vs Group P (mean 37.5 min, range 31-50 min) (P=0.001). Conclusion Treatment of emergence agitation in adults with remifentanil infusion is more effective than propofol, with a shorter time to extubation and discharge from PACU.
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Affiliation(s)
- Jun Li
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People’s Republic of China
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, People’s Republic of China
| | - Hongrui Zhu
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, People’s Republic of China
| | - Yu Wang
- Department of Anesthesiology, The First Affiliated Hospital of Soochow University, Soochow, People’s Republic of China
| | - Jiaqi Chen
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, People’s Republic of China
| | - Keqiang He
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, People’s Republic of China
| | - Sheng Wang
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, People’s Republic of China
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Frelich M, Lečbychová K, Vodička V, Ekrtová T, Sklienka P, Jor O, Straková H, Bílená M, Formánek M, Burša F. Effect of BIS-guided anesthesia on emergence delirium following general anesthesia in children: A prospective randomized controlled trial. Anaesth Crit Care Pain Med 2024; 43:101318. [PMID: 37918790 DOI: 10.1016/j.accpm.2023.101318] [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: 07/15/2023] [Revised: 10/25/2023] [Accepted: 10/26/2023] [Indexed: 11/04/2023]
Abstract
OBJECTIVE Emergence delirium (ED) is a postoperative complication in pediatric anesthesia characterized by a perception and psychomotor disorder, with a negative impact on postoperative recovery. As the use of inhalation anesthesia is associated with a higher incidence of ED, we investigated whether titrating the depth of general anesthesia with BIS monitor can reduce the incidence of ED. DESIGN Randomized, prospective, and double-blind. SETTING Patients undergoing endoscopic adenoidectomy under general anesthesia according to a uniform protocol. PATIENTS A total of 163 patients of both sexes aged 3-8 years were enrolled over 18 months. INTERVENTIONS Immediately after the induction of general anesthesia, a bispectral index (BIS) electrode was placed on the patient's forehead. In the study group, the depth of general anesthesia was monitored with the aim of achieving BIS values of 40-60. In the control group, the dose of sevoflurane was determined by the anaesthesiologist based on MAC (minimum alveolar concentration) and the end-tidal concentration. MEASUREMENTS The primary objective was to compare the occurrence of ED during the PACU (post-anesthesia care unit) stay in both arms of the study. The secondary objective was to determine the PAED score at 10 and 30 min in the PACU and the need for rescue treatment of ED. MAIN RESULTS 86 children were randomized in the intervention group and 77 children in the control group. During the entire PACU stay, 23.3% (38/163) of patients developed ED with PAED score >10: 35.1% (27/77) in the control group and 12.8% (11/86) in the intervention group (p = 0.001). Lower PAED scores were also found in the intervention group at 10 (p < 0.001) and 30 (p < 0.001) minutes compared to the control group. The need for rescue treatment did not differ between groups (p = 0.067). CONCLUSION Individualization of the depth of general anesthesia with BIS monitoring is an effective method of preventing ED in children. CLINICAL TRIAL REGISTRATION NCT04466579.
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Affiliation(s)
- Michal Frelich
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Ostrava, Czechia; Department of Intensive Medicine, Emergency Medicine and Forensic Studies, Faculty of Medicine, University of Ostrava, Czechia
| | - Karolína Lečbychová
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Ostrava, Czechia
| | - Vojtěch Vodička
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Ostrava, Czechia
| | - Tereza Ekrtová
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Ostrava, Czechia
| | - Peter Sklienka
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Ostrava, Czechia; Department of Intensive Medicine, Emergency Medicine and Forensic Studies, Faculty of Medicine, University of Ostrava, Czechia
| | - Ondřej Jor
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Ostrava, Czechia; Department of Intensive Medicine, Emergency Medicine and Forensic Studies, Faculty of Medicine, University of Ostrava, Czechia
| | - Hana Straková
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Ostrava, Czechia
| | - Markéta Bílená
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Ostrava, Czechia
| | - Martin Formánek
- Centre for Health Research, Faculty of Medicine, University of Ostrava, Czechia; Department of Paediatric Otorhinolaryngology, Faculty of Medicine, Masaryk University, Czechia
| | - Filip Burša
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Ostrava, Czechia; Department of Intensive Medicine, Emergency Medicine and Forensic Studies, Faculty of Medicine, University of Ostrava, Czechia.
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Cao H, Bao C, Tu H, Gao J, Huang J, Chen Q. Impact of intravenous administration of nalbuphine at different time points for postoperative analgesia and sedation in adenotonsillectomized children: a prospective, randomized controlled trial. WORLD JOURNAL OF PEDIATRIC SURGERY 2023; 6:e000662. [PMID: 38025902 PMCID: PMC10649886 DOI: 10.1136/wjps-2023-000662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 10/08/2023] [Indexed: 12/01/2023] Open
Abstract
Objective To compare the efficacy of intravenous administration of nalbuphine at different time points for postoperative analgesia and sedation in adenotonsillectomized children. Methods Patients with obstructive sleep apnea syndrome scheduled for adenotonsillectomy were randomly divided into group A (patients received intravenous nalbuphine 0.2 mg/kg before anesthesia induction), group B (patients received intravenous nalbuphine 0.2 mg/kg 10 min before the end of surgery), and group C (patients did not receive nalbuphine injection). The time points for measuring outcomes were before anesthesia induction (T0), extubation (T1), and 0, 15, 30, or 45 min in the postanesthesia care unit (PACU) (T2-T5, respectively). Results There were 40 patients in group A, 41 patients in group B and 39 patients in group C. Patients in group B had significantly lower FLACC (Face, Legs, Activity, Cry, Consolability) pain scores at T2-T5 than those in group C (all p<0.05). Patients in group B had higher Ramsay Sedation Score at T2-T4 than those in group C (all p<0.05). The proportion of patients who received remedial analgesia in the PACU in group A (17.5%, p=0.008) and group B (9.8%, p<0.001) was significantly lower than that in group C (46.2%). Conclusion Intravenous administration of nalbuphine 10 min before the end of adenotonsillectomy in children could decrease pain intensity and increase sedation levels during the recovery period with the reduction of remedial analgesia in the PACU.Trial registration number ChiCTR2200060118.
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Affiliation(s)
- Hongmin Cao
- Department of Anesthesiology, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang, China
| | - Chunying Bao
- Department of Anesthesiology, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang, China
| | - Haiya Tu
- Department of Anesthesiology, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang, China
| | - Jing Gao
- Department of Anesthesiology, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang, China
| | - Jinjin Huang
- Department of Anesthesiology, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang, China
| | - Qixing Chen
- Department of Clinical Research Center, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang, China
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Liang HH, Lu YW, Ou XX, Shi H, She YJ, Zhang MX. Effect of ice popsicle treatment on emergence agitation in children undergoing oral surgery with sevoflurane anaesthesia: A prospective randomized controlled study. J Pediatr Nurs 2023; 72:9-15. [PMID: 37030043 DOI: 10.1016/j.pedn.2023.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 03/24/2023] [Accepted: 03/24/2023] [Indexed: 04/10/2023]
Abstract
PURPOSE Emergence agitation is a common postoperative complication during recovery in children. The purpose of this study is to explore whether the use of ice popsicle could prevent emergence agitation in children undergoing oral surgery with sevoflurane anaesthesia. DESIGN AND METHODS In this prospective randomized controlled study, 100 children undergoing oral surgery were randomly assigned to Group 1 which received ice popsicle after emergence (intervention, n = 50) or Group 2 which received verbal encouragement from their parents (control, n = 50). The primary outcome was the 2-hour postoperative incidence of EA. RESULTS Group 1 had a significant lower incidence of emergence agitation (22% vs 58%, P < 0.001) compared with Group 2. The mean agitation score was significantly lower in Group 1 vs Group 2 at 10 minutes (1.64 vs 2.12, P = 0.024) and 20 min (1.60 vs 2.14, P = 0.004) after emergence. The peak agitation and pain scores were significantly lower in Group 1 than in Group 2 (P < 0.001). CONCLUSIONS Findings from this study suggest that ice popsicle is an effective, cheap, pleasurable, and easily administered method for alleviating emergence agitation in paediatric patients after oral surgery under general anaesthesia. These results are worthy of confirmation in other surgeries. PRACTICE IMPLICATIONS This approach is highly accepted by both children and their parents, and our findings support the effectiveness of ice popsicle in relieving emergence agitation and pain after oral surgery in children. CLINICAL TRIALS REGISTRATION Chinese Clinical Trial Registry, ChiCTR1800015634.
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Affiliation(s)
- Hui-Hong Liang
- Department of Anaesthesiology and Operation Room Nursing, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, 9 Jinsui Road, Guangzhou 510623, China
| | - You-Wei Lu
- Department of Anaesthesiology and Operation Room Nursing, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, 9 Jinsui Road, Guangzhou 510623, China
| | - Xing-Xu Ou
- Department of Anaesthesiology and Perioperative Medicine, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, 9 Jinsui Road, Guangzhou 510623, China
| | - Hui Shi
- Institute of Paediatrics, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, 9 Jinsui Road, Guangzhou 510623, China
| | - Ying-Jun She
- Department of Anaesthesiology and Perioperative Medicine, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, 9 Jinsui Road, Guangzhou 510623, China
| | - Mei-Xue Zhang
- Department of Anaesthesiology and Operation Room Nursing, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, 9 Jinsui Road, Guangzhou 510623, China.
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Luo MS. Bilevel positive airway pressure for gastroscopy with sedation in patients at risk of hypoxemia. J Clin Anesth 2023; 87:111110. [PMID: 36963230 DOI: 10.1016/j.jclinane.2023.111110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/08/2023] [Accepted: 03/13/2023] [Indexed: 03/26/2023]
Affiliation(s)
- Meng-Si Luo
- Department of Anesthesiology, Zhongshan Hospital of Traditional Chinese Medicine, Affiliated to Guangzhou University of Chinese Medicine, 3 Kangxin Road, Zhongshan, Guangdong 528400, China.
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