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Prevalence and Risk Factors of Mortality in Emphysematous Pyelonephritis Patients: A Meta-Analysis. World J Surg 2022; 46:2377-2388. [PMID: 35802159 DOI: 10.1007/s00268-022-06647-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Emphysematous pyelonephritis (EP) is a severe necrotizing infection of the renal parenchyma which is associated with significant case mortality. We sought to identify the incidence and predictive risk factors associated with EP mortality. METHODS Two electronic databases, PubMed and Web of Science, were searched from their inception until June 06, 2021 for relevant articles. Two independent teams reviewed abstracts and extracted data from the selected manuscripts. A meta-analysis has been reported in line with PRISMA 2020 and AMSTAR Guidelines. RESULTS Of the 1080 retrieved abstracts, 79 underwent full-text review and 45 studies were included in the final analysis, comprising a total cohort of 1303 patients and 177 mortalities. The pooled prevalence of mortality among the patients with EP disease was 13%. Our analysis found a significantly decreasing trend in mortality rates, an increasing trend in minimally invasive intervention and decreasing trends in emergency nephrectomy in the EP studies from 1985 to 2020. Significant risk factors that were associated with a negative impact on survival of EP patients included sepsis (OR = 15.99), shock (OR = 15.57), disturbance of consciousness (OR = 12.11), thrombocytopenia (OR 7.85), acute renal failure (OR = 5.41), Wan classification I (OR = 4.57), emergency nephrectomy (OR = 3.73), Huang-Tseng classification III-IV (OR = 2.4) and medical management alone (OR = 2.04). Female sex (OR = 0.52) and minimally invasive intervention (OR = 0.47) (percutaneous nephrostomy or ureteral stent placement) were associated with decreased mortality rates. CONCLUSIONS Our study results demonstrated several significant risk factors that could help guide treatment to reduce the mortality risk of EP patients. Clinically, early treatment with a combination of minimally invasive intervention and appropriate medical management may be protective for reducing mortality risk in EP patients.
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Desai R, Batura D. A systematic review and meta-analysis of risk factors and treatment choices in emphysematous pyelonephritis. Int Urol Nephrol 2022; 54:717-736. [PMID: 35103928 DOI: 10.1007/s11255-022-03131-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 01/25/2022] [Indexed: 12/31/2022]
Abstract
PURPOSE Emphysematous pyelonephritis (EPN) is an acute, severe necrotising infection of the kidney. There has been a shift from early nephrectomy to conservative methods. We conducted a meta-analysis to assess the impact of risk factors and treatment choices on outcomes in EPN. METHODS We conducted a database search of all studies in English, reporting more than 12 patients of EPN from 1980 to 2020. We compiled the demographics, clinical presentations, risk factors, critical diagnostic results, treatment modalities and outcomes, including mortality. RESULTS We identified 37 observational studies, 32 retrospective and 5 prospective. The studies reported on 1146 patients, of which 790(68.9%) were female, and 946 (82.5%) were diabetic. In addition, 184 (16.1%) patients had stones, and 235 (20.5%) had obstructive uropathy. Fever and flank pain were the most frequent symptoms. The most common clinical features were pyuria, fever, flank tenderness, and tachycardia. E. coli, Klebsiella pneumoniae and Proteus were the most frequent organisms isolated. X-ray KUB and ultrasound were used as initial diagnostic modalities, but CT scan was the usual diagnostic and confirmatory investigation. Confusion, shock, thrombocytopenia, sepsis, emergency nephrectomy and hyponatremia were significantly associated with mortality. In particular, confusion and hyponatremia were associated with a sevenfold increase in mortality risk. There was no evidence that diabetes, stones, obstructive uropathy, AKI or proteinuria was associated with higher mortality. Nevertheless, 143 of the total 1146 patients died (12.5%). While 26% of the patients who had upfront emergency nephrectomy died, only 9.7% and 10% of patients with medical management and medical management plus minimally invasive treatments died. However, patients that failed medical and minimally invasive treatments and needed salvage emergency nephrectomy had a mortality of upwards of 27%. CONCLUSION The risk factors for mortality in emphysematous pyelonephritis are shock, thrombocytopenia, confusion, hyponatremia and emergency nephrectomy. Conservative and minimally invasive treatment should be the initial management strategy for emphysematous pyelonephritis as they carry lesser mortality risks. The presence of risk factors may help predict the subset of patients who need aggressive treatment and minimally invasive treatment modalities or early nephrectomy.
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Affiliation(s)
- Rajeev Desai
- Department of Urology, London North West University Healthcare NHS Trust, Watford Road, Harrow, London, HA1 3UJ, UK
| | - Deepak Batura
- Department of Urology, London North West University Healthcare NHS Trust, Watford Road, Harrow, London, HA1 3UJ, UK.
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Mallikarjun N, Kone K, R. K. Keerthi Rams MD. Mortality in emphysematous pyelonephritis: Can we reduce it further by using a protocol-based treatment? The results of a prospective study. Urol Ann 2022; 14:73-80. [PMID: 35197707 PMCID: PMC8815352 DOI: 10.4103/ua.ua_164_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 03/28/2021] [Indexed: 11/04/2022] Open
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Jackson S, Seyfi D, Pandya K, Oo TH, Collett J, Indrajit B. A rare case - Escalation of care for high risk emphysematous pyelonephritis in rural Australia. Urol Case Rep 2020; 34:101490. [PMID: 33251113 PMCID: PMC7680776 DOI: 10.1016/j.eucr.2020.101490] [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: 10/15/2020] [Revised: 11/04/2020] [Accepted: 11/06/2020] [Indexed: 10/25/2022] Open
Abstract
Emphysematous Pyelonephritis (EP) is a rare necrotizing renal parenchymal infection characterised by gas within the kidney parenchyma. Management with emergency nephrectomy has transitioned to a graded medical, radiological intervention and surgical approach. We present a rare case of high-risk emphysematous pyelonephritis, outlining key high risk factors and demonstrating staggered care escalation within a rural Australian referral hospital.
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Affiliation(s)
- Stuart Jackson
- Dubbo Base Hospital, NSW, Australia.,University of Sydney, NSW, Australia
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Jain A, Manikandan R, Dorairajan LN, Sreenivasan SK, Bokka S. Emphysematous pyelonephritis: Does a standard management algorithm and a prognostic scoring model optimize patient outcomes? Urol Ann 2019; 11:414-420. [PMID: 31649464 PMCID: PMC6798304 DOI: 10.4103/ua.ua_17_19] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Objective: The objective of the study is to analyze the risk factors determining the outcomes of patients with emphysematous pyelonephritis (EPN) by the adoption of a standardized management algorithm as well as to develop a prognostic scoring model to risk stratify these patients. Materials and Methods: The hospital records of 72 consecutive patients with EPN from February 2012 to January 2018 were retrospectively reviewed. Demographic, clinicoradiographic, and laboratory characteristics were recorded. Patients were managed with a standard management protocol and based on outcomes divided into three groups. Group I survived with conservative management, Group II survived after emergency nephrectomy, and Group III expired. The risk factors for nephrectomy and mortality were analyzed. Results: The mean age was 53 years. Male to female ratio was 4:5. There were 61 (84.7%), 4 (5.6%), and 7 (10%) patients in Groups I, II, and III, respectively. Diabetes mellitus was the most common comorbidity detected in 62 (86%) of patients. Type II EPN was the most common radiological presentation observed in 32 (44%) patients. Overall survival rate was 90%, and kidney salvage rate was 80%. Escherichia coli was the most common organism isolated. Thirty-two (45%) patients exhibited resistance to third-generation cephalosporin antibiotics. Thrombocytopenia, low body mass index (BMI), presence of >2 comorbidities, high total leukocyte count (TLC), and hypoalbuminemia were significantly associated with mortality. On adoption of the prognostic scoring system, mortality rates according to the risk subgroups were as follows: favorable - 0%, intermediate - 19%, and poor - 100%. Conclusion: Conservative management adopting appropriate algorithm reduces mortality and avoids unnecessary emergency nephrectomies. Thrombocytopenia, low BMI, presence of >2 comorbidities, high TLC, and hypoalbuminemia were significantly associated with mortality.
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Affiliation(s)
- Amit Jain
- Department of Urology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Ramanitharan Manikandan
- Department of Urology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | | | | | - Sriharsha Bokka
- Department of Urology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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Wang Q, Sun M, Ma C, Lv H, Lu P, Wang Q, Liu G, Hu Z, Gao Y. Emphysematous pyelonephritis and cystitis in a patient with uremia and anuria: A case report and literature review. Medicine (Baltimore) 2018; 97:e11272. [PMID: 30407278 PMCID: PMC6250534 DOI: 10.1097/md.0000000000011272] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Emphysematous pyelonephritis (EPN) or cystitis (EC) is a severe infection of the urinary tract with high mortality. EPN is uncommon among the patients of end stage of renal failure (ESRD) CASE PRESENTATION:: A 38-year-old male with uremia and anuria who was on hemodialysis was found to have gas formation in the bilateral pelvis, ureters, and urinary bladder by CT scan. The diagnosis was emphysematous pyelonephritis and cystitis. And Foley catheter was placed and bladder irrigation was performed. Escherichia coli infection was identified in urine culture and antibiotic was prescribed accordingly. Gas disappeared completely and the patient recovered uneventfully. CONCLUSION This is the first case report of asymptomatic EPN and EC in uremic patient, and conservative management was optimistic in this condition. More attention should be paid to EPN and EC happening to ESRD patients.
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Affiliation(s)
- Qiang Wang
- Department of Nephrology, Qilu Hospital of Shandong University (Qingdao)
| | - Meifeng Sun
- Department of Rehabilitation, Affiliated Hospital of Qingdao University, PR China
| | - Chengjun Ma
- Department of Nephrology, Qilu Hospital of Shandong University (Qingdao)
| | - Hailin Lv
- Department of Nephrology, Qilu Hospital of Shandong University (Qingdao)
| | - Peng Lu
- Department of Nephrology, Qilu Hospital of Shandong University (Qingdao)
| | - Qi Wang
- Department of Nephrology, Qilu Hospital of Shandong University (Qingdao)
| | - Guangyi Liu
- Department of Nephrology, Qilu Hospital of Shandong University (Qingdao)
| | - Zhao Hu
- Department of Nephrology, Qilu Hospital of Shandong University (Qingdao)
| | - Yanxia Gao
- Department of Nephrology, Qilu Hospital of Shandong University (Qingdao)
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Barua SK, Bora SJ, Bagchi PK, Sarma D, Phukan M, Baruah SJ, Rajeev TP. Emphysematous infections of the urinary tract - an audit of 20 patients with review of literature. Int J Adolesc Med Health 2017; 31:/j/ijamh.ahead-of-print/ijamh-2017-0045/ijamh-2017-0045.xml. [PMID: 28820731 DOI: 10.1515/ijamh-2017-0045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Accepted: 06/04/2017] [Indexed: 12/23/2022]
Abstract
Emphysematous infection of the urinary tract is a rapidly progressive, necrotizing infection which results into collection of gas and subsequent destruction of the tissues. Although very rare among general population, such necrotizing infection is common, particularly among those with compromised immune status. With the rising trend of people afflicted with diabetes mellitus globally, this fulminating infection may pose a serious threat to the medical fraternity. A high index of suspicion and abdominal CT scan usually helps to establish the diagnosis at an early stage and thereby facilitating aggressive antimicrobial therapy and percutaneous drainage where indicated. Although, extirpation of infected renal unit was the treatment of choice earlier, with the advent of modern imaging, endourological procedures and broad spectrum antibiotics, majority of such patients can be treated with minimal morbidity and mortality even with salvaging of the renal units. We present here the outcome of management of 20 cases with varied spectrum of emphysematous infection.
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Affiliation(s)
- Sasanka Kumar Barua
- Department of Urology, Gauhati Medical College Hospital, Guwahati781032, Assam,India, Phone: +91 9864096583
| | - Somor Jyoti Bora
- Department of Urology, Gauhati Medical College Hospital, Guwahati781032, Assam,India
| | - Puskal Kumar Bagchi
- Department of Urology, Gauhati Medical College Hospital, Guwahati781032, Assam,India
| | - Debanga Sarma
- Department of Urology, Gauhati Medical College Hospital, Guwahati781032, Assam,India
| | - Mandeep Phukan
- Department of Urology, Gauhati Medical College Hospital, Guwahati781032, Assam,India
| | - Saumar Jyoti Baruah
- Department of Urology, Gauhati Medical College Hospital, Guwahati781032, Assam,India
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Yokoyama T, Shinozaki S, Arimura H, Nakatomi K, Wataya H. Emphysematous Pyelonephritis and Cystitis: Unusual Adverse Events during Concurrent Chemoradiotherapy for Lung Cancer. Case Rep Oncol 2017. [PMID: 28638336 PMCID: PMC5478188 DOI: 10.1159/000463381] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Various adverse events can occur during antineoplastic therapy. A 67-year-old diabetic woman developed an emphysematous urinary tract infection (UTI) associated with chemoradiotherapy for lung cancer. She had received weekly carboplatin plus paclitaxel with thoracic radiotherapy and developed a fever on day 19. Computed tomography showed a large quantity of gas within the urinary tract. She was therefore diagnosed with emphysematous UTI. Poor diabetes control due to the weekly administration of dexamethasone, an existing urinary tract obstruction, and bone marrow suppression were involved in her serious infection. The potential development of emphysematous UTI during chemoradiotherapy should be considered in at-risk patients.
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Affiliation(s)
- Tetsuya Yokoyama
- Division of Respiratory Medicine, Department of Internal Medicine, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
| | - Seiji Shinozaki
- Division of Respiratory Medicine, Department of Internal Medicine, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
| | - Hidenobu Arimura
- Division of Respiratory Medicine, Department of Internal Medicine, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
| | - Keita Nakatomi
- Division of Respiratory Medicine, Department of Internal Medicine, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
| | - Hiroshi Wataya
- Division of Respiratory Medicine, Department of Internal Medicine, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
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Sanford TH, Myers F, Chi T, Bagga HS, Taylor AG, Stoller ML. Emphysematous pyelonephritis: the impact of urolithiasis on disease severity. Transl Androl Urol 2016; 5:774-779. [PMID: 27785435 PMCID: PMC5071188 DOI: 10.21037/tau.2016.07.02] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Emphysematous pyelonephritis is a severe infection of the kidney associated with formation of gas in the renal parenchyma and/or collecting system. The purpose of this study was to evaluate outcomes of patients with emphysematous pyelonephritis in a contemporary cohort and to evaluate the impact of urolithiasis on disease severity. Methods A search of all imaging reports at University of California San Francisco (UCSF) for the term “emphysematous pyelonephritis” was undertaken from 2003–2014. Patients were included if there was clinical evidence of infection, no recent urologic instrumentation, and computerized tomography (CT) demonstrating gas in the renal parenchyma or collecting system. Clinical and laboratory variables were obtained from medical records. Results A total of 14 cases were identified. The majority of patients (57%) had gas confined to the collecting system. Three patients (21%) had gas in the renal parenchyma and 3 patients (21%) had gas extending into perirenal tissues. A total of 8 patients (57%) had concomitant urolithiasis. Seven patients (50%) were managed with antibiotic therapy alone while 6 patients (43%) required percutaneous drainage. No patients required immediate nephrectomy. There were no deaths. Patients with urolithiasis had less severe emphysematous pyelonephritis than patients without urolithiasis (P<0.05). Conclusions The majority of patients in this study had gas contained within the collecting system and were treated successfully with antibiotics alone. Percutaneous drainage was successfully utilized in patients with more advanced disease. No patients required emergent nephrectomy. Emphysematous pyelonephritis in patients with urolithiasis was less severe than in patients without urolithiasis.
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Affiliation(s)
- Thomas H Sanford
- Department of Urology, University of California San Francisco, San Francisco, California, USA
| | - Frank Myers
- Department of Urology, SUNY Downstate Medical Center, Brooklyn, New York, USA
| | - Thomas Chi
- Department of Urology, University of California San Francisco, San Francisco, California, USA
| | - Herman S Bagga
- Department of Urology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Andrew G Taylor
- Department of Radiology, University of California San Francisco, San Francisco, California, USA
| | - Marshall L Stoller
- Department of Urology, University of California San Francisco, San Francisco, California, USA
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Aboumarzouk OM, Hughes O, Narahari K, Coulthard R, Kynaston H, Chlosta P, Somani B. Emphysematous pyelonephritis: Time for a management plan with an evidence-based approach. Arab J Urol 2013; 12:106-15. [PMID: 26019934 PMCID: PMC4434438 DOI: 10.1016/j.aju.2013.09.005] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Revised: 09/21/2013] [Accepted: 09/22/2013] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Emphysematous pyelonephritis (EPN) is a life-threatening necrotising kidney infection, but there is no consensus on the best management. METHODS We systematically reviewed previous articles published from 1980 to 2013 that included studies reporting on EPN, and applying the Cochrane guidelines, we conducted a meta-analysis of the results. RESULTS In all, 32 studies were included, with results for 628 patients (mean age 56.6 years, range 33.8-79.9). There were 462 women, outnumbering men by 3:1. Diabetes was present in 85% of the cases. Fevers and rigor (74.7%), pyuria (78.2%) and pain (70.4%) were the most common symptoms. Shock was associated with 54.4% of deaths while obstructive uropathy was associated with 15.1% of deaths. Computed tomography was diagnostic in all the cases. Percutaneous drainage (PCD) and medical management (MM) alone were associated with a significantly lower mortality rate than was emergency nephrectomy (EN), with an odds ratio (95% confidence interval) for PCD vs. EN of 3.13 (1.89-5.16; P < 0.001), for EN vs. MM of 2.84 (1.62-4.99; P = 0.001), and of 0.91 (0.53-1.56; P = 0.73, i.e., no difference) for PCD vs. MM. Open drainage also had a significantly lower mortality rate than EN, with a ratio of 0.12 (0.02-0.91; P < 0.04). CONCLUSION The overall mortality rate was ≈18%; shock was associated with a high mortality rate and therefore should be managed aggressively. PCD and MM were associated with significantly higher survival rates than EN, and therefore EN should only be considered if the patient does not improve despite other treatments.
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Affiliation(s)
| | - Owen Hughes
- Department of Urology, University Hospital of Wales, Heath Park, Cardiff, Wales, UK
| | - Krishna Narahari
- Department of Urology, University Hospital of Wales, Heath Park, Cardiff, Wales, UK
| | - Richard Coulthard
- Department of Urology, University Hospital of Wales, Heath Park, Cardiff, Wales, UK
| | - Howard Kynaston
- Department of Urology, University Hospital of Wales, Heath Park, Cardiff, Wales, UK
| | - Piotr Chlosta
- Department of Urology, Jagiellonian University, Cracow, Poland
| | - Bhaskar Somani
- Department of Urology, University Hospital of Southampton NHS Foundation Trust, Southampton, UK
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Yang WS, Kim WY, Sohn CH, Seo DW, Lee JH, Kim W, Lim KS. Clinical Feature and Prognostic Factors of Emphysematous Pyelonephritis. Korean J Crit Care Med 2012. [DOI: 10.4266/kjccm.2012.27.2.89] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Won Soek Yang
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang Hwan Sohn
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Woo Seo
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Ho Lee
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Won Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyoung-Soo Lim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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