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Lu X, Xu L, Song Y, Yu X, Li Q, Liu F, Li X, Xi J, Wang S, Wang L, Wang Z. A Graphene Composite Film Based Wearable Far-Infrared Therapy Apparatus (GRAFT) for Effective Prevention of Postoperative Peritoneal Adhesion. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2024; 11:e2309330. [PMID: 38526158 PMCID: PMC11165485 DOI: 10.1002/advs.202309330] [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: 12/01/2023] [Revised: 03/10/2024] [Indexed: 03/26/2024]
Abstract
Postoperative peritoneal adhesion (PPA) is the most frequent complication after abdominal surgery. Current anti-adhesion strategies largely rely on the use of physical separating barriers creating an interface blocking peritoneal adhesion, which cannot reduce inflammation and suffers from limited anti-adhesion efficacy with unwanted side effects. Here, by exploiting the alternative activated macrophages to alleviate inflammation in adhesion development, a flexible graphene-composite-film (F-GCF) generating far-infrared (FIR) irradiation that effectively modulates the macrophage phenotype toward the anti-inflammatory M2 type, resulting in reduced PPA formation, is designed. The anti-adhesion effect of the FIR generated by F-GCF is determined in the rat abdominal wall abrasion-cecum defect models, which exhibit reduced incidence and area of PPA by 67.0% and 92.1% after FIR treatment without skin damage, significantly superior to the clinically used chitosan hydrogel. Notably, within peritoneal macrophages, FIR reduces inflammation reaction and promotes tissue plasminogen activator (t-PA) level via the polarization of peritoneal macrophages through upregulating Nr4a2 expression. To facilitate clinical use, a wirelessly controlled, wearable, F-GCF-based FIR therapy apparatus (GRAFT) is further developed and its remarkable anti-adhesion ability in the porcine PPA model is revealed. Collectively, the physical, biochemical, and in vivo preclinical data provide compelling evidence demonstrating the clinical-translational value of FIR in PPA prevention.
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Affiliation(s)
- Xiaohuan Lu
- Hubei Key Laboratory of Regenerative Medicine and Multi‐disciplinary Translational ResearchUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
- Hubei Provincial Engineering Research Center of Clinical Laboratory and Active Health Smart EquipmentUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
- Research Center for Tissue Engineering and Regenerative MedicineUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
- Department of Gastrointestinal SurgeryUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
| | - Luming Xu
- Hubei Key Laboratory of Regenerative Medicine and Multi‐disciplinary Translational ResearchUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
- Hubei Provincial Engineering Research Center of Clinical Laboratory and Active Health Smart EquipmentUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
- Research Center for Tissue Engineering and Regenerative MedicineUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
- Department of Clinical LaboratoryUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
| | - Yu Song
- Hubei Key Laboratory of Regenerative Medicine and Multi‐disciplinary Translational ResearchUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
- Hubei Provincial Engineering Research Center of Clinical Laboratory and Active Health Smart EquipmentUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
- Research Center for Tissue Engineering and Regenerative MedicineUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
| | - Xiangnan Yu
- Department of Gastrointestinal SurgeryThe First Affiliated Hospital of Nanchang UniversityNanchang330006China
| | - Qilin Li
- Hubei Key Laboratory of Regenerative Medicine and Multi‐disciplinary Translational ResearchUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
- Hubei Provincial Engineering Research Center of Clinical Laboratory and Active Health Smart EquipmentUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
- Research Center for Tissue Engineering and Regenerative MedicineUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
- Department of Clinical LaboratoryUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
| | - Feng Liu
- Hubei Key Laboratory of Regenerative Medicine and Multi‐disciplinary Translational ResearchUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
- Hubei Provincial Engineering Research Center of Clinical Laboratory and Active Health Smart EquipmentUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
- Research Center for Tissue Engineering and Regenerative MedicineUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
| | - Xiaoqiong Li
- Hubei Key Laboratory of Regenerative Medicine and Multi‐disciplinary Translational ResearchUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
- Hubei Provincial Engineering Research Center of Clinical Laboratory and Active Health Smart EquipmentUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
- Research Center for Tissue Engineering and Regenerative MedicineUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
- Department of Gastrointestinal SurgeryUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
| | - Jiangbo Xi
- School of Chemistry and Environmental EngineeringWuhan Institute of TechnologyWuhan430205China
| | - Shuai Wang
- Key Laboratory of Material Chemistry for Energy Conversion and Storage of Ministry of EducationDepartment of Chemistry and Chemical EngineeringHuazhong University of Science and TechnologyWuhan430074China
| | - Lin Wang
- Hubei Key Laboratory of Regenerative Medicine and Multi‐disciplinary Translational ResearchUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
- Hubei Provincial Engineering Research Center of Clinical Laboratory and Active Health Smart EquipmentUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
- Research Center for Tissue Engineering and Regenerative MedicineUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
- Department of Clinical LaboratoryUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
| | - Zheng Wang
- Hubei Key Laboratory of Regenerative Medicine and Multi‐disciplinary Translational ResearchUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
- Hubei Provincial Engineering Research Center of Clinical Laboratory and Active Health Smart EquipmentUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
- Research Center for Tissue Engineering and Regenerative MedicineUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
- Department of Gastrointestinal SurgeryUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022China
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Kunitomi Y, Nakashima M, Takeuchi M, Kawakami K. Efficacy of Daikenchuto in the prevention of bowel obstruction in patients with colorectal cancer undergoing laparoscopic surgery: An observational study using a Japanese administrative claims database. Support Care Cancer 2023; 31:133. [PMID: 36697914 DOI: 10.1007/s00520-023-07599-5] [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: 10/03/2022] [Accepted: 01/17/2023] [Indexed: 01/27/2023]
Abstract
PURPOSE Daikenchuto is an herbal medicine widely used in Japan without clear evidence to prevent bowel obstruction after abdominal surgery. We evaluated the efficacy of Daikenchuto in laparoscopic surgery for colorectal cancer (CRC). METHODS We included patients from the medical claims databases diagnosed with CRC between January 2012 and December 2019 and treated with laparoscopic surgery. We compared the Daikenchuto and control groups to evaluate early bowel obstruction (EBO) events for 1 year. The Daikenchuto group included patients prescribed Daikenchuto on postoperative day (POD) 0 or 1. An EBO event was defined as the use of a nasogastric tube, transnasal ileus tube, endoscopic balloon dilatation, or the requirement of reoperation for bowel obstruction from PODs 1 to 364. RESULTS In total, 46,458 patients met the eligibility criteria; 2407 and 44,051 patients were included in the Daikenchuto and control groups, respectively. Some of the patient's characteristics were significantly different between the groups. The frequencies of EBO events in the Daikenchuto and control groups were 5.7% (95% confidence interval: 4.8-6.7) and 4.6% (4.4-4.8), respectively. The most frequent events were nasogastric tube (3.1%, 2.9%) and transnasal ileus tube insertions (1.4%, 0.8%) in the Daikenchuto and control groups, respectively. The hospital stay was significantly shorter in the Daikenchuto group than in the control; this trend was confirmed in the sensitivity analysis. CONCLUSIONS Daikenchuto did not demonstrate efficacy for EBO. It might be adequate for shortening patient's hospital stay. Further studies are warranted.
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Affiliation(s)
- Yuji Kunitomi
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida Konoecho, Sakyoku, Kyoto, 606-8501, Japan.,Department of Data Science, Taiho Pharmaceutical Co., Ltd., 1-27 Kandanishiki-cho, Chiyoda-ku, Tokyo, 101-8444, Japan
| | - Masayuki Nakashima
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida Konoecho, Sakyoku, Kyoto, 606-8501, Japan
| | - Masato Takeuchi
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida Konoecho, Sakyoku, Kyoto, 606-8501, Japan
| | - Koji Kawakami
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida Konoecho, Sakyoku, Kyoto, 606-8501, Japan.
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Nakamura Y, Matsuda K, Yokoyama S, Iwamoto H, Mizumoto Y, Mitani Y, Oku Y, Yamaue H. High visceral to subcutaneous fat area ratio predicts early postoperative small bowel obstruction after surgery for colorectal cancer. Langenbecks Arch Surg 2022; 407:2021-2026. [PMID: 35488912 DOI: 10.1007/s00423-022-02518-4] [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: 09/10/2021] [Accepted: 04/13/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE Risks for postoperative small bowel obstruction have been demonstrated in several reports, most of which indicated male sex was a risk factor, but with the reason remaining unknown. We tested the hypothesis that it could be because males have more visceral fat than females. This prospective observational study aims to examine risks of early postoperative small bowel obstruction (EPSBO) after colorectal cancer surgery and the association between visceral to subcutaneous fat area ratio (V/S ratio) and EPSBO. METHODS Four hundred and seventy-four patients who underwent colectomy for colorectal cancer in our hospital were enrolled in this study. The influence of several factors including V/S ratio on the development of EPSBO was analyzed. RESULTS Thirty-one of the 474 patients (6.5%) developed EPSBO. EPSBO occurred more frequently in males (p = 0.03) and cases who developed postoperative anastomotic leakage (p < 0.001) or wound infection (p = 0.02). Higher V/S ratio was strongly related to male sex (p < 0.001). Multivariate analysis revealed higher V/S ratio (OR 2.25; p = 0.049) and anastomotic leakage (OR 5.86; p < 0.001) were independent risk factors for EPSBO. CONCLUSION Higher V/S ratio was significantly related to EPSBO, suggesting that one of the reasons EPSBO was more likely to occur in males because they have more visceral fat than females. Preoperative identification of this risk factor could help us watch out for this potential complication.
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Affiliation(s)
- Yuki Nakamura
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8510, Japan
| | - Kenji Matsuda
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8510, Japan.
| | - Shozo Yokoyama
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8510, Japan
| | - Hiromitsu Iwamoto
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8510, Japan
| | - Yuki Mizumoto
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8510, Japan
| | - Yasuyuki Mitani
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8510, Japan
| | - Yoshimasa Oku
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8510, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8510, Japan
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Yamada T, Hirata K, Ichikawa D, Ikeda M, Fujita F, Eto K, Yukawa N, Kojima Y, Matsuda A, Shimoyama R, Ochiai H, Kumamoto K, Takayama Y, Komono A, Sonoda H, Ohta R, Yokoyama Y, Yoshida H, Kaibori M, Takemasa I. Clinical impact of laparoscopic surgery and adhesion prevention material for prevention of small bowel obstruction. Ann Gastroenterol Surg 2022; 6:651-657. [PMID: 36091308 PMCID: PMC9444862 DOI: 10.1002/ags3.12569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/24/2022] [Accepted: 03/08/2022] [Indexed: 11/25/2022] Open
Abstract
Aim Adhesive small bowel obstructions (SBO) are one of the most common complications following abdominal surgery, and they decrease patient quality of life. Since 2000, laparoscopic surgery has been employed with increasing frequency, as has adhesion prevention material (APM). In this study we tried to evaluate whether laparoscopic surgery and APM reduce the incidence of SBO. Methods In Cohort 1, we included patients who developed SBO and received inpatient treatment between 2015 and 2018. We evaluated the elapsed time between precedent surgery and the onset of SBO, and what kind of surgery most often causes SBO. In Cohort 2, we included patients who underwent digestive surgery between 2012 and 2014 and evaluated SBO incidence within 5 y after the precedent surgery. Results In all, 2058 patients were included in Cohort 1. Of these, 164 had experienced no precedent surgery. Among patients with a history of abdominal surgery, 29.7% experienced SBO within 1 y after the precedent surgery and 48.1% within 3 y. Altogether, 18798 patients were analyzed in Cohort 2. The incidence of SBO after laparoscopic colorectal surgery was lower than that of open colorectal surgery (P < .001), and laparoscopic gastroduodenal surgery was also lower (P = .02). However, there were no differences between laparoscopic and open surgery for other types of surgery. The use of APM had no effect on SBO incidence in any type of abdominal surgery. Conclusions Laparoscopic surgery helps to reduce SBO incidence only in colorectal surgery, and possibly in gastroduodenal surgery. APM does not reduce SBO after abdominal surgery.
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Affiliation(s)
- Takeshi Yamada
- Department of Gastrointestinal and Hepato‐Billiary‐Pancreatic Surgery, Nippon Medical School Tokyo Japan
| | - Keiji Hirata
- First Department of Surgery University of Occupational and Environmental Health Fukuoka Japan
| | | | - Masataka Ikeda
- Division of lower GI, Department of Surgery Hyogo College of Medicine Nishinomiya Japan
| | - Fumihiko Fujita
- Departments of Surgery Kurume University School of Medicine Kurume Japan
| | - Ken Eto
- Department of Surgery The Jikei University School of Medicine Tokyo Japan
| | - Norio Yukawa
- Department of Surgery Yokohama City University Yokohama Japan
| | - Yutaka Kojima
- Department of Coloproctological Surgery Juntendo University Faculty of Medicine Tokyo Japan
| | - Akihisa Matsuda
- Department of Gastrointestinal and Hepato‐Billiary‐Pancreatic Surgery, Nippon Medical School Tokyo Japan
| | - Rai Shimoyama
- Department of Surgery Shonan Kamakura General Hospital Kamakura Japan
| | - Hideto Ochiai
- Department of Gastroenterological Surgery Iwata City Hospital Iwata Japan
| | - Kensuke Kumamoto
- Department of Gastroenterological Surgery Kagawa University Takamatsu Japan
| | | | - Akira Komono
- Department of Gastroenterological Surgery Fukuoka University Faculty of Medicine Fukuoka Japan
| | - Hiromichi Sonoda
- Department of Gastrointestinal and Hepato‐Billiary‐Pancreatic Surgery, Nippon Medical School Tokyo Japan
| | - Ryo Ohta
- Department of Gastrointestinal and Hepato‐Billiary‐Pancreatic Surgery, Nippon Medical School Tokyo Japan
| | - Yasuyuki Yokoyama
- Department of Digestive Surgery, Nippon Medical School Musashi‐Kosugi Hospital Kawasaki Japan
| | - Hiroshi Yoshida
- Department of Gastrointestinal and Hepato‐Billiary‐Pancreatic Surgery, Nippon Medical School Tokyo Japan
| | - Masaki Kaibori
- Department of Surgery Kansai Medical University Osaka Japan
| | - Ichiro Takemasa
- Department of Surgery, Surgical Oncology and Science Sapporo Medical University School of Medicine Sapporo Japan
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Risk factors for readmission for early small bowel obstruction following laparoscopic Roux-en-Y gastric bypass: an MBSAQIP analysis. Surg Obes Relat Dis 2021; 17:1041-1048. [PMID: 33965351 DOI: 10.1016/j.soard.2021.02.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/27/2021] [Accepted: 02/27/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Small bowel obstruction (SBO) following laparoscopic Roux-en-Y gastric bypass (LRYGB) is associated with significant morbidity. OBJECTIVES To evaluate the rate of and risk factors for readmission for SBO within 30 days of LRYGB. SETTING Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)-accredited centers. METHODS This is a retrospective study using the MBSAQIP database. A query was performed from 2015-2018 for patients who underwent LRYGB and required readmission for SBO. Those who had a reoperation, intervention, readmission, or expired from causes other than SBO were excluded. Descriptive, bivariate, and binary logistic regression analyses were performed. RESULTS Among 184,660 patients undergoing LRYGB, 1189 (.64%) required readmission due to SBO. Among the readmission cases, 978 (82.5%) were identified as having intestinal obstruction (unspecified), 108 (9.1%) incisional hernia, and 100 (8.4%) internal hernia. Among these cases, 69% had a reoperation and 1.3% expired during the 30-day period. From a logistic regression model, parameters independently associated with an increased risk for readmission for early SBO include being female (adjusted odds ratio [AOR], 1.53) or black (AOR, 1.41) and having gastroesophageal reflux (AOR, 1.35), a history of myocardial infarction (AOR, 1.76), a history of deep vein thrombosis (AOR, 1.73), previous obesity surgery/foregut surgery (AOR, 1.79), a robotic-assisted procedure (AOR, 1.23), concurrent hiatal hernia repair (AOR, 1.66) and adhesiolysis (AOR, 1.42). CONCLUSION The rate of readmission for early SBO following LRYGB was less than 1%. The majority of these cases required reoperation. The increased intraoperative complexity of LRYGB is associated with an increased risk of readmission due to early SBO.
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Abstract
Pituitary adenomas (PAs) are defined as benign monoclonal tumors in the pituitary gland that cause symptoms due to either hormonal hypersecretion or a space-occupying effect, and are classified as functioning or non-functioning. Because of their rarity and slow-growing with symptomless nature in most cases, it has been challenging to investigate the epidemiology of PAs. Considering their public health impact and association with increased morbidity and mortality, however, it is essential to understand the prevalence and incidence of PAs in order to improve patient outcomes and to minimize the resultant burden on the health care system. Fortunately, developments in imaging modalities and easier access to large-scale population data have enabled investigators to analyze the epidemiology of PAs more accurately. This review summarizes previously reported epidemiologic data on functioning PAs in Korea and other countries.
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Affiliation(s)
- Sang Ouk Chin
- Department of Endocrinology and Metabolism, Kyung Hee University College of Medicine, Seoul, Korea
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Park KH, Lee EJ, Seo GH, Ku CR. Risk for Acromegaly-related Comorbidities by Sex in Korean Acromegaly. J Clin Endocrinol Metab 2020; 105:5696792. [PMID: 31903478 DOI: 10.1210/clinem/dgz317] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 01/02/2020] [Indexed: 11/19/2022]
Abstract
CONTEXT Reports on the incidence, characteristics, and comorbidity in Asian patients with acromegaly are scarce. OBJECTIVE To evaluate the incidence of acromegaly and the risk of comorbidities in East Asia, especially South Korea. DESIGN This nationwide population-based cohort study using the Korean Health Insurance Review and Assessment claims database evaluated the incidence of acromegaly, initially diagnosed from 2010 to 2013. We identified comorbidities during, before, and 2 years after diagnosis. Acromegaly and control cases (718 and 7180, respectively) were included in the analysis. SETTING A longitudinal case-control study using a nationwide population cohort. RESULTS The mean annual incidence rate of acromegaly was 3.57 cases per 1 000 000. Malignancies occurred in 61 patients with acromegaly (8.5%) during the study period and thyroid cancer was the most common malignancy (n = 38). In the acromegaly group, the overall risk of malignancy was higher: hazard ratio (HR), 2.82 (95% confidence interval [CI]: 2.12-3.74). Malignancy risk was more pronounced in females, with increased risk from the prediagnosis period that is sustained until the postdiagnosis period. Prevalence of diabetes mellitus (DM) and heart failure increased significantly in acromegalic patients. Over the entire period, DM developed in 51.1% and 57.0% of male and female acromegalic patients, respectively. Mortality risk was higher (HR 1.65, 95%; CI: 1.13-2.41) and statistically significant in females (HR 1.75, 95%; CI: 1.07-2.84). CONCLUSION Comorbidities associated with acromegaly differed by sex in Korean subjects. High malignancy and mortality risk should be considered in female patients when managing acromegaly in Korea.
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Affiliation(s)
- Kyeong Hye Park
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Gyeonggi, Republic of Korea
| | - Eun Jig Lee
- Endocrinology, Institute of Endocrine Research, Department of Internal Medicine, Severance Hospital Pituitary Tumor Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Gi Hyeon Seo
- Health Insurance Review and Assessment Service, Seoul, Republic of Korea
| | - Cheol Ryong Ku
- Endocrinology, Institute of Endocrine Research, Department of Internal Medicine, Severance Hospital Pituitary Tumor Center, Yonsei University College of Medicine, Seoul, Republic of Korea
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