1
|
Wondemagegnehu BD. Presentation management and outcome of phlegmonous and inflammed appendicitis in children in Ethiopia: retrospective review. BMC Surg 2023; 23:278. [PMID: 37710191 PMCID: PMC10503200 DOI: 10.1186/s12893-023-02191-4] [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: 06/13/2023] [Accepted: 09/08/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Acute appendicitis is the leading cause of emergency pediatric surgical admissions in the world. The diagnosis is may be difficult and is often dependent on clinical parameters. This study was aimed at reviewing the clinical presentations, the management and outcomes in children with inflamed and phlegmonous appendicitis with reference to the operative findings. METHODS The records of 211 children 5 to 15 years of age who were operated for acute appendicitis with intra operative findings of inflamed or phlegmonous appendicitis who met inclusion criteria were entered and analyzed using SPSS (IBM) V.26. Descriptive and regression tests were done with p < 0.05 considered statistically significant. RESULTS Of 211 children with inflamed and phlegmonous appendicitis, the M: F was 1.48:1 with a median age of 11 years. 58.3% of them presented within 24 h with the commonest symptoms being right lower abdominal pain, anorexia, and vomiting (96.2%,96.2%, 85.3%,) respectively. 96.7% of them had right lower abdominal tenderness. 73% had neutrophils ≥ 75%, and of 171 patients who had abdominal ultrasound scan, 97.7% showed appendiceal diameter ≥ 6 mm. Intraoperatively 56.4% of them were found to have phlegmonous appendicitis. In a retrospective Pediatric Appendiceal Score, only 52.6% of patients fall into the high-risk category, who could be confirmed on preoperative clinical assessment. Postoperatively 90% of them discharged improved with a mean hospital stay of 2.26(SD = 0.9) days. There was no association between the sex of the child and the intraoperative finding of inflamed or phlegmonous appendicitis (p = 0.77). CONCLUSION Pediatric appendicitis affects more male children in their second decade of life. Most had phlegmonous appendicitis and presented within 24 h. Duration of illness has little effect on the progress of appendicitis. Surgical management is safe for inflamed and phlegmonous appendicitis with a reasonable hospital stay and a low rate of complications.
Collapse
|
2
|
Rassi R, Muse F, Cuestas E. [Appendicitis predictive score for children younger than 4 years]. REVISTA DE LA FACULTAD DE CIENCIAS MÉDICAS 2023; 80:119-125. [PMID: 37402291 PMCID: PMC10443412 DOI: 10.31053/1853.0605.v80.n2.40962] [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: 04/18/2023] [Accepted: 05/05/2023] [Indexed: 07/06/2023] Open
Abstract
Introduction The clinical presentation of acute appendicitis in infants and young children is nonspecific. The diagnosis is often delayed and is accompanied by high rates of appendiceal perforation. The aim of the present study was to develop an early diagnostic scale for acute appendicitis in children less than 4 years of age. Results: The scale had a high discrimination index area under the ROC curve of 0.96 (95%CI 0.88-0.99), sensitivity of 95.1% (95%CI 86.3-99.0%), specificity of 90.0% (95%CI 55.7-89.5%), positive predictive value of 98.3% (95%CI 90.0-99.7%) and negative predictive value of 75.0% (95%CI 49.4-90.2). Conclusions: In this study, a risk score based on characteristics of children less than 4 years with abdominal pain was developed that may help predict a patient’s risk of developing acute appendicitis. Patients and methods 100 children less than 4 years of age with a presumptive diagnosis of acute appendicitis were retrospectively evaluated in 4 hospitals. The case group comprised 90 patients with histopathological diagnosis of positive appendicitis (with inflammation in the appendiceal wall) while the control group comprised 10 patients with a histopathological diagnosis of negative appendicitis (without inflammation). Epidemiological, clinical, laboratory, and ultrasound variables were screened using Least Absolute Shrinkage and Selection Operator (LASSO) and logistic regression to construct a predictive risk score. Accuracy of the score was measured by the area under the receiver operating characteristic curve. Final model comprised 4 variables (Blumberg's sign, C-reactive protein, neutrophil-lymphocyte index and positive ultrasound). Results The scale had a high discrimination index area under the ROC curve of 0.96 (95%CI 0.88-0.99), sensitivity of 95.1% (95%CI 86.3-99.0%), specificity of 90.0% (95%CI 55.7-89.5%), positive predictive value of 98.3% (95%CI 90.0-99.7%) and negative predictive value of 75.0% (95%CI 49.4-90.2). Conclusions In this study, a risk score based on characteristics of children less than 4 years with abdominal pain was developed that may help predict a patient’s risk of developing acute appendicitis.
Collapse
Affiliation(s)
- Ricardo Rassi
- Hospital Privado Universitario de Córdoba. Córdoba, Argentina..
| | - Florencia Muse
- Servicio de Cirugía Pediátrica, Hospital Infantil Municipal, Córdoba, Argentina.
| | - Eduardo Cuestas
- Departamento de Pediatría y Neonatología, Hospital Privado Universitario de Córdoba, Córdoba, Argentina. .
| |
Collapse
|
3
|
Larger Physique as a Risk Factor for Infantile Appendicitis: A Retrospective Study. Pediatr Rep 2022; 14:20-25. [PMID: 35076592 PMCID: PMC8788474 DOI: 10.3390/pediatric14010004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 12/30/2021] [Indexed: 12/04/2022] Open
Abstract
The clinical features and risk factors of acute appendicitis in infants are unclear. Our aim was to evaluate the association between anthropometrics and the occurrence of infantile appendicitis. This was a retrospective study of infants (<6 years of age) and school-age children (6-10 years of age) of Asian ethnicity who required hospitalization for appendicitis at our two participating institutions between 2004 and 2018. The Z-score for height, body weight, and body mass index (BMI) was compared between the two groups, as well as between patients presenting with perforated and non-perforated appendicitis. The analysis included data from 73 infants and 362 school-age children. Z-scores were greater in infants than in school-age children for height (0.37 versus -0.03, p = 0.003) and body weight (0.12 versus -0.36, p = 0.023), with no between-group difference for the Z-score of BMI. There was no difference in Z-scores for height, weight, and BMI between the perforated and non-perforated appendicitis infant groups. Infants presenting with acute appendicitis were characterized by a larger physique but with normal proportion. This trend was not observed in school-age children. Therefore, larger infants presenting with abdominal pain should be screened for appendicitis.
Collapse
|
4
|
Salim J, Agustina F, Maker JJR. Pre-Coronavirus Disease 2019 Pediatric Acute Appendicitis: Risk Factors Model and Diagnosis Modality in a Developing Low-Income Country. Pediatr Gastroenterol Hepatol Nutr 2022; 25:30-40. [PMID: 35087731 PMCID: PMC8762600 DOI: 10.5223/pghn.2022.25.1.30] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 09/21/2021] [Accepted: 10/03/2021] [Indexed: 11/22/2022] Open
Abstract
PURPOSE Pediatric acute appendicitis has a stable incidence rate in Western countries with an annual change of -0.36%. However, a sharp increase was observed in the Asian region. The Indonesian Health Department reveals appendicitis as the fourth most infectious disease, with more than 64,000 patients annually. Hence, there is an urgent need to identify and evaluate the risk factors and diagnostic modalities for accurate diagnosis and early treatment. This study also clarifies the usage of pediatric appendicitis score (PAS) for children <5 years of age. METHODS The current study employed a cross-sectional design with purposive sampling through demographic and PAS questionnaires with ultrasound sonography (USG) results. The analysis was performed using the chi-square and Mann-Whitney tests and logistic regression. RESULTS This study included 21 qualified patients with an average age of 6.76±4.679 years, weighing 21.72±10.437 kg, and who had been hospitalized for 4.24±1.513 days in Siloam Teaching Hospital. Compared to the surgical gold standard, PAS and USG have moderate sensitivity and specificity. Bodyweight and stay duration were significant for appendicitis (p<0.05); however, all were confounders in the multivariate regression analysis. Incidentally, a risk prediction model was generated with an area under the curve of 72.73%, sensitivity of 100.0%, specificity of 54.5%, and a cut-off value of 151. CONCLUSION PAS outperforms USG in the sensitivity of diagnosing appendicitis, whereas USG outperforms PAS in terms of specificity. This study demonstrates the use of PAS in children under 5 years old. Meanwhile, no risk factors were significant in multivariate pediatric acute appendicitis risk factors.
Collapse
Affiliation(s)
- Jonathan Salim
- Faculty of Medicine, Pelita Harapan University, Tangerang, Indonesia
| | - Flora Agustina
- Faculty of Medicine, Pelita Harapan University, Tangerang, Indonesia.,Pediatric Surgery Department, Siloam Hospitals Lippo Village, Tangerang, Indonesia
| | | |
Collapse
|
5
|
Fujii T, Tanaka A, Katami H, Shimono R. Usefulness of the pediatric appendicitis score for assessing the severity of acute appendicitis in children. Pediatr Int 2020; 62:70-73. [PMID: 31654464 DOI: 10.1111/ped.14032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 07/25/2019] [Accepted: 10/01/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND We investigated relationships between the Pediatric Appendicitis Score (PAS) and pathological progression and disease severity in pediatric acute appendicitis. METHODS We retrospectively evaluated 72 children who underwent surgery for acute appendicitis. We divided them into groups: simple appendicitis (n = 28) or complicated appendicitis (n = 44). We compared the influence of age, body temperature, blood test findings, hospitalization period, number of complications, and PAS between the groups. We calculated the sensitivity, specificity, positive predictive value, and negative predictive value of the PAS for diagnosing complicated appendicitis. A receiver operating characteristic curve was constructed to evaluate the cut-off value for diagnosing complicated appendicitis. To assess the severity of acute appendicitis, we divided the patients into groups according to that cut-off value. RESULTS There were statistically significant differences in the PAS between simple appendicitis and complicated appendicitis (5.8 versus 7.9). The receiver operating characteristic curve indicated a PAS cut-off value of 8. A PAS ≥ 8 had a sensitivity of 73%, a specificity of 89%, a positive predictive value of 91%, and a negative predictive value of 68%. A PAS ≥ 8 was associated with significantly longer hospitalization and more complications than a PAS < 8. CONCLUSIONS The PAS may be associated with pathological progression and disease severity in appendicitis.
Collapse
Affiliation(s)
- Takayuki Fujii
- Department of Pediatric Surgery, Faculty of Medicine, Kagawa University, Kitagun, Japan
| | - Aya Tanaka
- Department of Pediatric Surgery, Faculty of Medicine, Kagawa University, Kitagun, Japan
| | - Hiroto Katami
- Department of Pediatric Surgery, Faculty of Medicine, Kagawa University, Kitagun, Japan
| | - Ryuichi Shimono
- Department of Pediatric Surgery, Faculty of Medicine, Kagawa University, Kitagun, Japan
| |
Collapse
|
6
|
Reddan T, Corness J, Harden F, Hu W, Mengersen K. Bayesian Approach to Predicting Acute Appendicitis Using Ultrasonographic and Clinical Variables in Children. Healthc Inform Res 2019; 25:212-220. [PMID: 31406613 PMCID: PMC6689514 DOI: 10.4258/hir.2019.25.3.212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 05/07/2019] [Accepted: 05/26/2019] [Indexed: 11/23/2022] Open
Abstract
Objectives Ultrasound has an established role in the diagnostic pathway for children with suspected appendicitis. Relevant clinical information can influence the diagnostic probability and reporting of ultrasound findings. A Bayesian network (BN) is a directed acyclic graph (DAG) representing variables as nodes connected by directional arrows permitting visualisation of their relationships. This research developed a BN model with ultrasonographic and clinical variables to predict acute appendicitis in children. Methods A DAG was designed through a hybrid method based on expert opinion and a review of literature to define the model structure; and the discretisation and weighting of identified variables were calculated using principal components analysis, which also informed the conditional probability table of nodes. Results The acute appendicitis target node was designated as an outcome of interest influenced by four sub-models, including Ultrasound Index, Clinical History, Physical Assessment, and Diagnostic Tests. These sub-models included four sonographic, three blood-test, and six clinical variables. The BN was scenario tested and evaluated for face, predictive, and content validity. A lack of similar networks complicated concurrent and convergent validity evaluation. Conclusions To our knowledge, this is the first BN model developed for the identification of acute appendicitis incorporating imaging variables. It has particular benefit for cases in which variables are missing because prior probabilities are built into corresponding nodes. It will be of use to clinicians involved in ultrasound examination of children with suspected appendicitis, as well as their treating clinicians. Prospective evaluation and development of an online tool will permit validation and refinement of the BN.
Collapse
Affiliation(s)
- Tristan Reddan
- Medical Imaging and Nuclear Medicine, Queensland Children's Hospital, South Brisbane, Australia.,Faculty of Science and Engineering, Queensland University of Technology, Brisbane, Australia
| | - Jonathan Corness
- Medical Imaging and Nuclear Medicine, Queensland Children's Hospital, South Brisbane, Australia
| | | | - Wenbiao Hu
- Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Kerrie Mengersen
- Faculty of Science and Engineering, Queensland University of Technology, Brisbane, Australia
| |
Collapse
|
7
|
Caruso AM, Pane A, Garau R, Atzori P, Podda M, Casuccio A, Mascia L. Acute appendicitis in children: not only surgical treatment. J Pediatr Surg 2017; 52:444-448. [PMID: 27612631 DOI: 10.1016/j.jpedsurg.2016.08.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Revised: 07/28/2016] [Accepted: 08/13/2016] [Indexed: 12/26/2022]
Abstract
PURPOSE An accurate diagnosis of acute appendicitis is important to avoid severe outcome or unnecessary surgery but management is controversial. The aim of study was to evaluate, in younger and older children, the efficacy of conservative management for uncomplicated appendicitis and the outcome of complicated forms underwent early surgery. METHODS Children with acute appendicitis were investigated by clinical, laboratory variables and abdominal ultrasound and divided in two groups: complicated and uncomplicated. Complicated appendicitis underwent early surgery; uncomplicated appendicitis started conservative treatment with antibiotic. If in the next 24-48h it was worsening, the conservative approach failed and patients underwent late surgery. RESULTS A total of 362 pediatric patients were included. One hundred sixty-five underwent early appendectomy; 197 patients were at first treated conservatively: of these, 82 were operated within 24-48h for failure. The total percentage of operated patients was 68.2%. An elevated association was found between surgery and ultrasound. CONCLUSIONS Conservative treatment for uncomplicated appendicitis had high percentage of success (58%). Complications in operated patients were infrequent. Our protocol was effective in order to decide which patients treat early surgically and which conservatively; specific red flags (age and onset) can identified patients at most risk of complications or conservative failure. TYPE OF STUDY treatment study. LEVEL OF EVIDENCE II.
Collapse
Affiliation(s)
| | - Alessandro Pane
- Pediatric Surgical Unit, SS Trinità Hospital, Cagliari, Italy
| | - Roberto Garau
- Pediatric Surgical Unit, SS Trinità Hospital, Cagliari, Italy
| | - Pietro Atzori
- Pediatric Surgical Unit, SS Trinità Hospital, Cagliari, Italy
| | - Marcello Podda
- Pediatric Surgical Unit, SS Trinità Hospital, Cagliari, Italy
| | | | - Luigi Mascia
- Pediatric Surgical Unit, SS Trinità Hospital, Cagliari, Italy
| |
Collapse
|
8
|
Almaramhy HH. Acute appendicitis in young children less than 5 years: review article. Ital J Pediatr 2017; 43:15. [PMID: 28257658 PMCID: PMC5347837 DOI: 10.1186/s13052-017-0335-2] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 01/19/2017] [Indexed: 12/29/2022] Open
Abstract
Despite wide spread availability of sophisticated diagnostic imaging, acute appendicitis in pre-school children remains a diagnostic challenge. Most of these children present late, often with complications e.g. appendicular perforation, abscess formation and peritonitis and as result hospital stay is prolonged and is associated with increased morbidity and mortality.The purpose of this article is to review peculiar features of acute appendicitis in preschool children.
Collapse
Affiliation(s)
- Hamdi Hameed Almaramhy
- Department of Surgery, College of Medicine, Taibah University, AL-Madinah Al-Munawarah, Kingdom of Saudi Arabia.
| |
Collapse
|
9
|
Salö M, Ohlsson B, Arnbjörnsson E, Stenström P. Appendicitis in children from a gender perspective. Pediatr Surg Int 2015; 31:845-53. [PMID: 26140839 DOI: 10.1007/s00383-015-3729-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/23/2015] [Indexed: 01/07/2023]
Abstract
BACKGROUND The incidence in appendicitis and the appendectomy rate are different between boys and girls. This study aimed to further evaluate appendicitis in children from a gender perspective. Gender differences in presentation, perioperative care, and outcome after appendectomy were examined. METHOD A single, institution-based, retrospective study was conducted at a tertiary pediatric surgery center. All children <15 years of age who underwent appendectomy for suspected appendicitis or who were conservatively treated for an appendiceal abscess, from 2006 to 2014, were included. Patient demographics, symptoms, preoperative management including time to appendectomy, operative characteristics, and postoperative course including complications and length of hospital stay were evaluated. RESULTS The study included 427 children: 183 girls and 244 boys. The median postoperative follow-up time was 40 (range 1-106) months. The genders did not differ significantly in age, mean weight, symptoms, laboratory results, time to appendectomy, postoperative complications, postoperative pain management, antibiotic treatment, and length of hospital stay. The frequencies of hopping/percussion/coughing tenderness in the right lower quadrant (61 and 51%, p = 0.042), phlegmonous appendicitis (56 and 45%, p = 0.032), perforated appendicitis (18 and 10%, p = 0.043), and open appendectomy (57 and 28%, p = 0.048) were significantly higher in boys. Girls had significantly higher frequencies of preoperative imaging (50 and 38%, p = 0.021), negative appendectomy (18 and 7%, p = 0.005), gangrenous appendicitis (18 and 11%, p = 0.049), and operative complications (7 and 2%, p = 0.015). In girls, the Pediatric Appendicitis Score (PAS) was more specific (59 and 41%, respectively, p = 0.032) and had a greater negative predictive value (33 and 11%, respectively, p = 0.003) than in boys. CONCLUSION In children with appendicitis, there are some gender differences. Girls had negative appendectomies more often, despite having more preoperative imaging and they had operative complications more frequently, despite having less frequent perforations. Boys had a higher frequency of perforation even though their time to appendectomy equaled that of girls. These findings and the reasons behind them must be further studied.
Collapse
Affiliation(s)
- Martin Salö
- Department of Clinical Sciences, Pediatrics, Lund University, Lund, Sweden,
| | | | | | | |
Collapse
|
10
|
Takakura S, Yokoyama H, Suzuyama C, Tatsushima K, Yamashita M, Gondou M, Morita C, Hata T, Takii M, Kawai K, Sudo N. Three cases of appendicitis with anorexia nervosa under inpatient care. J Eat Disord 2015; 3:38. [PMID: 26550478 PMCID: PMC4636842 DOI: 10.1186/s40337-015-0076-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 10/28/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Little is known about the occurrence of appendicitis during the re-nourishment period in anorexia nervosa (AN). We report three cases of appendicitis in patients with AN that occurred after hospitalization for treatment of AN. CASE PRESENTATION Case 1 is a 34-year-old female, case 2 is a 17-year-old female and case 3 is a 38-year-old female. Constipation was observed in all three cases. Careful management of defecation might be essential to prevent appendicitis among AN patients during the re-nourishment period under inpatient care. In addition, mild and diffuse symptoms were observed in all three cases. Therefore, diagnosis proved to be difficult to make and abdominal computed tomography was particularly helpful in all cases. As the symptoms were diffuse, the condition of appendicitis turned out to be more severe and complicated in one case. Additionally, the incidence of appendicitis in AN in the current study might be higher than that in the normal population. CONCLUSIONS These findings suggest that appendicitis should be considered as one of the potentially important complications in the therapy for AN.
Collapse
Affiliation(s)
- Shu Takakura
- Department of Psychosomatic Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka 812-8582 Japan
| | - Hiroaki Yokoyama
- Department of Psychosomatic Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka 812-8582 Japan
| | - Chie Suzuyama
- Department of Psychosomatic Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka 812-8582 Japan
| | - Keita Tatsushima
- Department of Psychosomatic Medicine, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka 812-8582 Japan
| | - Makoto Yamashita
- Department of Psychosomatic Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka 812-8582 Japan
| | - Motoharu Gondou
- Department of Psychosomatic Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka 812-8582 Japan
| | - Chihiro Morita
- Department of Psychosomatic Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka 812-8582 Japan
| | - Tomokazu Hata
- Department of Psychosomatic Medicine, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka 812-8582 Japan
| | - Masato Takii
- Department of Psychosomatic Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka 812-8582 Japan
| | - Keisuke Kawai
- Department of Psychosomatic Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka 812-8582 Japan
| | - Nobuyuki Sudo
- Department of Psychosomatic Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka 812-8582 Japan ; Department of Psychosomatic Medicine, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka 812-8582 Japan
| |
Collapse
|