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Bertoletti L, Girard P, Élias A, Espitia O, Schmidt J, Couturaud F, Mahé I, Sanchez O. [Translation into French and republication of: "Recurrent venous thromboembolism in anticoagulated cancer patients: diagnosis and treatment"]. Rev Med Interne 2024; 45:289-299. [PMID: 38806295 DOI: 10.1016/j.revmed.2024.05.017] [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: 11/17/2023] [Accepted: 11/17/2023] [Indexed: 05/30/2024]
Abstract
Patients with cancer are at significantly increased risk of venous thromboembolism (VTE), due both to the impact of malignant disease itself and to the impact of certain anticancer drugs on haemostasis. This is true both for first episode venous thromboembolism and recurrence. The diagnosis and management of VTE recurrence in patients with cancer poses particular challenges, and these are reviewed in the present article, based on a systematic review of the relevant scientific literature published over the last decade. Furthermore, it is uncertain whether diagnostic algorithms for venous thromboembolism, validated principally in untreated non-cancer patients, are also valid in anticoagulated cancer patients: the available data suggests that clinical decision rules and D-dimer testing perform less well in this clinical setting. In patients with cancer, computed tomography pulmonary angiography and venous ultrasound appear to be the most reliable diagnostic tools for diagnosis of pulmonary embolism and deep vein thrombosis respectively. Options for treatment of venous thromboembolism include low molecular weight heparins (at a therapeutic dose or an increased dose), fondaparinux or oral direct factor Xa inhibitors. The choice of treatment should take into account the nature (pulmonary embolism or VTE) and severity of the recurrent event, the associated bleeding risk, the current anticoagulant treatment (type, dose, adherence and possible drug-drug interactions) and cancer progression.
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Affiliation(s)
- L Bertoletti
- Service de médecine vasculaire et thérapeutique, CHU de Saint-Étienne, Inserm, UMR1059, équipe Dysfonction vasculaire et hémostase, université Jean-Monnet, CIC-1408, 42000 Saint-Étienne, France; F-CRIN INNOVTE network, Saint-Étienne, France.
| | - P Girard
- F-CRIN INNOVTE network, Saint-Étienne, France; Institut du thorax Curie-Montsouris, institut mutualiste Montsouris, Paris, France
| | - A Élias
- F-CRIN INNOVTE network, Saint-Étienne, France; Service de cardiologie et de médecine vasculaire, délégation recherche clinique et innovation, centre hospitalier intercommunal Toulon La Seyne-sur-Mer, Toulon, France
| | - O Espitia
- Service de médecine interne et vasculaire, Institut du thorax, Nantes université, CHU de Nantes, Inserm UMR 1087-CNRS UMR 6291, Team III Vascular & Pulmonary diseases, Nantes, France
| | - J Schmidt
- F-CRIN INNOVTE network, Saint-Étienne, France; Service d'urgence, CHU de Clermont-Ferrand, Lapsco-UMR UBP-CNRS 6024, université Clermont Auvergne, Clermont-Ferrand, France
| | - F Couturaud
- F-CRIN INNOVTE network, Saint-Étienne, France; Département de médecine interne, médecine vasculaire et pneumologie, CHU de Brest, Inserm U1304-GETBO, université de Brest, Brest, France
| | - I Mahé
- F-CRIN INNOVTE network, Saint-Étienne, France; Service de médecine interne, hôpital Louis-Mourier, AP-HP, Colombes, France; Université Paris Cité, Inserm UMR S1140, Innovations thérapeutiques en hémostase, Paris, France
| | - O Sanchez
- F-CRIN INNOVTE network, Saint-Étienne, France; Université Paris Cité, Inserm UMR S1140, Innovations thérapeutiques en hémostase, Paris, France; Service de pneumologie et de soins intensifs, hôpital européen Georges-Pompidou, AP-HP, Paris, France
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Bertoletti L, Girard P, Elias A, Espitia O, Schmidt J, Couturaud F, Mahé I, Sanchez O. Recurrent venous thromboembolism in anticoagulated cancer patients: Diagnosis and treatment. Arch Cardiovasc Dis 2024; 117:84-93. [PMID: 38065753 DOI: 10.1016/j.acvd.2023.11.006] [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: 11/17/2023] [Accepted: 11/17/2023] [Indexed: 12/27/2023]
Abstract
Patients with cancer are at significantly increased risk of venous thromboembolism (VTE), due both to the impact of malignant disease itself and to the impact of certain anticancer drugs on haemostasis. This is true both for first episode venous thromboembolism and recurrence. The diagnosis and management of VTE recurrence in patients with cancer poses particular challenges, and these are reviewed in the present article, based on a systematic review of the relevant scientific literature published over the last decade. Furthermore, it is uncertain whether diagnostic algorithms for venous thromboembolism, validated principally in untreated non-cancer patients, are also valid in anticoagulated cancer patients: the available data suggests that clinical decision rules and D-dimer testing perform less well in this clinical setting. In patients with cancer, computed tomography pulmonary angiography and venous ultrasound appear to be the most reliable diagnostic tools for diagnosis of pulmonary embolism and deep vein thrombosis respectively. Options for treatment of venous thromboembolism include low molecular weight heparins (at a therapeutic dose or an increased dose), fondaparinux or oral direct factor Xa inhibitors. The choice of treatment should take into account the nature (pulmonary embolism or VTE) and severity of the recurrent event, the associated bleeding risk, the current anticoagulant treatment (type, dose, adherence and possible drug-drug interactions) and cancer progression.
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Affiliation(s)
- Laurent Bertoletti
- Service de médecine vasculaire et thérapeutique, CHU de Saint-Étienne, INSERM, UMR1059, Équipe Dysfonction Vasculaire et Hémostase, Université Jean-Monnet, INSERM, CIC-1408, CHU Saint-Etienne, Saint-Etienne, France; F-CRIN INNOVTE network, Saint-Etienne, France.
| | - Philippe Girard
- Institut du thorax Curie-Montsouris, institut mutualiste Montsouris, Paris, France; F-CRIN INNOVTE network, Saint-Etienne, France
| | - Antoine Elias
- Service de cardiologie et de médecine vasculaire, délégation recherche clinique et innovation, centre hospitalier intercommunal Toulon La Seyne-sur-Mer, Toulon, France; F-CRIN INNOVTE network, Saint-Etienne, France
| | - Olivier Espitia
- Service de médecine interne et vasculaire, institut du thorax, Nantes université, CHU de Nantes, Inserm UMR 1087-CNRS UMR 6291, Team III Vascular & Pulmonary diseases, Nantes, France
| | - Jeannot Schmidt
- Service d'urgence, CHU de Clermont-Ferrand, LAPSCO-UMR UBP-CNRS 6024, Université Clermont Auvergne, Clermont-Ferrand, France; F-CRIN INNOVTE network, Saint-Etienne, France
| | - Francis Couturaud
- Département de médecine interne, médecine vasculaire et pneumologie, CHU de Brest, Inserm U1304-GETBO, université de Brest, Brest, France; F-CRIN INNOVTE network, Saint-Etienne, France
| | - Isabelle Mahé
- Service de médecine interne, hôpital Louis-Mourier, AP-HP, Colombes, France; Université Paris Cité, Inserm UMR S1140, innovations thérapeutiques en hémostase, Paris, France; F-CRIN INNOVTE network, Saint-Etienne, France
| | - Olivier Sanchez
- Université Paris Cité, Inserm UMR S1140, innovations thérapeutiques en hémostase, Paris, France; Service de pneumologie et de soins intensifs, Hôpital européen Georges-Pompidou, AP-HP, Paris, France; F-CRIN INNOVTE network, Saint-Etienne, France
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Noncontrast MRI in assessing venous reflux of legs using QFlow analysis and radial basis function neural network technique. Sci Rep 2023; 13:3263. [PMID: 36828951 PMCID: PMC9958037 DOI: 10.1038/s41598-023-30437-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 02/23/2023] [Indexed: 02/26/2023] Open
Abstract
Since venous reflux is difficult to quantify, triggered angiography non-contrast-enhanced (TRANCE)-magnetic resonance imaging (MRI) is a novel tool for objectively evaluating venous diseases in the lower extremities without using contrast media. This study included 26 pre-intervention patients with superficial venous reflux in the lower extremities and 15 healthy volunteers. The quantitative flow (QFlow) analyzed the phase shift information from the pixels within the region of interest from MRI. The fast and simple radial basis function neural network (RBFNN) learning model is constructed by determining the parameters of the radial basis function and the weights of the neural network. The input parameters were the variables generated through QFlow, while the output variables were morbid limbs with venous reflux and normal limb classification. The stroke volume, forward flow volume, absolute stroke volume, mean flux, stroke distance, and mean velocity of greater saphenous veins from QFlow analysis could be used to discriminate the morbid limbs of pre-intervention patients and normal limbs of healthy controls. The neural network successfully classified the morbid and normal limbs with an accuracy of 90.24% in the training stage. The classification of venous reflux using the RBFNN model may assist physicians in clinical settings.
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A Novel Tool for a Challenging Disease: Stasis Leg Ulcers Assessed Using QFlow in Triggered Angiography Noncontrast Enhanced Magnetic Resonance Imaging. J Pers Med 2021; 11:jpm11090857. [PMID: 34575634 PMCID: PMC8472672 DOI: 10.3390/jpm11090857] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 08/25/2021] [Accepted: 08/26/2021] [Indexed: 02/07/2023] Open
Abstract
Imaging characteristics of stasis leg ulcers (SLUs) are not easily demonstrated through existing diagnostic tools. Early diagnosis and treatment are crucial. This pilot study was conducted to assess the quantitative flow (QFlow) in triggered angiography noncontrast enhanced (TRANCE) magnetic resonance imaging (MRI) to identify the hemodynamics of victims with stasis leg ulcers (SLUs). This study included 33 patients with SLUs and 14 healthy controls (HC). The 33 patients with SLUs were divided into a reflux (15 patients) and a nonreflux group (18 patients). QFlow was done in the reflux, the nonreflux, and the HC. The stroke volume (SV), forward flow volume (FFV), absolute flow volume (AFV), mean flow (MF), and mean velocity (MV) were higher in the reflux than in the HC group in most segments, namely the external iliac vein (EIV), popliteal vein (PV), and great saphenous vein (GSV) (SV, p = 0.008; FFV, p = 0.008; absolute stroke volume (ASV), p = 0.008; MF, p = 0.002; MV, p = 0.009). No differences in the QFlow patterns were found in the GSV segment between the nonreflux group and the HC. Excellent performance in discriminating SLU with superficial venous reflux was reported for SV in the EIV and the PV (area under the curve (AUC) = 0.851 and 0.872), FFV in the EIV and PV (AUC = 0.854 and 0.869), ASV in the EIV and PV (AUC = 0.848 and 0.881), and MF in the EIV and PV (AUC = 0.866 and 0.868). The cutoff levels of SV/FFV/ASV/MF in the EIV/FV/PV/GSV for discriminating the SLU with superficial venous reflux were identified (p < 0.005). In conclusion, SLUs present different QFlow patterns by different etiology. The QFlow parameters of all vessel segments were higher in the morbid limbs of the reflux group than HC. The GSV segment of the nonreflux group displayed a pattern like the HC.
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Chen CW, Tseng YH, Wong MY, Lin YH, Yang TY, Hsu YC, Lin BS, Huang YK. Using Non-Contrast MRA to Discriminate between Obstructive and Nonobstructive Venous Diseases of the Legs. Diagnostics (Basel) 2021; 11:1392. [PMID: 34441326 PMCID: PMC8394703 DOI: 10.3390/diagnostics11081392] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 07/25/2021] [Accepted: 07/29/2021] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Venous interventions of the legs are less predictable owing to a lock of objective tools. METHODS One hundred and twenty patients with lower extremity venous disease were evaluated anatomically using TRANCE MRI. Then, a QFlow analysis was performed in 53 patients with only one leg affected for hemodynamic evaluation. Those patients with complete QFlow were classified into obstructive and nonobstructive. RESULTS The QFlow-namely, stroke volume, forward flow volume, mean flux, stroke distance (SD), and mean velocity (MV) in the external iliac vein (EIV), femoral vein (FV), popliteal vein (PV), and great saphenous vein (GSV). The obstructed group had a shorter SD and lower MV in the EIV, EIV/FV, and GSV/PV (SD: p-values of 0.025, 0.05, and 0.043, respectively; MV: p-values of 0.02, 0.05, and 0.048, respectively). A good performance in discriminating obstructive venous disease was reported for SD in the EIV (area under the curve (AUC) = 67.9%, 95% confidence interval (CI) = 53.2-82.7%), EIV/FV (AUC = 72.4%, 95% CI = 58.2-86.5%), and GSV/PV (AUC = 67.9%, 95% CI = 51.7-84.1%). The SD in the EIV, EIV/FV, and GSV/PV had the ability to discriminate between obstructive and nonobstructive diseases (p-values of 0.025, 0.005, and 0.043). The MV in the EIV, EIV/FV, and GSV/PV had ability to discriminate between obstructive and nonobstructive venous diseases (p-values of 0.02, 0.005, and 0.048). CONCLUSIONS The SD and MV were lower for obstructive than nonobstructive disease in the EIV.
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Affiliation(s)
- Chien-Wei Chen
- Department of Diagnostic Radiology, Chia Yi Chang Gung Memorial Hospital and Chang Gung University, Chiayi 61363, Taiwan; (C.-W.C.); (Y.-C.H.)
| | - Yuan-Hsi Tseng
- Division of Thoracic and Cardiovascular Surgery, Chia Yi Chang Gung Memorial Hospital and Chang Gung University, Taoyuan 33323, Taiwan; (Y.-H.T.); (M.Y.W.); (Y.-H.L.)
| | - Min Yi Wong
- Division of Thoracic and Cardiovascular Surgery, Chia Yi Chang Gung Memorial Hospital and Chang Gung University, Taoyuan 33323, Taiwan; (Y.-H.T.); (M.Y.W.); (Y.-H.L.)
| | - Yu-Hui Lin
- Division of Thoracic and Cardiovascular Surgery, Chia Yi Chang Gung Memorial Hospital and Chang Gung University, Taoyuan 33323, Taiwan; (Y.-H.T.); (M.Y.W.); (Y.-H.L.)
| | - Teng-Yao Yang
- Department of Cardiology, Chia Yi Chang Gung Memorial Hospital and Chang Gung University, Taoyuan 33323, Taiwan;
| | - Yin-Chen Hsu
- Department of Diagnostic Radiology, Chia Yi Chang Gung Memorial Hospital and Chang Gung University, Chiayi 61363, Taiwan; (C.-W.C.); (Y.-C.H.)
| | - Bor-Shyh Lin
- Institute of Imaging and Biomedical Photonics, National Yang Ming Chiao Tung University and Department of Medical Research, Chi-Mei Medical Center, Tainan 71004, Taiwan;
| | - Yao-Kuang Huang
- Division of Thoracic and Cardiovascular Surgery, Chia Yi Chang Gung Memorial Hospital and Chang Gung University, Taoyuan 33323, Taiwan; (Y.-H.T.); (M.Y.W.); (Y.-H.L.)
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Chen CW, Tseng YH, Fang YF, Wong MY, Lin YH, Huang YK. Superficial Venous Reflux Intervention Guided by Triggered Angiography Non-Contrast-Enhanced Sequence Magnetic Resonance Imaging: Different QFlow Pattern from Health Controls. J Pers Med 2021; 11:jpm11080751. [PMID: 34442395 PMCID: PMC8398290 DOI: 10.3390/jpm11080751] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 02/07/2023] Open
Abstract
(1) Background: To assess the effectiveness of triggered angiography non-contrast-enhanced (TRANCE)-magnetic resonance imaging (MRI) in superficial venous reflux and its difference from health controls. (2) Methods: Thirty patients underwent TRANCE MRI before surgical intervention of their superficial venous reflux of the legs. Ten healthy volunteers were included as a control. (3) Results: TRANCE MRI involves the major tributaries, thus enhances the additional ablations in 20% of patients. QFlow pattern of superficial venous reflux (QFlow GSV/PV MF ratio > 1) was compared with the duplex scan (SFJ reflux) using Cohen’s kappa coefficient at 0.967. The 30 morbid legs undergoing TRANCE MRI-guide interventions and the healthy volunteers’ legs on the same side were compared. The stroke volumes (SV) are higher in EIV (p = 0.021) in the left-leg-intervention group. The mean flux (MF) is higher in the EIV (p = 0.012) and trend of increasing in GSV segment (p = 0.087) in the left-leg-intervention group. The QFlow of 10 patients with right leg intervention are higher in GSV in the right-leg-intervention group (SV p = 0.002; FFV p = 0.001; MF p = 0.001). QFlow data is shown for all legs for superficial venous intervention with GSV/PV (MF) ratio > 1. (4) Conclusions: Typical figures in QFlow (GSV/PV MF ratio > 1) could be observed in the morbid limbs but not in the controls.
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Affiliation(s)
- Chien-Wei Chen
- Department of Diagnostic Radiology, Chia-Yi Gung Memorial Hospital and Chang Gung University, College of Medicine, Taoyuan 333, Taiwan;
| | - Yuan-Hsi Tseng
- Division of Thoracic and Cardiovascular Surgery, Chia-Yi Chan Gung Memorial Hospital and Chang Gung University, College of Medicine, Taoyuan 333, Taiwan; (Y.-H.T.); (M.Y.W.); (Y.-H.L.)
| | - Yueh-Fu Fang
- Department of Thoracic Medicine, Linkou Chang Gung Memorial Hospital and Chang Gung University, College of Medicine, Taoyuan 333, Taiwan;
| | - Min Yi Wong
- Division of Thoracic and Cardiovascular Surgery, Chia-Yi Chan Gung Memorial Hospital and Chang Gung University, College of Medicine, Taoyuan 333, Taiwan; (Y.-H.T.); (M.Y.W.); (Y.-H.L.)
| | - Yu-Hui Lin
- Division of Thoracic and Cardiovascular Surgery, Chia-Yi Chan Gung Memorial Hospital and Chang Gung University, College of Medicine, Taoyuan 333, Taiwan; (Y.-H.T.); (M.Y.W.); (Y.-H.L.)
| | - Yao-Kuang Huang
- Division of Thoracic and Cardiovascular Surgery, Chia-Yi Chan Gung Memorial Hospital and Chang Gung University, College of Medicine, Taoyuan 333, Taiwan; (Y.-H.T.); (M.Y.W.); (Y.-H.L.)
- Correspondence:
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Tseng YH, Chen CW, Wong MY, Yang TY, Lin BS, Ting H, Huang YK. Discriminating Reflux from Non-Reflux Diseases of Superficial Veins in Legs by Novel Non-Contrast MR with QFlow Technique. J Pers Med 2021; 11:jpm11040242. [PMID: 33810500 PMCID: PMC8066982 DOI: 10.3390/jpm11040242] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 03/21/2021] [Accepted: 03/22/2021] [Indexed: 11/16/2022] Open
Abstract
Objectives: To find an objective diagnostic tool for the superficial veins in legs. Methods: This study included 137 patients who underwent TRANCE-MRI from 2017 to 2020 (IRB: 202001570B0). Among them, 53 with unilateral leg venous diseases underwent a QFlow scan and were classified into the reflux and non-reflux groups according to the status of the great saphenous veins. Results: The QFlow, namely stroke volume (SV), forward flow volume (FFV), mean flux (MF), stroke distance (SD), and mean velocity (MV) measured in the external iliac, femoral, popliteal, and great saphenous vein (GSV). The SV, FFV, SD, MF, SD, and MV in the GSV (morbid/non-morbid limbs) demonstrated a favorable ability to discriminate reflux from non-reflux in the ROC curve. The SD in the GSV and GSV/PV ratio (p = 0.049 and 0.047/cutoff = 86 and 117.1) and the MV in the EIV/FV ratio, GSV, and GSV/PV ratio (p = 0.035, 0.034, and 0.025/cutoff = 100.9, 86.1, and 122.9) exhibited the ability to discriminate between reflux and non-reflux group. The SD, MV, and FFV have better ability to discriminate a reflux from non-reflux group than the SV and MF. Conclusions: QFlow may be used to verify the reflux of superficial veins in the legs. An increasing GSV/PV ratio is a hallmark of reflux of superficial veins in the legs.
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Affiliation(s)
- Yuan-Hsi Tseng
- Division of Thoracic and Cardiovascular Surgery, Chiayi Chang Gung Memorial Hospital, College of Medicine, Chia-Yi and Chang Gung University, Taoyuan 33302, Taiwan; (Y.-H.T.); (M.Y.W.)
| | - Chien-Wei Chen
- Department of Diagnostic Radiology, Chiayi Chang Gung Memorial Hospital, College of Medicine, Chia-Yi and Chang Gung University, Taoyuan 33302, Taiwan;
- Institute of Medicine, Chung Shan Medical University, Taichung 408, Taiwan;
| | - Min Yi Wong
- Division of Thoracic and Cardiovascular Surgery, Chiayi Chang Gung Memorial Hospital, College of Medicine, Chia-Yi and Chang Gung University, Taoyuan 33302, Taiwan; (Y.-H.T.); (M.Y.W.)
- Institute of Imaging and Biomedical Photonics, National Chiao Tung University, Tainan 300, Taiwan;
| | - Teng-Yao Yang
- Department of Cardiology, Chiayi Chang Gung Memorial Hospital, College of Medicine, Chia-Yi and Chang Gung University, Taoyuan 33302, Taiwan;
| | - Bor-Shyh Lin
- Institute of Imaging and Biomedical Photonics, National Chiao Tung University, Tainan 300, Taiwan;
| | - Hua Ting
- Institute of Medicine, Chung Shan Medical University, Taichung 408, Taiwan;
| | - Yao-Kuang Huang
- Division of Thoracic and Cardiovascular Surgery, Chiayi Chang Gung Memorial Hospital, College of Medicine, Chia-Yi and Chang Gung University, Taoyuan 33302, Taiwan; (Y.-H.T.); (M.Y.W.)
- Correspondence:
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