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Izumino H, Tajima G, Tasaki O, Inokuma T, Hatachi G, Takagi K, Miyazaki T, Matsumoto K, Tsuchiya T, Sato S, Nagayasu T. Balance of the prooxidant and antioxidant system is associated with mortality in critically ill patients. J Clin Biochem Nutr 2023; 72:157-164. [PMID: 36936878 PMCID: PMC10017322 DOI: 10.3164/jcbn.22-79] [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: 07/23/2022] [Accepted: 11/06/2022] [Indexed: 01/28/2023] Open
Abstract
It is well known that oxidative stress causes certain diseases and organ damage. However, roles of oxidative stress in the acute phase of critical patients remain to be elucidated. This study aimed to investigate the balance of oxidative and antioxidative system and to clarify the association between oxidative stress and mortality in critically ill patients. This cohort study enrolled 247 patients transported to our emergency department by ambulance. Blood was drawn on hospital arrival, and serum derivatives of reactive oxidant metabolites (dROMs, oxidative index) and biological antioxidant potential (BAP, antioxidative index) were measured. Modified ratio (MR) is also calculated as BAP/dROMs/7.51. There were 197 survivors and 50 non-survivors. In the non-survivors, dROMs were significantly lower (274 vs 311, p<0.01), BAP was significantly higher (2,853 vs 2,138, p<0.01), and MR was significantly higher (1.51 vs 0.92, p<0.01) compared to those in the survivors. The AUC of MR was similar to that for the APACHE II score. Contrary to our expectations, higher BAP and lower dROMs were observed on admission in non-survivors. This may suggest that the antioxidative system is more dominant in the acute phase of severe insults and that the balance toward a higher antioxidative system is associated with mortality.
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Affiliation(s)
- Hiroo Izumino
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Sciences, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan
- Acute and Critical Care Center, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Goro Tajima
- Acute and Critical Care Center, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
- Department of Emergency Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan
- To whom correspondence should be addressed. E-mail:
| | - Osamu Tasaki
- Acute and Critical Care Center, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
- Department of Emergency Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan
| | - Takamitsu Inokuma
- Acute and Critical Care Center, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Go Hatachi
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Sciences, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan
| | - Katsunori Takagi
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Sciences, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan
| | - Takuro Miyazaki
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Sciences, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan
| | - Keitaro Matsumoto
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Sciences, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan
| | - Tomoshi Tsuchiya
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Sciences, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan
| | - Shuntaro Sato
- Clinical Research Center, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Takeshi Nagayasu
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Sciences, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan
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Valente T, Arbex AK. Glycemic Variability, Oxidative Stress, and Impact on Complications Related to Type 2 Diabetes Mellitus. Curr Diabetes Rev 2021; 17:e071620183816. [PMID: 32674737 DOI: 10.2174/1573399816666200716201550] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 07/01/2020] [Accepted: 07/03/2020] [Indexed: 11/22/2022]
Abstract
Chronic hyperglycemia is an established risk factor for the development of complications in both type 1 and type 2 diabetes, but glycemic variability has emerged as a possible independent risk factor for diabetes complications, possibly through oxidative stress. In this review, methods to access glycemic variability and oxidative stress, as well as their correlations, are discussed. Non-pharmacological and pharmacological strategies are also debated to achieve better glycemic control, not only by HbA1c target but also with reduced glycemic fluctuations, possibly minimizing the risk of diabetes complications.
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Affiliation(s)
- Tatiana Valente
- Division of Endocrinology, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
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Gorni D, Finco A. Oxidative stress in elderly population: A prevention screening study. Aging Med (Milton) 2020; 3:205-213. [PMID: 33103041 PMCID: PMC7574639 DOI: 10.1002/agm2.12121] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 06/16/2020] [Accepted: 06/19/2020] [Indexed: 12/21/2022] Open
Abstract
Background Aging is a multifactorial phenomenon, characterized by a progressive decline in the efficiency of biochemical and physiological processes and an increased susceptibility to disease. There is increasing evidence that aging and age‐related disease are correlated with an oxidative stress (OS) condition. The latter is characterized by an imbalance between reactive species (RS), in particular reactive oxygen species (ROS) and antioxidant reserve. Objectives The aim of this study is to evaluate the two main markers of oxidative stress, plasmatic peroxide concentration (through d‐ROMs FAST test, derivates‐Reactive Oxygen Metabolites) and plasmatic antioxidant power measured by iron‐reducing power (PAT test, Plasma Antioxidant Test) in 290 apparently healthy volunteers over 60, and their possible correlation with age and gender. Materials and methods Human capillary blood samples from healthy volunteers were used in this observational study for the evaluation of the markers of OS. Results The data obtained broadly demonstrate that the majority of elderly people display an OS condition characterized by increased levels of peroxides and a slight reduction in antioxidant reserve. Conclusions Seniors have a greater propensity to develop a condition of oxidative stress, and therefore it is important to associate the monitoring of oxidative stress markers and, if necessary, antioxidant supplementation, with a healthy lifestyle.
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Affiliation(s)
- Davide Gorni
- Department of Oxidation Research Cor. Con. International Srl Parma Italy
| | - Annarosa Finco
- Department of Oxidation Research Cor. Con. International Srl Parma Italy
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Kohata Y, Ohara M, Nagaike H, Fujikawa T, Osaka N, Goto S, Fukase A, Kushima H, Hiromura M, Terasaki M, Mori Y, Fukui T, Ouchi M, Suzuki T, Hirano T, Yamagishi SI. Association of Hemoglobin A1c, 1,5-Anhydro-D-Glucitol and Glycated Albumin with Oxidative Stress in Type 2 Diabetes Mellitus Patients: A Cross-Sectional Study. Diabetes Ther 2020; 11:655-665. [PMID: 31997224 PMCID: PMC7048877 DOI: 10.1007/s13300-020-00772-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Oxidative stress plays a central role in the development and progression of vascular complications in patients with type 2 diabetes mellitus (T2DM). We have previously shown that markers of glucose variability evaluated by continuous glucose monitoring (CGM) are positively associated with oxidative stress in patients with T2DM. However, the evaluation of the glycemic variability by CGM remains a time- and money-consuming procedure. Therefore, this study investigated the independent correlates of oxidative stress among various other clinical markers routinely measured in primary care. METHODS This was a retrospective cross-sectional study with 234 T2DM patients to examine which clinical variables, including 1,5-anhydro-D-glucitol (1,5-AG) and glycated albumin (GA), were independently associated with oxidative stress. Oxidative stress was measured using the diacron-reactive oxygen metabolites (d-ROMs) test. The relationships between d-ROMs and clinical factors, such as blood glucose, glycated hemoglobin (HbA1c), 1,5-AG, GA, lipid parameters, and blood pressure, were examined. RESULTS Multiple stepwise regression analysis revealed that 1,5-AG (inversely), GA, triglycerides, use of metformin and being female were independently associated with d-ROMs. When patients with T2DM were stratified into two groups with HbA1c < 8.0% and HbA1c ≥ 8.0%, 1,5-AG (inversely), HbA1c, use of metformin and being female were independently associated with d-ROMs in diabetes patients with HbA1c < 8.0%, whereas GA, fasting plasma glucose and being female were independently associated with d-ROMs in patients with HbA1c ≥ 8.0%. CONCLUSION Our present study suggests that 1,5-AG and GA are the strongest correlates of oxidative stress in patients with well and poorly controlled T2DM, respectively.
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Affiliation(s)
- Yo Kohata
- Department of Medicine, Division of Diabetes, Metabolism, and Endocrinology, Showa University School of Medicine, Tokyo, Japan
| | - Makoto Ohara
- Department of Medicine, Division of Diabetes, Metabolism, and Endocrinology, Showa University School of Medicine, Tokyo, Japan.
| | - Hiroe Nagaike
- Department of Medicine, Division of Diabetes, Metabolism, and Endocrinology, Showa University School of Medicine, Tokyo, Japan
| | - Tomoki Fujikawa
- Department of Medicine, Division of Diabetes, Metabolism, and Endocrinology, Showa University School of Medicine, Tokyo, Japan
| | - Naoya Osaka
- Department of Medicine, Division of Diabetes, Metabolism, and Endocrinology, Showa University School of Medicine, Tokyo, Japan
| | - Satoshi Goto
- Department of Medicine, Division of Diabetes, Metabolism, and Endocrinology, Showa University School of Medicine, Tokyo, Japan
| | - Ayako Fukase
- Department of Medicine, Division of Diabetes, Metabolism, and Endocrinology, Showa University School of Medicine, Tokyo, Japan
| | - Hideki Kushima
- Department of Medicine, Division of Diabetes, Metabolism, and Endocrinology, Showa University School of Medicine, Tokyo, Japan
| | - Munenori Hiromura
- Department of Medicine, Division of Diabetes, Metabolism, and Endocrinology, Showa University School of Medicine, Tokyo, Japan
| | - Michishige Terasaki
- Department of Medicine, Division of Diabetes, Metabolism, and Endocrinology, Showa University School of Medicine, Tokyo, Japan
| | - Yusaku Mori
- Department of Medicine, Division of Diabetes, Metabolism, and Endocrinology, Showa University School of Medicine, Tokyo, Japan
| | - Tomoyasu Fukui
- Department of Medicine, Division of Diabetes, Metabolism, and Endocrinology, Showa University School of Medicine, Tokyo, Japan
| | - Motoshi Ouchi
- Department of Pharmacology and Toxicology, Dokkyo Medical University School of Medicine, Tochigi, Japan
| | - Tatsuya Suzuki
- Division of Geriatric Medicine, Nippon Medical School, Tokyo, Japan
| | - Tsutomu Hirano
- Department of Medicine, Division of Diabetes, Metabolism, and Endocrinology, Showa University School of Medicine, Tokyo, Japan
- Diabetes Center, Ebina General Hospital, Ebina, Japan
| | - Sho-Ichi Yamagishi
- Department of Medicine, Division of Diabetes, Metabolism, and Endocrinology, Showa University School of Medicine, Tokyo, Japan
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Kobayashi H, Iorio EL, Yoshino A. Effects of mode of delivery on pro-oxidant/antioxidant balance in fetal circulation. J Matern Fetal Neonatal Med 2018; 32:3294-3299. [PMID: 30231659 DOI: 10.1080/14767058.2018.1526911] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Objective: This study was undertaken to assess the influence of mode of delivery on the balance between pro-oxidant/antioxidant systems in fetal circulation. Materials and methods: Both umbilical arterial and venous blood samples were obtained from 37 pregnant women who delivered by spontaneous vaginal delivery (VD group) and from 29 pregnant women who delivered by elective cesarean section (CS group). Oxidative stress and antioxidant activity were evaluated by reactive oxygen metabolites (d-ROMs) and biological antioxidant potential (BAP), respectively. Results: The d-ROMs values of the VD group were higher than that of the CS group in both umbilical arterial and venous blood and these differences were found to be statistically significant (p < .01 and p < .01, respectively). The BAP values of only the umbilical arterial blood were found to be statistically significant (p < .01), with values from the VD group being higher than those of the CS group. In all measurements, the d-ROMs values averaged below 120 CARR U and BAP values averaged above 2200 µmol/L. The ratio of BAP/d-ROMs difference was found to be statistically significant (p < .01) only in the umbilical venous blood, with ratios in the VD group being lower than those in the CS group. Conclusions: Our statistical analyses suggest that vaginal delivery has an effect on increasing oxidative stress as a result of the stress of labor and that an elective cesarean section does not impair the mother's oxidative stress status. Furthermore, the high BAP values in all the measurements suggest that neonates just after birth have the ability to cope with oxidative stress. Rationale In many studies, the diversity of views on the influence of mode of delivery on the redox status of neonates is likely to be caused by the use of different biomarkers to measure either the oxidative stress, the antioxidant activity, or both. Furthermore, incomplete explanation for sampling cord blood in these studies, either arterial, venous blood or both, complicates matters. To solve the above, this study was designed to assess the effects of mode of delivery on both pro-oxidants, via d-ROMs, and antioxidants, via BAP, in both umbilical arterial and venous blood samples obtained just after birth. There are no existing studies of BAP in both umbilical arterial and venous blood to which we can refer. In conclusion, our study suggests that the pro-oxidant/antioxidant balance in neonates just after birth is better than may be expected when compared to the potentials of adults (including pregnant mothers) according to interpretations of BAP/d-ROMs. This can be understood that neonates may have already been endowed with the ability to cope with oxidative stress, as informed by high BAP values in both umbilical arterial and venous blood. Vaginal delivery may have an effect on increasing oxidative stress as a result of the stress of labors (as measured by d-ROMs), and an elective cesarean section, which has better BAP/d-ROMs in umbilical venous blood than that of vaginal delivery, may not impair the mother's oxidative stress status.
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Affiliation(s)
- Hisaaki Kobayashi
- a Department of Obstetrics , Nishisaitama Chuo National Hospital , Tokorozawa , Japan.,b Department of Gynecology , Nishisaitama Chuo National Hospital , Tokorozawa , Japan
| | | | - Akihiro Yoshino
- a Department of Obstetrics , Nishisaitama Chuo National Hospital , Tokorozawa , Japan.,b Department of Gynecology , Nishisaitama Chuo National Hospital , Tokorozawa , Japan
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Ishiguro K, Yokota S. Alterations in Polyphenol and Inulin Contents of Roasted Jerusalem Artichoke (<i>Helianthus tuberosus </i>L.). J JPN SOC FOOD SCI 2018. [DOI: 10.3136/nskkk.65.7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Ohara M, Fukui T, Ouchi M, Watanabe K, Suzuki T, Yamamoto S, Yamamoto T, Hayashi T, Oba K, Hirano T. Relationship between daily and day-to-day glycemic variability and increased oxidative stress in type 2 diabetes. Diabetes Res Clin Pract 2016; 122:62-70. [PMID: 27810687 DOI: 10.1016/j.diabres.2016.09.025] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 09/12/2016] [Accepted: 09/26/2016] [Indexed: 10/20/2022]
Abstract
AIMS To determine the association of daily and day-to-day glucose variability with oxidative stress. METHODS This was a cross-sectional analysis of 68 patients with type 2 diabetes mellitus (T2DM) over 72h of continuous glucose monitoring. Fasting plasma glucose (FPG) and hemoglobin A1c (HbA1c) were measured before breakfast on day 1. Glucose variability, mean glucose level (MGL), mean amplitude of glycemic excursions (MAGE), mean of daily differences (MODD) in glucose levels and area under the postprandial plasma glucose curve (AUCPP) were measured on days 2 and 3. Plasma oxidant capacity against N,N-diethylparaphenylenediamine was measured with the diacron-reactive oxygen metabolites (d-ROMs) test on day 1. RESULTS Overall, 66.2% males with the mean age of 63.2±12.6years, diabetes duration of 12.9±10.4years, and HbA1c level of 8.1±1.6% (65±17mmol/mol) were included. MGL (r=0.330), HbA1c (r=0.326), MAGE (r=0.565), MODD (r=0.488), and AUCPP (r=0.254) exhibited significant correlations with d-ROMs and not FPG; these correlations remained significant after adjustment for clinical factors (sex, age, duration of diabetes, smoking habit, insulin use, statin use, angiotensin II receptor blocker use, BMI, LDL-C, HDL-C, TG, eGFR, and systolic blood pressure) (R2=0.268, R2=0.268, R2=0.417, R2=0.314, and R2=0.347, respectively). MAGE was significantly correlated with MODD (r=0.708) and MAGE and MODD were independently correlated with d-ROMs by multivariate analysis. CONCLUSIONS Therefore, oxidative stress is associated with daily and day-to-day glucose variability in patients with T2DM.
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Affiliation(s)
- Makoto Ohara
- Department of Medicine, Division of Diabetes, Metabolism, and Endocrinology, Showa University School of Medicine, Japan.
| | - Tomoyasu Fukui
- Department of Medicine, Division of Diabetes, Metabolism, and Endocrinology, Showa University School of Medicine, Japan
| | - Motoshi Ouchi
- Department of Pharmacology and Toxicology, Dokkyo Medical University School of Medicine, Japan
| | - Kentaro Watanabe
- Department of Neurology, Hematology, Metabolism, Endocrinology and Diabetology (DNHMED), Yamagata University Faculty of Medicine, Japan
| | - Tatsuya Suzuki
- Division of Geriatric Medicine, Nippon Medical School, Japan
| | - Saki Yamamoto
- Department of Medicine, Division of Diabetes, Metabolism, and Endocrinology, Showa University School of Medicine, Japan
| | - Takeshi Yamamoto
- Department of Medicine, Division of Diabetes, Metabolism, and Endocrinology, Showa University School of Medicine, Japan
| | - Toshiyuki Hayashi
- Department of Medicine, Division of Diabetes, Metabolism, and Endocrinology, Showa University School of Medicine, Japan
| | - Kenzo Oba
- Department of Internal Medicine, Oarai Coast Core Clinic, Japan
| | - Tsutomu Hirano
- Department of Medicine, Division of Diabetes, Metabolism, and Endocrinology, Showa University School of Medicine, Japan
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Kim JH, Baik HW, Yoon YS, Joung HJ, Park JS, Park SJ, Jang EJ, Park SW, Kim SJ, Kim MJ, Jeon DO, Cho HJ, Lee SJ, Im SG, Jang SK. Measurement of antioxidant capacity using the biological antioxidant potential test and its role as a predictive marker of metabolic syndrome. Korean J Intern Med 2014; 29:31-9. [PMID: 24574831 PMCID: PMC3932393 DOI: 10.3904/kjim.2014.29.1.31] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Revised: 11/07/2012] [Accepted: 11/29/2012] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND/AIMS Oxidative stress increases the risk of cardiovascular complications of metabolic syndrome (MetS). This study was conducted to examine the difference in antioxidant capacity according to the presence of MetS, and to characterize the association between antioxidant capacity and MetS-related factors. METHODS We used the biological antioxidant potential (BAP) test to estimate antioxidant capacity. The BAP test has recently been used as an indicator of antioxidant capacity. We measured BAP levels in 45 patients with MetS (mean age, 44.6 ± 1.1 years) and 47 age- and sex-matched controls (mean age, 42.7 ± 1.1 years). To evaluate the association between antioxidant capacity and MetS, adiponectin, high-sensitivity C-reactive protein (hs-CRP), interleukin-6, tumor necrosis factor-α, and homeostatic model assessment for insulin resistance (HOMA-IR), linear regression and logistic analyses were performed. RESULTS The mean BAP of the MetS group (1,937.3 ± 36.5 µmol/L) was significantly lower than that of the non-MetS group (2,101.7 ± 29.5 µmol/L). Also, the mean BAP was low in persons having low high density lipoprotein and high triglyceride. Reduced antioxidant capacity was significantly associated with adiponectin, HOMA-IR and hs-CRP after adjusting for age and sex. The odds ratios for MetS with BAP, log adiponectin, log HOMA-IR, and log hs-CRP were 0.63 (95% confidence interval [CI], 0.49 to 0.82), 0.22 (0.10 to 0.51), 14.24 (4.35 to 46.58), and 1.93 (1.36 to 2.75), respectively. CONCLUSIONS Persons with MetS showed reduced antioxidant capacity. We identified relationships between antioxidant capacity measured by BAP test and MetS, as well as MetS-related factors, such as insulin resistance, hs-CRP, and adiponectin.
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Affiliation(s)
- Jung Hee Kim
- Department of Internal Medicine, Bundang Jesaeng Hospital, Seongnam, Korea
| | - Hyun Wook Baik
- Department of Internal Medicine, Bundang Jesaeng Hospital, Seongnam, Korea
| | - Yeong Sook Yoon
- Department of Family Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Hyo Jee Joung
- Seoul National University Graduate School of Public Health, Seoul, Korea
| | - Ju Sang Park
- Department of Internal Medicine, Bundang Jesaeng Hospital, Seongnam, Korea
| | - Sang Jong Park
- Department of Internal Medicine, Bundang Jesaeng Hospital, Seongnam, Korea
| | - Eun Jeong Jang
- Department of Internal Medicine, Bundang Jesaeng Hospital, Seongnam, Korea
| | - Sang Woon Park
- Department of Internal Medicine, Bundang Jesaeng Hospital, Seongnam, Korea
| | - Sang Jung Kim
- Department of Internal Medicine, Bundang Jesaeng Hospital, Seongnam, Korea
| | - Mi Jeoung Kim
- Department of Internal Medicine, Bundang Jesaeng Hospital, Seongnam, Korea
| | - Dong Ok Jeon
- Department of Internal Medicine, Bundang Jesaeng Hospital, Seongnam, Korea
| | - Hyo Jin Cho
- Department of Internal Medicine, Bundang Jesaeng Hospital, Seongnam, Korea
| | - Sang Jin Lee
- Department of Internal Medicine, Bundang Jesaeng Hospital, Seongnam, Korea
| | - Sung Gyu Im
- Department of Internal Medicine, Bundang Jesaeng Hospital, Seongnam, Korea
| | - Sun Kyung Jang
- Department of Internal Medicine, Bundang Jesaeng Hospital, Seongnam, Korea
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