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Urhuț MC, Săndulescu LD, Ciocâlteu A, Cazacu SM, Dănoiu S. The Clinical Value of Multimodal Ultrasound for the Differential Diagnosis of Hepatocellular Carcinoma from Other Liver Tumors in Relation to Histopathology. Diagnostics (Basel) 2023; 13:3288. [PMID: 37892109 PMCID: PMC10606610 DOI: 10.3390/diagnostics13203288] [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: 09/03/2023] [Revised: 09/26/2023] [Accepted: 10/17/2023] [Indexed: 10/29/2023] Open
Abstract
Recent advances in the field of ultrasonography offer promising tools for the evaluation of liver tumors. We aim to assess the value of multimodal ultrasound in differentiating hepatocellular carcinomas (HCCs) from other liver lesions. We prospectively included 66 patients with 72 liver tumors. The histological analysis was the reference standard for the diagnosis of malignant liver lesions, and partially for benign tumors. All liver lesions were assessed by multiparametric ultrasound: standard ultrasound, contrast-enhanced ultrasound (CEUS), the point shear wave elastography (pSWE) using shear wave measurement (SWM) method and real-time tissue elastography (RTE). To diagnose HCCs, CEUS achieved a sensitivity, specificity, accuracy and positive predictive value (PPV) of 69.05%, 92.86%, 78.57% and 93.55%, respectively. The mean shear-wave velocity (Vs) value in HCCs was 1.59 ± 0.29 m/s, which was lower than non-HCC malignancies (p < 0.05). Using a cut-off value of 1.58 m/s, SWM achieved a sensitivity of 54.76%, and 82.35% specificity, for differentiating HCCs from other malignant lesions. The combination of SWM and CEUS showed higher sensitivity (79.55%) compared with each technique alone, while maintaining a high specificity (89.29%). In RTE, most HCCs (61.53%) had a mosaic pattern with dominant blue areas corresponding to type "c" elasticity. Elasticity type "c" was 70.59% predictive for HCCs. In conclusion, combining B-mode ultrasound, CEUS, pSWE and RTE can provide complementary diagnostic information and potentially decrease the requirements for other imaging modalities.
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Affiliation(s)
- Marinela-Cristiana Urhuț
- Department of Gastroenterology, Emergency County Hospital of Craiova, Doctoral School, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
| | - Larisa Daniela Săndulescu
- Department of Gastroenterology, Research Center of Gastroenterology and Hepatology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania; (A.C.); (S.M.C.)
| | - Adriana Ciocâlteu
- Department of Gastroenterology, Research Center of Gastroenterology and Hepatology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania; (A.C.); (S.M.C.)
| | - Sergiu Marian Cazacu
- Department of Gastroenterology, Research Center of Gastroenterology and Hepatology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania; (A.C.); (S.M.C.)
| | - Suzana Dănoiu
- Department of Pathophysiology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
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Beydoğan E, Yalçın A. Is 2D SWE sufficient as clinical diagnosis in patients with plantar fasciitis? Acta Radiol 2021; 64:147-152. [PMID: 34851153 DOI: 10.1177/02841851211058928] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The use of shear wave elastography (SWE) seems to be an important imaging method in the diagnosis of plantar fasciitis (PF). PURPOSE To compare patients diagnosed with PF with similar and young healthy control groups in terms of B-mode ultrasound (US) and SWE results and to evaluate the elasticity of the plantar fascia. MATERIAL AND METHODS A total of 140 feet of 70 participants were evaluated, including 30 patients and 40 healthy individuals as the control. Clinical, B-mode US, and SWE evaluations were performed for each patient. In addition, American Orthopedic Foot and Ankle Score (AOFAS) was calculated to evaluate pain and foot function in both groups. RESULTS Of the patients in the PF group, 40 (88%) were women and the healthy control groups had similar sex distributions (P = 0.23). The AOFAS score was lower in feet with PF compared to the other groups (P < 0.001). Of 30 patients with PF, 15 (50%) had bilateral PF and 15 (50%) unilateral PF. In addition, ≥4 mm thickness measurement, which was used as a diagnostic criterion for PF as a US finding, could be shown in 11 (73.3%) patients with unilateral PF and 6 (40%) patients with bilateral PF. CONCLUSION In conclusion, the evaluation of the diagnosis of PF with clinical findings and regular follow-up of measurements with SWE can provide measurement results with higher sensitivity in the diagnosis of PF.
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Affiliation(s)
- Engin Beydoğan
- Van Research and Training Hospital, Department of Radiology, Van, Turkey
| | - Atilla Yalçın
- Taksim Research and Training Hospital, Department of Orthopedics and Traumatology, Istanbul, Turkey
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Different Effects of Foam Rolling on Passive Tissue Stiffness in Experienced and Nonexperienced Athletes. J Sport Rehabil 2019; 29:926-933. [PMID: 31775121 DOI: 10.1123/jsr.2019-0172] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 08/02/2019] [Accepted: 09/15/2019] [Indexed: 11/18/2022]
Abstract
CONTEXT Foam rolling (FR) has been developed into a popular intervention and has been established in various sports disciplines. However, its effects on target tissue, including changes in stiffness properties, are still poorly understood. OBJECTIVE To investigate muscle-specific and connective tissue-specific responses after FR in recreational athletes with different FR experience. DESIGN Case series. SETTING Laboratory environment. PARTICIPANTS The study was conducted with 40 participants, consisting of 20 experienced (EA) and 20 nonexperienced athletes (NEA). INTERVENTION The FR intervention included 5 trials per 45 seconds of FR of the lateral thigh in the sagittal plane with 20 seconds of rest between each trial. MAIN OUTCOME MEASURES Acoustic radiation force impulse elastosonography values, represented as shear wave velocity, were obtained under resting conditions (t0) and several times after FR exercise (0 min [t1], 30 min [t2], 6 h [t3], and 24 h [t4]). Data were assessed in superficial and deep muscle (vastus lateralis muscle; vastus intermedius muscle) and in connective tissue (iliotibial band). RESULTS In EA, tissue stiffness of the iliotibial band revealed a significant decrease of 13.2% at t1 (P ≤ .01) and 12.1% at t3 (P = .02). In NEA, a 6.2% increase of stiffness was found at t1, which was not significantly different to baseline (P = .16). For both groups, no significant iliotibial band stiffness changes were found at further time points. Also, regarding muscle stiffness, no significant changes were detected at any time for EA and NEA (P > .05). CONCLUSIONS This study demonstrates a significant short-term decrease of connective tissue stiffness in EA, which may have an impact on the biomechanical output of the connective tissue. Thus, FR effects on tissue stiffness depend on the athletes' experience in FR, and existing studies have to be interpreted cautiously in the context of the enrolled participants.
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Application of Acoustic Radiation Force Impulse Elastography in Imaging of Delayed Onset Muscle Soreness: A Comparative Analysis With 3T MRI. J Sport Rehabil 2018; 27:348-356. [DOI: 10.1123/jsr.2017-0003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Context: Delayed onset muscle soreness is one of the most common reasons for impaired muscle performance in sports and is associated with reduced muscle strength and frequently observed both in professional and recreational athletes. Objective: To emphasize the diagnostic value of acoustic radiation force impulse (ARFI) in imaging of delayed onset muscle soreness by comparing findings with high-resolution 3T magnetic resonance imaging T2-weighted sequences. Design: Case series. Setting: Laboratory environment. Participants: Fifteen healthy students (7 females and 8 males; mean [SD]: age 24 [4] y, height 178 [10] cm, body weight 67 [12] kg). Main Outcome Measures: ARFI values, represented as shear wave velocities of the gastrocnemius muscle and soleus muscle, as well as conventional ultrasound, high-resolution 3T magnetic resonance imaging, creatine kinase activity, extension range of the ankle joint, calf circumference, and muscle soreness were assessed before (baseline) and 60 hours after (postintervention) a standardized eccentric exercise. Results: ARFI shear wave velocity values of the gastrocnemius muscle revealed a statistically significant decrease of 19.1% between baseline (2.2 [0.26] m/s) and postintervention (1.78 [0.24] m/s); P = .01. At follow-up, the magnetic resonance imaging investigations showed intramuscular edema for the gastrocnemius muscle in all participants corresponding to a significant raise in T2 signal intensity (P = .001) and in T2-time values (P = .004). Conclusions: ARFI elastography seems to be an additional sensitive diagnostic modality in the diagnostic workup of delayed onset muscle soreness. Intramuscular shear wave velocities could represent an additional imaging marker for the assessment and monitoring of ultrastructural muscle injuries and therefore be helpful for individual training composition in elite sports.
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Ultrasound elastography of the lower uterine segment in women with a previous cesarean section: Comparison of in-/ex-vivo elastography versus tensile-stress-strain-rupture analysis. Eur J Obstet Gynecol Reprod Biol 2018; 225:172-180. [PMID: 29729520 DOI: 10.1016/j.ejogrb.2018.04.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 04/10/2018] [Indexed: 01/05/2023]
Abstract
OBJECTIVES The purpose of this study was to assess, if the biomechanical properties of the lower uterine segment (LUS) in women with a previous cesarean section (CS) can be determined by ultrasound (US) elastography. The first aim was to establish an ex-vivo LUS tensile-stress-strain-rupture(break point) analysis with the possibility of simultaneously using US elastography. The second aim was to investigate the relationship between measurement results of LUS stiffness using US elastography in-/ex-vivo with results of tensile-stress-strain-rupture analysis, and to compare different US elastography LUS-stiffness-measurement methods ex-vivo. STUDY DESIGN An explorative experimental, in-/ex-vivo US study of women with previous CS was conducted. LUS elasticity was measured by point Shear Wave Elastography (pSWE) and bidimensional Shear-Wave-Elastography (2D-SWE) first in-vivo during preoperative examination within 24 h before repeat CS (including resection of the thinnest part of the LUS = uterine scar area during CS), second within 1 h after operation during the ex-vivo experiment, followed by tensile-stress-strain-rupture analysis. Pearson's correlation coefficient and scatter plots, Bland-Altman plots and paired T-tests, were used. RESULTS Thirty three women were included in the study; elastography measurements n = 1412. The feasibility of ex-vivo assessment of LUS by quantitative US elastography using pSWE and 2D-SWE to detect stiffness of LUS was demonstrated. The strongest correlation with tensile-stress-strain analysis was found in the US elastography examination carried out with 2D-SWE (0.78, p < 0.001, 95%CI [0.48, 0.92]). The laboratory experiment illustrated that, the break point - as a surrogate marker for the risk of rupture of the LUS after CS - is linearly dependent on the thickness of the LUS in the scar area (Coefficient of correlation: 0.79, p < 0.001, 95%CI [0.55, 0.91]). Two extremely stiff LUS-specimens (outlier or extreme values) rupture even at less stroke/strain than would be expected by their thickness. CONCLUSION This study confirms that US elastography can help in determining viscoelastic properties of the LUS in women with a previous CS. The data from our small series are promising. However whether individual extreme values of high stiffness and consecutive restricted biomechanical resilience can explain the phenomenon of rupture during TOLAC in cases of LUS with adequate thickness remains a question which prospective trials have to analyze before US elastography can be introduced into clinical practice.
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Putz FJ, Hautmann MG, Banas MC, Jung EM. Investigation of the acute plantar fasciitis with contrast-enhanced ultrasound and shear wave elastography - first results. Clin Hemorheol Microcirc 2018; 67:415-423. [PMID: 28885209 DOI: 10.3233/ch-179222] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The plantar fasciitis is a common disease with a high prevalence in public and a frequent cause of heel pain. OBJECTIVE In our pilot study, we wanted to characterise the feasibility of shear-wave elastography and contrast-enhanced ultrasound (CEUS) in the assessment of the plantar fasciitis. METHODS 23 cases of painful heels were examined by B-Mode ultrasound, Power Doppler (PD), shear wave elastography and contrast-enhanced ultrasound before anti-inflammatory radiation. Time-intensity-curves were analysed by the integrated software. The results for area-under-the-curve (AUC), peak, time-to-peak (TTP) and mean-transit-time (MTT) were compared between the plantar fascia and the surrounding tissue. RESULTS All cases showed thickening of the plantar fascia, in most cases with interstitial oedema (87.0%). Shear wave elastography showed inhomogeneous stiffness of the plantar fascia. 83.3% of cases showed a visible hyperperfusion in CEUS at the proximal plantar fascia in comparison to the surrounding tissue. This hyperperfusion could also be found in 75.0% of cases with no signs of vascularisation in PD. AUC (p = 0.0005) and peak (p = 0.037) were significantely higher in the plantar fascia than in the surrounding tissue. CONCLUSION CEUS and shear wave elastography are new diagnostic tools in the assessment of plantar fasciitis and can provide quantitative parameters for monitoring therapy.
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Affiliation(s)
- Franz Josef Putz
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany
| | - Matthias G Hautmann
- Department of Radiotherapy, University Hospital Regensburg, Regensburg, Germany
| | - Miriam C Banas
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany
| | - Ernst Michael Jung
- Department of Radiology and Interdisciplinary Ultrasound, University Hospital Regensburg, Regensburg, Germany
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Ahn SJ, Lee JM, Chang W, Lee SM, Kang HJ, Yang H, Yoon JH, Park SJ, Han JK. Prospective Validation of Intra- and Interobserver Reproducibility of a New Point Shear Wave Elastographic Technique for Assessing Liver Stiffness in Patients with Chronic Liver Disease. Korean J Radiol 2017; 18:926-935. [PMID: 29089825 PMCID: PMC5639158 DOI: 10.3348/kjr.2017.18.6.926] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Accepted: 08/01/2017] [Indexed: 12/12/2022] Open
Abstract
Objective To assess intra- and inter-observer reproducibility of a new point shear wave elastography technique (pSWE, S-Shearwave, Samsung Medison) and compare its accuracy in assessing liver stiffness (LS) with an established pSWE technique (Virtual Touch Quantification, VTQ). Materials and Methods Thirty-three patients were enrolled in this Institutional Review Board-approved prospective study. LS values were measured by VTQ on an Acuson S2000 system (Siemens Healthineer) and S-Shearwave on an RS-80A (Samsung Medison) in the same session, followed by two further S-Shearwave sessions for inter- and intra-observer variation at 8-hour intervals. The technical success rate (SR) and reliability of the measurements of both pSWE techniques were compared. The intra- and inter-observer reproducibility of S-Shearwave was determined by intraclass correlation coefficients (ICCs). LS values were measured by both methods of pSWE. The diagnostic performance in severe fibrosis (F ≥ 3) and cirrhosis (F = 4) was evaluated using the receiver operating characteristics curve analysis and the Obuchowski measure with the LS values of transient elastography as the referenced standard. Results The VTQ (100%, 33/33) and S-Shearwave (96.9%, 32/33) techniques did not display a significant difference in technical SR (p = 0.63) or reliability of LS measurements (96.9%, 32/33; 93.9%, 30/32, respectively, p = 0.61). The inter- and intra-observer agreement for LS measurements using the S-Shearwave technique was excellent (ICC = 0.98 and 0.99, respectively). The mean LS values of both pSWE techniques were not significantly different and exhibited a good correlation (r = 0.78). To detect F ≥ 3 and F = 4, VTQ and S-Shearwave showed comparable diagnostic accuracy as indicated by the following outcomes: areas under receiver operating characteristics curve (AUROC) = 0.87 (95% confidence intervals [CI] 0.70–0.96), 0.89 for VTQ (95% CI 0.74–0.97), respectively; and AUROC = 0.84 (95% CI 0.67–0.94), 0.94 (95% CI 0.80–0.99) for S-Shearwave (p > 0.48), respectively. The Obuchowski measures were similarly high for S-Shearwave and VTQ (0.94 vs. 0.95). Conclusion S-Shearwave shows excellent inter- and intra-observer agreement and diagnostic effectiveness comparable to VTQ in detecting LS.
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Affiliation(s)
- Su Joa Ahn
- Department of Radiology, Seoul National University Hospital, Seoul 03080, Korea
| | - Jeong Min Lee
- Department of Radiology, Seoul National University Hospital, Seoul 03080, Korea.,Institute of Radiation Medicine, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Won Chang
- Department of Radiology, Seoul National University Hospital, Seoul 03080, Korea
| | - Sang Min Lee
- Department of Radiology, Seoul National University Hospital, Seoul 03080, Korea
| | - Hyo-Jin Kang
- Department of Radiology, Seoul National University Hospital, Seoul 03080, Korea
| | - Hyunkyung Yang
- Department of Radiology, Seoul National University Hospital, Seoul 03080, Korea
| | - Jeong Hee Yoon
- Department of Radiology, Seoul National University Hospital, Seoul 03080, Korea
| | - Sae Jin Park
- Department of Radiology, Seoul National University Hospital, Seoul 03080, Korea
| | - Joon Koo Han
- Department of Radiology, Seoul National University Hospital, Seoul 03080, Korea.,Institute of Radiation Medicine, Seoul National University College of Medicine, Seoul 03080, Korea
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Hollerieth K, Gaßmann B, Wagenpfeil S, Kemmner S, Heemann U, Stock KF. Does standoff material affect acoustic radiation force impulse elastography? A preclinical study of a modified elastography phantom. Ultrasonography 2017; 37:140-148. [PMID: 29032665 PMCID: PMC5885480 DOI: 10.14366/usg.17002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Revised: 07/26/2017] [Accepted: 07/28/2017] [Indexed: 12/21/2022] Open
Abstract
PURPOSE This study was conducted to determine the influence of standoff material on acoustic radiation force impulse (ARFI) measurements in an elasticity phantom by using two different probes. METHODS Using ARFI elastography, 10 observers measured the shear wave velocity (SWV, m/sec) in different lesions of an elasticity phantom with a convex 4C1 probe and a linear 9L4 probe. The experimental setup was expanded by the use of an interposed piece of porcine muscle as standoff material. The probe pressure on the phantom was registered. RESULTS Faulty ARFI measurements occurred more often when quantifying the hardest lesion (74.0 kPa 4.97 m/sec) by the 9L4 probe with the porcine muscle as a standoff material interposed between the probe and the phantom. The success rate for ARFI measurements in these series was 52.4%, compared with 99.5% in the other series. The SWV values measured with the 9L4 probe were significantly higher (3.33±1.39 m/sec vs. 2.60±0.74 m/sec, P<0.001 in the group without muscle) and were closer to the reference value than those measured with the 4C1 probe (0.25±0.23 m/sec vs. 0.85±1.21 m/sec, P<0.001 in the same group). The SWV values measured when using the muscle as a standoff material were lower than those without the muscle (significant for 9L4, P=0.040). The deviation from the reference value and the variance increased significantly with the 9L4 probe if the muscle was in situ (B=0.27, P=0.004 and B=0.32, P<0.001). In our study, the pressure exerted by the operator had no effect on the SWV values. CONCLUSION The presence of porcine muscle acting as a standoff material influenced the occurrence of failed measurements as well as the variance and the accuracy of the measured values. The linear high-frequency probe was particularly affected.
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Affiliation(s)
- Katharina Hollerieth
- Department of Nephrology, Klinikum Rechts der Isar of the Technical University of Munich, Munich, Germany
| | | | - Stefan Wagenpfeil
- Institute for Medical Biometry, Epidemiology and Medical Informatics, Saarland University, Campus Homburg, Homburg, Saar, Germany
| | - Stephan Kemmner
- Department of Nephrology, Klinikum Rechts der Isar of the Technical University of Munich, Munich, Germany
| | - Uwe Heemann
- Department of Nephrology, Klinikum Rechts der Isar of the Technical University of Munich, Munich, Germany
| | - Konrad Friedrich Stock
- Department of Nephrology, Klinikum Rechts der Isar of the Technical University of Munich, Munich, Germany
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Yoon K, Jeong WK, Kim Y, Kim MY, Kim TY, Sohn JH. 2-dimensional shear wave elastography: Interobserver agreement and factors related to interobserver discrepancy. PLoS One 2017; 12:e0175747. [PMID: 28414822 PMCID: PMC5393601 DOI: 10.1371/journal.pone.0175747] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 03/30/2017] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To evaluate the interobserver reproducibility of two-dimensional shear wave elastography (2D-SWE) in measuring liver stiffness (LS) and to investigate factors related to liver 2D-SWE. MATERIALS AND METHODS A prospective study was conducted between August 2011 and August 2012 in rheumatoid arthritis patients who had been treated with methotrexate. Interobserver reproducibility of 2D-SWE was evaluated, and the relationship between interobserver difference in LS and related factors was analyzed using linear regression analyses. We considered age, sex, alanine transaminase, cholesterol, body mass index (BMI), and waist circumference as clinical factors, and the mean value of standard deviation (SDM), its difference between two examiners, mean diameter of the regions of interest (ROIM), and its difference in the elasticity map as investigation factors. The cut-off value for significant factors to predict interobserver discrepancies in LS-based fibrosis stage was also inspected. RESULTS In total, 176 patients were enrolled. The intraclass correlation coefficient between the two examiners was 0.784. In the univariate analysis, SDM and ROIM were independently associated with interobserver differences in LS as well as BMI, waist circumference, and the difference of ROI, but SDM and ROIM were the only ones significantly related in multivariate analysis (p<0.001 and p = 0.021, respectively). The best cut-off value for SDM in predicting interobserver discrepancy in LS-based fibrosis stage was 1.4. CONCLUSIONS Interobserver reproducibility of 2D-SWE for measuring LS was good and SDM was the most significantly associated factor with interobserver differences in LS and interobserver discordance in LS-based fibrosis stage.
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Affiliation(s)
- Kibo Yoon
- Department of Radiology, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Gyeonggi-do, Korea
| | - Woo Kyoung Jeong
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yongsoo Kim
- Department of Radiology, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Gyeonggi-do, Korea
| | - Min Yeong Kim
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae Yeob Kim
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Gyeonggi-do, Korea
| | - Joo Hyun Sohn
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Gyeonggi-do, Korea
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