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Chidiac C, Wharton K, Garcia AV, Rhee DS. Cryoablation Reduces Opioid Consumption and Length of Stay After Pulmonary Metastasectomy. J Surg Res 2024; 296:704-710. [PMID: 38364698 DOI: 10.1016/j.jss.2024.01.044] [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: 11/03/2023] [Revised: 01/12/2024] [Accepted: 01/19/2024] [Indexed: 02/18/2024]
Abstract
INTRODUCTION Intraoperative cryoablation of intercostal thoracic nerves is gaining popularity as a technique that decreases postoperative pain in thoracic surgery. Our study evaluates the efficacy and safety of cryoablation in pain management of pediatric cancer patients undergoing thoracotomy. METHODS We reviewed cancer patients undergoing thoracotomies for pulmonary metastasis resection at our children's hospital from 2017 to 2023. Patients who received cryoablation were compared to those who did not. Our primary outcomes were self-reported postoperative pain scores (from 0 to 10) and opioid consumption, measured as oral morphine equivalent per kilogram. RESULTS Thirty eight procedures were performed in 17 patients, of which 11 (64.7%) were males. Cryoablation was used in 14 (32.4%) procedures, while it was not in 24 (67.6%). Median age (17 y in both groups, P = 0.84) and length of surgery (300 cryoablation versus 282 no cryoablation, P = 0.65) were similar between the groups. Patients treated with cryoablation had a shorter hospital stay compared to those who did not (3.0 versus 4.5 d, respectively, P = 0.04) and received a lower total dose of opioids (2.2 oral morphine equivalent per kilogram versus 14.4, P = 0.004). No significant difference was noted in daily pain scores between the two groups (3.8 cryoablation versus 3.9 no cryoablation, P = 0.93). There was no difference in rates of readmissions between the cryoablation and no-cryoablation groups (14.3% versus 8.3%, P = 0.55). CONCLUSIONS Our study suggests that cryoablation of the thoracic nerves during a thoracotomy is associated with reduced opiate consumption and shorter hospital stay. Cryoablation appears to be a promising technique for pain management in this patient population.
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Affiliation(s)
- Charbel Chidiac
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kristin Wharton
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alejandro V Garcia
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniel S Rhee
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Young AM, Viktorsson SA, Strobel RJ, Rotar EP, Cramer C, Scott C, Carrott P, Blank RS, Martin LW. Five-Year Sustained Impact of a Thoracic Enhanced Recovery After Surgery Program. Ann Thorac Surg 2024; 117:422-430. [PMID: 37923241 DOI: 10.1016/j.athoracsur.2023.10.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 09/25/2023] [Accepted: 10/20/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Our thoracic enhanced recovery program (ERP) decreased the use of postoperative morphine equivalents and hospital costs 1 year after implementation at our tertiary center. The sustainability and potential increasing benefit of this program were evaluated. METHODS From 2015 to 2021, we prospectively analyzed the outcomes of patients who underwent elective pleural, pulmonary, or mediastinal operations at our institution. Patients were separated on the basis of the incision (video-assisted thoracoscopic surgery [VATS] or thoracotomy). The ERP protocol was initiated on May 1, 2016, and includes preoperative education, carbohydrate loading, opioid-sparing analgesia, conservative fluid management, protective ventilation, and early ambulation. Outcomes of patients before (2015, pre-VATS and pre-thoracotomy) and after (May 1, 2016, to December 31, 2021, ERP-VATS and ERP-thoracotomy) ERP implementation were compared. RESULTS The cohort included 1079 patients (pre-ERP era, n = 224 [21%]; ERP era, n = 855 [79%]). There was a median reduction of 1.5 hospital days per patient for ERP-thoracotomy and 1 hospital day per patient for ERP-VATS. Median postoperative morphine equivalents decreased in both groups (125 vs 45 mg, in ERP-thoracotomy; 84 vs 23 mg, ERP-VATS; P < .001), as did total admission cost ($32,118 vs $23,775, ERP-thoracotomy; $17,367 vs $11,560, ERP-VATS; P < .001). Median total fluid balance during the hospital stay decreased significantly. Rates of postoperative atrial fibrillation and urinary retention decreased across both subgroups. CONCLUSIONS ERP for thoracic surgery is sustainable and has been demonstrated to improve patient outcomes, to decrease opioid use, and to lower hospital costs. Therefore, it has the potential to become the standard of care.
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Affiliation(s)
- Andrew M Young
- Department of Surgery, School of Medicine, University of Virginia, Charlottesville, Virginia
| | - Sindri A Viktorsson
- Department of Surgery, School of Medicine, University of Virginia, Charlottesville, Virginia
| | - Raymond J Strobel
- Department of Surgery, School of Medicine, University of Virginia, Charlottesville, Virginia
| | - Evan P Rotar
- Department of Surgery, School of Medicine, University of Virginia, Charlottesville, Virginia
| | - Christopher Cramer
- Department of Surgery, School of Medicine, University of Virginia, Charlottesville, Virginia
| | - Christopher Scott
- Department of Surgery, School of Medicine, University of Virginia, Charlottesville, Virginia
| | - Phil Carrott
- Department of Surgery, School of Medicine, University of Virginia, Charlottesville, Virginia
| | - Randal S Blank
- Department of Anesthesiology, School of Medicine, University of Virginia, Charlottesville, Virginia
| | - Linda W Martin
- Department of Surgery, School of Medicine, University of Virginia, Charlottesville, Virginia.
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Holladay JD, McKee C, Nafiu OO, Tobias JD, Beltran RJ. Continuous Erector Spinae Plane Block for Pain Management Following Thoracotomy for Aortic Coarctectomy. J Med Cases 2024; 15:26-30. [PMID: 38328811 PMCID: PMC10846499 DOI: 10.14740/jmc4177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 01/17/2024] [Indexed: 02/09/2024] Open
Abstract
Pain following thoracotomy is one of the most severe forms of postoperative pain. Post-thoracotomy pain may increase the risk of post-surgical pulmonary complications, postoperative mortality, prolong hospitalization, and increase utilization of healthcare resources. To mitigate these effects, anesthesia providers commonly employ continuous epidural infusions, paravertebral blocks, and systemic opioids for pain management and improvement of pulmonary mechanics. We report the use of a continuous erector spinae plane block (ESPB) via a peripheral nerve catheter for postoperative pain management of an 18-year-old patient who underwent complex aortic coarctation repair via lateral thoracotomy, aided by cardiopulmonary bypass. Continuous ESPB proved to be an acceptable alternative for postoperative pain control, producing a substantial multi-dermatomal sensory block, resulting in adequate pain control, reduced opioid consumption, and a potentially shorter hospital stay.
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Affiliation(s)
- Jay D. Holladay
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH 43205, USA
| | - Christopher McKee
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH 43205, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Olubukola O. Nafiu
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH 43205, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph D. Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH 43205, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Ralph J. Beltran
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH 43205, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
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Kang Q, Wu L, Liu Y, Zhang X. Ultrasound-guided medial branch of the superior laryngeal nerve block to reduce peri-operative opioids dosage and accelerate patient recovery. PLoS One 2023; 18:e0295127. [PMID: 38079433 PMCID: PMC10712872 DOI: 10.1371/journal.pone.0295127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 11/08/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND To explore whether the medial branch block of superior laryngeal nerve can reduce the stress response of patients undergoing intubation and further reduce the dosage of opioids. METHODS 80 patients undergoing gynecological laparoscopic surgery were selected, and randomly divided into 4 groups. All patients in the experimental groups received bilateral internal branch of superior laryngeal nerve block and transversus abdominis plane block. But the dosage of sufentanil used for anesthesia induction in the group A, B, and C was 0.4, 0.2, and 0μg/kg, respectively. Group D do not underwent supralaryngeal nerve block and the dosage of sufentanil was 0.4μg/kg. The heart rate (HR) and mean arterial pressure(MAP) were recorded at the time of entering the operating room(T1), before intubation after induction(T2), immediately after intubation(T3), 5min after intubation(T4), before extubation(T5), immediately after extubation(T6), 5min after extubation(T7). We also recorded the stay time in the recovery room, the number of cases of postoperative sore throat, the number of cases of nausea and vomiting, the first intestinal exhaust time, the length of hospital stay after operation. RESULTS The HR of group A, C and D at T3 was significantly higher than that at T2(P < 0.01), while the HR of group B had no significant change. The HR of group A, C and D at T4 was lower than that at T3(P < 0.01), while the HR of group B had no obvious change. The HR of group C and D at T3 was significantly higher than that at T1 (P < 0.01). The MAP of group A and D at T4 was significantly lower than that at T1 (P<0.001). The first postoperative intestinal exhaust time in group A, B and C was significantly shorter than that in group D. The length of hospital stay after operation in group B and C was shorter than that in group D. CONCLUSIONS Ultrasound-guided superior laryngeal nerve block combined with 0.2μg/kg sufentanil can reduce the intubation reaction, have better hemodynamic stability, reduce the first postoperative intestinal exhaust time and postoperative hospital stay, thereby accelerating the postoperative recovery of patients.
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Affiliation(s)
- Qiuxiang Kang
- Department of Anesthesiology, Ningbo Medical Centre Lihuili Hospital, Ningbo, China
| | - Liang Wu
- Department of Anesthesiology, Guilin Medical University Affiliated Hospital, Guilin, China
| | - Yaohong Liu
- Department of Anesthesiology, Hainan Hospital of Chinese PLA General Hospital, Hainan, China
| | - Xu Zhang
- Department of Anesthesiology, Ningbo Medical Centre Lihuili Hospital, Ningbo, China
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Gross DJ, Alnajar A, Cotamo LM, Sarris-Michopoulos M, Villamizar NR, Nguyen DM. Postoperative day 1 discharge following robotic thoracoscopic pulmonary anatomic resections in the era of enhanced recovery protocol: A single-institution experience. JTCVS OPEN 2023; 16:875-885. [PMID: 38204704 PMCID: PMC10774976 DOI: 10.1016/j.xjon.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 06/16/2023] [Accepted: 08/10/2023] [Indexed: 01/12/2024]
Abstract
Objective Implementation and continuing optimization of enhanced recovery protocol after thoracic surgery results in significant improvement of postoperative outcomes. We observed a 10-fold increase in the rate of postoperative day (POD) 1 discharges following robotic thoracoscopic anatomic resections over time. We aimed to determine factors associated with safe POD1 discharges. Methods We performed a retrospective analysis of a prospectively maintained database of robotic anatomic pulmonary resections between July 1, 2012, and June 30, 2022, with patients of the last 2.5 years forming the basis of this study. Data collected included demographics, insurance types, Area Deprivation Index (indicator of poverty), and operative and postoperative variables including length of stay, opioid use, daily pain levels, readmissions, and outpatient interventions. Factors associated with POD1 were analyzed using a logistic regression module. Result In total, 279 patients met inclusion criteria (91 POD1 discharges, 32.6%; none discharged with a pleural catheter). There was neither an increase of postdischarge interventions for pleural complications nor readmission in early discharge patients. After adjusting for relevant factors, younger age, right middle lobectomy, lower opioid use on POD1, operating room finish before 4 PM, and low Area Deprivation Index were significantly associated with POD1 discharge. A subanalysis of 49 patients, who could have been discharged on POD1, identified hypoxemia requiring home oxygen, atrial fibrillation, and poorly controlled pain being common mitigatable clinical factors delaying POD1 discharge. Conclusions Safe POD1 discharge following robotic thoracoscopic anatomic resection was achieved in 32% of cases. Identification of positive and negative factors affecting early discharge provides guidance for further modifications to increase the number of POD1 discharges.
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Affiliation(s)
- Daniel J. Gross
- Division of Thoracic and Foregut Surgery, The DeWitt Daughtry Department of Surgery, The University of Miami, Miami, Fla
| | - Ahmed Alnajar
- Division of Thoracic and Foregut Surgery, The DeWitt Daughtry Department of Surgery, The University of Miami, Miami, Fla
| | - Luis Miguel Cotamo
- Division of Thoracic and Foregut Surgery, The DeWitt Daughtry Department of Surgery, The University of Miami, Miami, Fla
| | - Michael Sarris-Michopoulos
- Division of Thoracic and Foregut Surgery, The DeWitt Daughtry Department of Surgery, The University of Miami, Miami, Fla
| | - Nestor R. Villamizar
- Division of Thoracic and Foregut Surgery, The DeWitt Daughtry Department of Surgery, The University of Miami, Miami, Fla
| | - Dao M. Nguyen
- Division of Thoracic and Foregut Surgery, The DeWitt Daughtry Department of Surgery, The University of Miami, Miami, Fla
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Tam JKC. Opioid prescription guideline is important to enhanced recovery after thoracic surgery protocol. J Thorac Dis 2023; 15:5275-5277. [PMID: 37969260 PMCID: PMC10636438 DOI: 10.21037/jtd-23-1208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 08/25/2023] [Indexed: 11/17/2023]
Affiliation(s)
- John Kit Chung Tam
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiac, Thoracic, and Vascular Surgery, National University Heart Centre Singapore, Singapore, Singapore
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Gross DJ, Alnajar A, Villamizar NR, Nguyen DM. Achieving opioid-free discharge following robotic thoracic surgery: A single-institution experience. JTCVS OPEN 2023; 15:508-519. [PMID: 37808010 PMCID: PMC10556950 DOI: 10.1016/j.xjon.2023.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 06/22/2023] [Accepted: 06/26/2023] [Indexed: 10/10/2023]
Abstract
Objectives Enhanced recovery after thoracic surgery (ERATS) protocols use a combination of analgesics for pain control and have been associated with decreased opioid requirements. We investigated the impact of continual ERATS refinement on the incidence of opioid-free discharge. Methods We retrospectively analyzed our prospectively maintained institutional database for elective, opioid-naive robotic thoracoscopic procedures. Demographics, operative outcomes, postoperative opioid dispensed (morphine milligram equivalent), and opioid discharge status were collected. Our primary outcome of interest was factors associated with opioid-free discharge; our secondary objective was to determine the incidence of new persistent opioid users. Results In total, 466 patients from our optimized ERATS protocol were included; 309 (66%) were discharged without opioids. However, 34 (11%) of patients discharged without opioids required a prescription postdischarge. Conversely, 7 of 157 patients (11%), never filled their opioid prescriptions given at discharge. Factors associated with opioid-free discharges were nonanatomic resections, mediastinal procedures, minimal pain, and lack of opioid usage on the day of discharge. More importantly, 3.2% of opioid-free discharge patients became new persistent opioid users versus 10.8% of patients filling opioid prescriptions after discharges (P = .0013). Finally, only 2.3% of opioid-naive patients of the entire cohort became chronic opioid users; there was no difference in the incidence of chronic use by opioid discharge status. Conclusions Optimized opioid-sparing ERATS protocols are highly effective in reducing opioid prescription on the day of discharge. We observed a very low rate of new persistent or chronic opioid use in our cohort, further highlighting the role ERATS protocols in combating the opioid epidemic.
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Affiliation(s)
- Daniel J. Gross
- Division of Thoracic Surgery, The DeWitt Daughtry Department of Surgery, The University of Miami, Miami, Fla
| | - Ahmed Alnajar
- Division of Thoracic Surgery, The DeWitt Daughtry Department of Surgery, The University of Miami, Miami, Fla
| | - Nestor R. Villamizar
- Division of Thoracic Surgery, The DeWitt Daughtry Department of Surgery, The University of Miami, Miami, Fla
| | - Dao M. Nguyen
- Division of Thoracic Surgery, The DeWitt Daughtry Department of Surgery, The University of Miami, Miami, Fla
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Boisen ML, Fernando RJ, Alfaras-Melainis K, Hoffmann PJ, Kolarczyk LM, Teeter E, Schisler T, Ritchie PJ, La Colla L, Rao VK, Gelzinis TA. The Year in Thoracic Anesthesia: Selected Highlights From 2021. J Cardiothorac Vasc Anesth 2022; 36:4252-4265. [PMID: 36220681 DOI: 10.1053/j.jvca.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 08/10/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Michael L Boisen
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Rohesh J Fernando
- Cardiothoracic Section, Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC
| | | | - Paul J Hoffmann
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | - Emily Teeter
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC
| | - Travis Schisler
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver General Hospital, Vancouver, BC, Canada
| | - Peter J Ritchie
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Luca La Colla
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Vidya K Rao
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA
| | - Theresa A Gelzinis
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA.
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Choi SB, Yun S, Kim SJ, Park YB, Oh K. Effects of exposure to ambient air pollution on pulmonary function impairment in South Korea: Korea National Health and Nutritional Examination Survey. Epidemiol Health 2021; 43:e2021082. [PMID: 34665957 PMCID: PMC8861554 DOI: 10.4178/epih.e2021082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 10/18/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES This study aimed to investigate the association between pulmonary function and air pollution using 2007–2017 data from the Korea National Health and Nutrition Examination Survey, a nationwide cross-sectional representative survey. METHODS A total of 27,378 participants that had sampling weights from a complex sample survey were included in this study. Using the data for forced expiratory volume in 1 second and forced vital capacity, the participants with pulmonary function impairment were classified according to the criteria of restrictive lung disease and chronic obstructive pulmonary disease (COPD). Exposure to ambient air pollution was estimated using the Community Multiscale Air Quality model. Multivariate linear and logistic regression analyses with complex samples were used to determine the associations between pulmonary function and air pollution after adjusting for covariates. RESULTS In total, 13.2% of the participants aged >40 years had COPD, and 10.7% were classified as being in the restrictive lung disease group. According to the multivariate logistic regression model, the odds ratios for the fourth quartiles of particulate matter less than 10 μm in diameter (PM10), particulate matter less than 2.5 μm in diameter (PM2.5) and carbon monoxide (CO) with a 2-year lag period were 1.203 (95% confidence interval [CI], 1.036 to 1.396), 1.283 (95% CI, 1.101 to1.495), and 1.292 (95% CI, 1.110 to 1.504), respectively, using the restrictive lung disease group as an event after adjusting for covariates in the complex sample. CONCLUSIONS Long-term exposure to PM10, PM2.5, and CO was significantly associated with pulmonary function, especially restrictive lung disease.
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Affiliation(s)
- Soo Beom Choi
- Division of Health and Nutrition Survey and Analysis, Korea Disease Control and Prevention Agency, Cheongju, South Korea
| | - Sungha Yun
- Division of Health and Nutrition Survey and Analysis, Korea Disease Control and Prevention Agency, Cheongju, South Korea
| | - Sun-Ja Kim
- Division of Health and Nutrition Survey and Analysis, Korea Disease Control and Prevention Agency, Cheongju, South Korea
| | - Yong Bum Park
- Lung Research Institute of Hallym University College of Medicine, Chuncheon, South Korea.,Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Seoul, South Korea
| | - Kyungwon Oh
- Division of Health and Nutrition Survey and Analysis, Korea Disease Control and Prevention Agency, Cheongju, South Korea
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