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Ye E, Wu K, Ye H, Zhang W, Chu L, Zhang K, Xie G, Jin Y, Fang X. Comparison of 95% effective dose of remimazolam besylate and propofol for gastroscopy sedation on older patients: A single-centre randomized controlled trial. Br J Clin Pharmacol 2023; 89:3401-3410. [PMID: 37387195 DOI: 10.1111/bcp.15839] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 05/31/2023] [Accepted: 06/24/2023] [Indexed: 07/01/2023] Open
Abstract
AIMS Advanced age is an important risk factor for adverse events during procedural sedation. Remimazolam is safe and effective in gastroscopic sedation. However, the ideal dose and application for older patients are not well known. We aim to investigate its 95% effective dose (ED95) for older patients undergoing gastroscopy and to assess its safety and efficacy, with propofol as the comparison. METHODS The trial consists of 2 parts, patients aged >65 years and scheduled for outpatient painless gastroscopy were enrolled. In the first part, Dixon's up-and-down methodology was used to determine the ED95 of remimazolam besylate and propofol for gastroscopic insertion, in combination with 0.2 μg/kg remifentanil. In the second part, patients in each group received 0.2 μg/kg remifentanil and ED95 dose of the study drugs for sedation induction, supplemental doses were added to maintain sedation depth when necessary. The primary outcome was the incidence of adverse events. The secondary outcome was the recovery time. RESULTS The ED95 of remimazolam besylate and propofol induction were 0.2039 (95% confidence interval 0.1753-0.3896) mg/kg and 1.9733 (95% confidence interval 1.7346-3.7021) mg/kg respectively. Adverse events were reported in 26 (40.6%) patients in the remimazolam group and 54 (83.1%) in the propofol group (P < .0001), whereas the remimazolam group presented a higher incidence of hiccups (P = .0169). Besides, the median time to awakening was approximately 1 min shorter with remimazolam than with propofol (P < .05). CONCLUSION For older patients undergoing gastroscopy, the ED95 dose of remimazolam is a safer alternative than propofol when inducing the same sedation depth.
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Affiliation(s)
- Enci Ye
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Keyang Wu
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Hui Ye
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Wenyuan Zhang
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Lihua Chu
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Kai Zhang
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Guohao Xie
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yue Jin
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xiangming Fang
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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Recio SZ, Abdennadher M. Intractable hiccups after VNS implantation: a case report. BMC Neurol 2023; 23:297. [PMID: 37563736 PMCID: PMC10413770 DOI: 10.1186/s12883-023-03352-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 07/28/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND Hiccups (medically termed, "singultus"), when intractable, can cause significant medical consequences such as aspiration, malnutrition, and depression, leading to poor quality of life. Several case reports have shown that vagus nerve stimulator (VNS) implantation can help treat central idiopathic intractable hiccups. However, we present a contrary case of a patient who developed intractable singultus following VNS placement for medically refractory epilepsy. CASE PRESENTATION We report a 71-year-old male patient with drug-resistant epilepsy who underwent VNS implantation and developed intractable hiccups shortly thereafter. The hiccups were severe and persistent, such that the patient developed a Mallory-Weiss tear, which required intensive care, invasive intubation and mechanical ventilation, and a prolonged rehabilitation course. Despite multiple therapies including phrenic nerve block and Nissen fundoplication, the patient's hiccups persisted and only stopped once the VNS was permanently deactivated. CONCLUSIONS Little is known about the incidence of hiccups after VNS implantation. We present one case of hiccups as a direct consequence of VNS implantation. The clinical impact of this report is significant given the relative unfamiliarity of hiccups as an adverse effect of VNS implantation. Neurologists and epileptologists, who present VNS implantation as a surgical option for seizure control to their patients, should be aware of the possibility of singultus development and its significant physical and emotional ramifications.
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Affiliation(s)
- Susan Zhang Recio
- Department of Neurology, Boston Medical Center/Boston University Chobanian & Avedisian School of Medicine, Boston, MA, 02118, USA
| | - Myriam Abdennadher
- Department of Neurology, Boston Medical Center/Boston University Chobanian & Avedisian School of Medicine, Boston, MA, 02118, USA.
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Habadi MI, Hamza N, Balla Abdalla TH, Al-Gedeei A. Persistent Hiccups As Presenting Symptom of COVID-19: A Case of 64-Year-Old Male From International Medical Center, Jeddah, Saudi Arabia. Cureus 2021; 13:e20158. [PMID: 35003987 PMCID: PMC8723778 DOI: 10.7759/cureus.20158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2021] [Indexed: 12/02/2022] Open
Abstract
The possibilities of coronavirus disease 2019 (COVID-19) to present with atypical manifestations have reported. Information of COVID-19 atypical signs and symptoms is still emerging globally. One of these presentations is persistent hiccups. One of the hypotheses is that COVID-19 has been linked to several neurological manifestations and effects. Some observations noticed phrenic nerve paralysis after COVID-19 infection leading to pulmonary failure. We report one case of COVID-19-positive patient where he presented with persistent hiccups. Many predisposing factors might lead to the development of hiccups in COVID-19 infection such as a history of smoking, phrenic and vagus nerve damage or irritation, high inflammatory markers, lower lobe pneumonia, ground-glass-like appearance on x-rays. We hypothesize that hiccups are the first sign of serious deterioration of patients with COVID-19 and such patients are at high risk of developing kidney injury and intubation.
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Rao PN, Wu CL, YaDeau JT. Midazolam-Induced Hiccups Reversed by Flumazenil: A Case Report. A A Pract 2021; 15:e01547. [PMID: 34807869 DOI: 10.1213/xaa.0000000000001547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Hiccups are a common phenomenon experienced by many people and are usually short-lived with spontaneous resolution of symptoms. Certain anesthetic medications have been associated with the development of hiccups, though the underlying pathophysiology and reflex arcs remain poorly understood. We describe a patient who developed hiccups lasting 9 days following an orthopedic surgery and again developed hiccups during a subsequent surgery after only having received midazolam; flumazenil administration led to sustained cessation of his hiccup symptoms immediately.
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Affiliation(s)
- Prashant N Rao
- From the Department of Anesthesiology, Critical Care, and Pain Management, Hospital for Special Surgery, New York, New York
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Persistent Postoperative Hiccups. Case Rep Anesthesiol 2020; 2020:8867431. [PMID: 32695523 PMCID: PMC7355363 DOI: 10.1155/2020/8867431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/29/2020] [Accepted: 06/04/2020] [Indexed: 01/16/2023] Open
Abstract
Hiccups are a common and poorly understood pathologic phenomenon. While hiccups often occur suddenly and episodically, they may persist for weeks and sometimes months. There is a paucity of data regarding the precise etiology and optimal treatment for persistent hiccups. Frequently considered a benign and frustrating condition, hiccups are sometimes a presenting symptom for pulmonary embolism and cardiac disease. We present a patient with gastroesophageal reflux disease who developed 11 days of recurrent hiccups following an orthopedic procedure.
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Abstract
PURPOSE OF REVIEW Singultus or hiccups (HU) is a common, usually temporary, event. Its potentially serious consequences are often overlooked. This review explores published evidence describing HU burden (clinical, economic, and quality of life [QoL] consequences) across patient populations. RECENT FINDINGS Literature review identified 81 articles (including 57 individual case reports). We extracted relevant information to better understand the burden of HU and to identify knowledge gaps for future study. HU are physiologic events that can complicate existing medical conditions and treatments regardless of duration. Relatively short episodes can have devastating consequences in patients who have pre-existing conditions. HU appear to impact physical and psychological health, diminish QoL, increase healthcare resource use, and increase costs. A better understanding of HU burden is needed.
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Mathew J, Shen S, Liu H. Intraoperative Laryngeal Mask Airway-Related Hiccup: An Overview. ACTA ACUST UNITED AC 2019; 7:145-151. [PMID: 33869664 PMCID: PMC8048698 DOI: 10.31480/2330-4871/103] [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] [Indexed: 12/01/2022]
Abstract
Hiccup is an involuntary contraction of the diaphragm and intercostal muscles resulting in sudden inspiration and closure of the glottis. The presence of hiccup in the perioperative period can be a challenging problem. Sudden movements of the patient from hiccups can interfere preoperative diagnostic procedures, intraoperative hiccup may delay the beginning of surgery, interfere with the surgical process, and affect intraoperative monitoring, and postoperative hiccup may affect would healing and hemodynamic stability. Hiccup can lead to have increased aspiration risk. Hiccup are is an incompletely understood phenomenon with multiple etiologies. Intraoperative hiccup related to laryngeal mask airway placement has been reported, and it presents unique challenges in diagnosis and management. Both pharmacological and non-pharmacological interventions have been utilized with various level of success. All treatment strategies are primarily aimed at interrupting the hiccup reflex arc.
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Affiliation(s)
- Johann Mathew
- Department of Anesthesiology, Temple University Hospital, 3401 N Broad Street, Philadelphia, PA 19140, USA
| | - Shiqian Shen
- Department of Anesthesia, Critical Care & Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Henry Liu
- Department of Anesthesiology, Drexel University College of Medicine, Reading Hospital/Tower Health System, 420 S 5th Avenue, West Reading, PA 19611, USA
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Unsedated Outpatient Percutaneous Endoscopic Gastrostomy in Stroke Patients: Is It Feasible and Safe? Surg Laparosc Endosc Percutan Tech 2019; 29:383-388. [PMID: 31033632 DOI: 10.1097/sle.0000000000000661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Percutaneous endoscopic gastrostomy (PEG) is an established practice for long-term nutrition in dysphagia-suffering stroke patients. This study sought to determine the feasibility and safety of outpatient, unsedated PEG implementation in stroke patients. This retrospective cohort study involved stroke victims who underwent unsedated outpatient PEG insertion from 2014 to 2017 at our Surgical Endoscopy Unit. Patients were given pharyngeal anesthesia with lidocaine 10% spray, while the PEG tube was placed under local anesthesia. The incidence of intraprocedural and postprocedural complications and 30-day mortality rate were recorded. Data from 127 cases were analyzed. The procedures were performed with minor, transient complications, which resolved after rescue maneuvers. No intraprocedural and postprocedural major complications or death were observed. During the 30-day follow-up, the most important complication involved a single case of accidental PEG removal that was successfully resolved surgically. Unsedated PEG insertion appears to be a feasible, well-tolerated, and safe option for stroke-related dysphagia.
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Singh SA, Prakash K, Sharma S, Dhakate G, Bhatia V. Comparison of propofol alone and in combination with ketamine or fentanyl for sedation in endoscopic ultrasonography. Korean J Anesthesiol 2017; 71:43-47. [PMID: 29441174 PMCID: PMC5809707 DOI: 10.4097/kjae.2018.71.1.43] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 04/03/2017] [Accepted: 04/16/2017] [Indexed: 12/13/2022] Open
Abstract
Background We evaluated whether the addition of a small dose of ketamine or fentanyl would lead to a reduction in the total dose of propofol consumed without compromising the safety and recovery of patients having endoscopic ultrasonography (EUS). Methods A total of 210 adult patients undergoing elective EUS under sedation were included in the study. Patients were randomized into three groups. Patients were premedicated intravenously with normal saline in group 1, 50 µg fentanyl in group 2, and 0.5 mg/kg ketamine in group 3. All patients received intravenous propofol for sedation. Propofol consumption in mg/kg/h was noted. The incidence of hypotension, bradycardia, desaturation, and coughing was noted. The time to achieve a Post Anesthesia Discharge Score (PADS) of 10 was also noted. Results There were 68 patients in group 1, 70 in group 2, and 72 in group 3. The amount of propofol consumed was significantly higher in group 1 (9.25 [7.3–13.2]) than in group 2 (8.8 [6.8–12.2]) and group 3 (7.6 [5.7–9.8]). Patient hemodynamics and oxygenation were well maintained and comparable in all groups. The time to achieve a PADS of 10 was significantly higher in group 3 compared to the other two groups. Conclusions The use of 50 µg fentanyl or 0.5 mg/kg ketamine in a single dose during EUS reduces the dose of propofol required for sedation. However, unlike the addition of fentanyl, the addition of ketamine increased the time to recovery. Thus, 50 µg fentanyl is a good additive to propofol infusion for sedation during EUS to reduce the requirement for propofol without affecting the time to recovery.
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Affiliation(s)
- Shweta A Singh
- Department of Anaesthesiology and Critical Care, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Kelika Prakash
- Department of Anaesthesiology and Critical Care, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Sandeep Sharma
- Department of Anaesthesiology and Critical Care, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Gaurav Dhakate
- Department of Anaesthesiology and Critical Care, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Vikram Bhatia
- Department of Hepatology, Institute of Liver & Biliary Sciences, New Delhi, India
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El-Tahan MR, Doyle DJ, Telmesani L, Al’Ghamdi A, Khidr AM, Abdeen MM. Dexmedetomidine suppresses intractable hiccup during anesthesia for cochlear implantation. J Clin Anesth 2016; 31:208-11. [DOI: 10.1016/j.jclinane.2016.02.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 08/14/2015] [Accepted: 02/11/2016] [Indexed: 10/21/2022]
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Lee GW, Kim RB, Go SI, Cho HS, Lee SJ, Hui D, Bruera E, Kang JH. Gender Differences in Hiccup Patients: Analysis of Published Case Reports and Case-Control Studies. J Pain Symptom Manage 2016; 51:278-83. [PMID: 26596880 DOI: 10.1016/j.jpainsymman.2015.09.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 09/24/2015] [Accepted: 10/06/2015] [Indexed: 12/18/2022]
Abstract
CONTEXT Although sporadic male predominance in hiccup patients has been reported, the association between gender differences and triggering factors has rarely been evaluated in patients with hiccups. OBJECTIVES The aim of this study was to investigate whether gender differences exist in hiccup patients by analyzing all previously published hiccup literature containing gender and etiology information. METHODS Published literature on this topic was identified using a standardized search strategy in the PubMed, SCOPUS, and CINAHL electronic databases. The literature search included studies published from January 1990 to December 2013. Searches were limited to English-language publications. Of 476 identified studies, 318 studies were eligible including eight case-control studies that contained nonhiccup control groups. Triggering factors for hiccups were categorized into two types: central nervous system (CNS) and non-CNS causes. Odds ratios (ORs) were calculated for the eight case-control studies and event rates for the other studies by meta-analysis. In addition, gender differences and mean ages were analyzed for the case studies. RESULTS Pooled OR was 2.42 (95% confidence interval [CI] 1.40-4.17) with inclination for male predominance. Subgroup analysis by cause showed clear male predominance in the non-CNS type with OR of 11.72 (95% CI 3.16-43.50), whereas indistinct in the CNS type with OR of 1.74 (95% CI 0.95-3.16). Of the remaining 310 studies with 864 patients, previous findings were consistent. Male predominance was consistent in non-CNS (85.1%, 95% CI 78.2-90.2) and unknown origin (82.2%, 95% CI 75.8-87.2) patients, whereas mitigating the sex discrepancy in those with CNS origin (65.8%, 95% CI 53.1-76.5). CONCLUSION We demonstrated male predominance in hiccup patients. This gender difference for hiccups was more pronounced in patients with non-CNS causes, whereas indistinct in patients with CNS causes.
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Affiliation(s)
- Gyeong-Won Lee
- Department of Internal Medicine, School of Medicine, Gyeongsang National University, Jinju, Republic of Korea
| | - Rock Bum Kim
- Department of Preventive Medicine, Dong-A University, Busan, Republic of Korea; Environmental Health Center, Dong-A University, Busan, Republic of Korea
| | - Se Il Go
- Department of Internal Medicine, School of Medicine, Gyeongsang National University, Jinju, Republic of Korea
| | - Hyun Seop Cho
- Department of Internal Medicine, School of Medicine, Gyeongsang National University, Jinju, Republic of Korea
| | - Seung Jun Lee
- Department of Internal Medicine, School of Medicine, Gyeongsang National University, Jinju, Republic of Korea
| | - David Hui
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Jung Hun Kang
- Department of Internal Medicine, School of Medicine, Gyeongsang National University, Jinju, Republic of Korea.
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Tang JH, Cheng CL, Kuo YL, Tsui YN. Paired comparison of procedural sequence in same-day bidirectional endoscopy with moderate sedation and carbon dioxide insufflation: A prospective observational study. Saudi J Gastroenterol 2016; 22:360-365. [PMID: 27748321 PMCID: PMC5051219 DOI: 10.4103/1319-3767.191140] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND/AIMS Same-day bidirectional endoscopy (BDE) is a commonly performed procedure, but the optimal sequence of the procedure with carbon dioxide insufflation is not well established. In this study, we investigated the optimal sequence for same-day BDE without polypectomy under moderate sedation and carbon dioxide insufflation in terms of sedation doses and colonoscopy performance. PATIENTS AND METHODS We performed a prospective observational study of 63 asymptomatic patients who were admitted for physical check-ups. A colonoscopy-esophagogastroduodenoscopy (EGD) examination was performed first and then an EGD-colonoscopy examination was performed within 1.5 years. RESULTS The total procedure time, procedure complexity, bowel preparation quality, cecal intubation time, colon polyp detection rate, and adverse events were similar between the two study groups. The total doses of fentanyl and midazolam were significantly higher for the colonoscopy-EGD group than that for the EGD-colonoscopy group (70.8 ± 9.6 μg vs. 56.6 ± 9.2 μg and 6.1 ± 1.3 mg vs. 4.6 ± 1.1 mg, P < 0.0001 and P < 0.0001, respectively). The recovery time to discharge was significantly longer for the colonoscopy-EGD group compared to the EGD-colonoscopy group (38.5 ± 3.9 min vs. 31.9 ± 3.2 min, P < 0.001, respectively). CONCLUSIONS EGD-colonoscopy is the optimal sequence for same-day BDE. In this order, the procedures are better tolerated, the sedation doses are reduced, and the recovery time is shorter.
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Affiliation(s)
- Jui-Hsiang Tang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chi-Liang Cheng
- Division of Gastroenterology, Department of Medicine, Evergreen General Hospital, Taoyuan City, Taiwan,Address for correspondence: Dr. Chi-Liang Cheng, Division of Gastroenterology, Evergreen General Hospital, 150 Huan-Zhong East Rd., Zhongli District, Taoyuan City 320, Taiwan. E-mail:
| | - Yen-Lin Kuo
- Division of Gastroenterology, Department of Medicine, Evergreen General Hospital, Taoyuan City, Taiwan
| | - Yi-Ning Tsui
- Division of Gastroenterology, Department of Medicine, Evergreen General Hospital, Taoyuan City, Taiwan
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