Otorhinolaryngological Management in Taiwanese Patients with Mucopolysaccharidoses.

Background: Mucopolysaccharidoses (MPSs) are lysosomal storage disorders wherein glycosaminoglycans accumulate because the enzymes that degrade them are insufficient. The earliest symptoms, which are the main reasons for seeking consultation, are otorhinolaryngological and commonly occur in MPS I, II, IV, and VI. This retrospective study aimed to determine the occurrence of otorhinolaryngological manifestations in MPS patients in Taiwan and to analyze the prognosis of surgical intervention, including its effect on symptoms. Methods: We reviewed 42 patients (30 males and 12 females), with a median age of 20.5 years, who had MPS (16.7% type I, 35.7% type II, 19.0% type IIIB, 21.4% type IVA, and 7.2% type VI). The following otorhinolaryngological manifestations were collected: annual number of upper respiratory tract infections (URTIs) and otitis media with effusion (OME) episodes, adenoid size, tonsillar size, and apnea-hypopnea index (AHI). Results: Among 42 patients, we found recurrent otitis media in 42.9% of the patients, hearing loss in 83.3% (mixed: 52.4%, conductive: 21.4%, and sensorineural: 9.5%), frequent URTIs in 47.6%, and obstructive sleep apnea syndrome in 35.7%. Moreover, 76% of the patients underwent ear, nose, and throat (ENT) surgery, including adenoidectomy, tonsillectomy, tympanostomy with ventilation tube insertion, tracheotomy, and supraglottoplasty. Conclusions: MPS patients had a high incidence of ENT problems. ENT surgery reduced the severity of hearing loss, degree of symptoms related to upper airway obstruction, and severity of respiratory tract and otological infections of patients with MPS.

Office-based salivary gland ductal irrigation in patients with chronic sialoadenitis: A preliminary study.

BACKGROUND/PURPOSE: To evaluate the therapeutic responsiveness of office-based salivary gland ductal irrigation in patients with chronic sialoadenitis. METHODS: Between August 2017 and April 2019, 55 patients comprising the following three disease groups were enrolled: Sjogren's syndrome: 39 patients; postradiotherapy sialoadenitis: ten patients; and post-RAI sialoadenitis: six patients. Quantitative salivary scintigraphy was recorded, and a formulated questionnaire including the Summated Xerostomia Inventory was utilized to assess acute/chronic symptoms. All patients received at least three serial salivary gland ductal irrigations with a one-month interval in our outpatient department. RESULTS: The general response rates for each disease groups are as follows: Sjogren's syndrome: 61.5% (24/39); postradiotherapy: 60% (6/10); and post-RAI: 83.3% (5/6). Among the patients with Sjogren's syndrome, the parotid scintigraphic Tmin showed a significant positive correlation with the responsiveness of salivary irrigation (P = 0.046), whereas the treatment tended to be irresponsive in patients who previously took medicine for their related discomfort (P = 0.009). In the postradiotherapy and post-RAI groups, no significant factors were found to be associated with the responsiveness of irrigation. CONCLUSION: Simple salivary ductal irrigation without complex equipment can be performed as an outpatient procedure to alleviate glandular swelling or xerostomia in patients with Sjogren's syndrome, postradiotherapy sialoadenitis or post-RAI sialoadenitis, and it can be considered an alternative management approach for patients refractory to conventional strategies.

Intraductal injection as an effective drug delivery route in the management of salivary gland diseases.

While conservative approaches for chronic sialoadenitis are in current use, the utility of intraductal injection therapy remains unclear. The purpose of this study is to provide evidence that substances delivered through intraductal injection of the salivary gland are able to be effectively distributed throughout the gland. Methylene blue dye (0.1 %) was injected intraductally into a porcine parotid gland (5 ml) of one group and the porcine submandibular gland (1 or 2 ml, n = 6 for each preparation) of another group. After the injection, the ductal systems were evaluated, sectioned, and observed microscopically. Color area analysis was performed on submandibular gland sections, and the infiltration ratio of the dye was calculated. The papillae of both Stensen's and Wharton's duct openings were easily identified with intraductally delivered methylene blue dye. The dye infiltration began from the central ductal region of the gland and could be easily observed to gradually disperse to the peripheral regions in each acinar. There were no statistically significant differences in infiltration ratios between anterior, midline, and posterior section of the submandibular gland. Also, there were no statistically significant differences in the ratios between 1 and 2 ml injections at all the three section positions. This study demonstrated that desired substances can be evenly delivered throughout the salivary gland through intraductal injections. The use of intraductal injections might serve as a potential therapeutic procedure in the management of salivary gland diseases.

A trans-well-based cellular model for the rapid pre-evaluation of tympanic membrane repair materials.

It is important to have a standardized tympanic membrane (TM) perforation platform to evaluate the various myringoplasty materials that have been studied and developed extensively during recent years. However, currently there are no cellular models specifically designed for this purpose, and animal models remain unsatisfactory. The purpose of this study is to propose an inexpensive, readily available, well-controlled, and easy-to-create cellular model as a substitute for use in the evaluation of TM repairing materials. A trans-well model was created using a cell culture insert with a round hole created at the center of the polycarbonate membrane. HaCaT cells were cultured on the fenestrated culture insert, and the desired myringoplasty graft was placed at the center of the window for one week and observed by fluorescent microscopy under vital staining. Under this cellular model, there was notable migration of HaCaT cells onto the positive control graft (rabbit fascia), while only a few cell clusters were observed on the negative control graft (paper). Model validation showed that the cell migration ratio for the PLLA + 1% hyaluronic acid (HA) graft is significantly higher than using myringoplasty paper, poly L-lactide (PLLA), or PLLA + 0.5% HA (p < 0.05). This trans-well-based cellular model might be a useful pre-evaluation platform for the evaluation of TM repairing materials. The model is inexpensive, readily available, easy to create, and standardized for use.

Post-sialendoscopy ductoplasty by salivary duct stent placements.

With damage to a duct or papilla after sialendoscopy, a stent may be necessary to prevent re-stenosis and for maintaining the salivary duct open after complete sialendoscopy. However factors affecting outcomes and complications after stent placement remain unclear. This study aimed to report preliminary experiences in salivary duct stent placement after sialendoscopy. Data from 35 procedures in 33 patients who received sialendoscopy with salivary duct stent placements at Mackay Memorial Hospital between October 2013 and June 2014 were recorded and compared for clinical data, as well as procedural techniques, findings, and outcomes. In the 35 stent placement procedures, the hypospadias silastic stent tubes were used in 27 and the Fr. 5 pediatric feeding tubes were used in the remaining eight. When the hypospadias silastic stent tubes were used for stenting, the stent obstruction and irritation rates were higher compared to those who used the Fr. 5 pediatric feeding tube (100 vs. 0 % and 67 vs. 33 %, respectively). None of the stents secured by a 5-0 nylon suture were complicated by dislocation but when the stents were secured by 6-0 nylon sutures, the dislocation rate went as high as 47.4 %. The duration needed for salivary duct stent placement might be potentially shortened to only 2 weeks. If a salivary duct stent is intended to be placed for a certain period before its scheduled removal, a suture strength equivalent or stronger than the 5-0 nylon suture should be considered for stent fixation.

Single-incision mesh repair versus traditional native tissue repair for pelvic organ prolapse: results of a cohort study.

INTRODUCTION AND HYPOTHESIS: To compare the efficacy and safety of the Elevate™ anterior and posterior prolapse repair system and traditional vaginal native tissue repair in the treatment of stage 2 or higher pelvic organ prolapse. METHODS: A cohort study was conducted between January 2010 and July 2012. Patients who underwent transvaginal pelvic reconstruction surgery for prolapse were recruited. The primary outcome was anatomical success 1 year after surgery. The secondary outcome included changes in the quality of life and surgical complications. Recurrence of prolapse was defined as stage 2 or higher prolapse based upon the pelvic organ prolapse qQuantification system. RESULTS: Two hundred and one patients (100 in the Elevate™ repair group and 101 in the traditional repair group) were recruited and analyzed. The anatomical success rate of the anterior compartment was significantly higher in the Elevate™ repair group than in the traditional repair group (98 % vs 87 %, p = 0.006), but not for the apical (99 % vs. 6 %, p = 0.317) or posterior (100 % vs 97 %, p = 0.367) compartments after a median 12 months of follow-up. Both groups showed significant improvements in the quality of life after surgery with no statistical difference. Mesh-related complications included extrusion (3 %) and the need for revision of the vaginal wound (1 %). Those in the mesh repair group had a longer hospital stay (p = 0.04), operative time (p < 0.001), and greater estimated blood loss (p = 0.05). Other complications were comparable with no statistical difference. CONCLUSIONS: The Elevate™ prolapse repair system had a better 1-year anatomical cure rate of the anterior compartment than traditional repair, with slightly increased morbidity.

Sialendoscopy with holmium:YAG laser treatment for multiple large sialolithiases of the Wharton duct: a case report and literature review.

Sialolithiasis is defined as calcified stone(s) in the salivary duct or glands. Submandibular gland sialolithiasis is the most common (80 to 90%), followed by parotid gland sialolithiasis (5 to 15%). The typical clinical presentation is salivary gland swelling after eating. As the swelling persists, symptoms owing to local inflammation, such as pain and trismus, emerge. In severe cases, cellulitis and even abscess formation occur and subsequently lead to salivary gland atrophy or fistula formation if the sialolithiasis remains untreated. The most common treatment is complete excision of the affected gland together with the stone(s). In some cases, intraoral sialolithotomy is performed when the stone is solitary and easily palpable through the oral cavity. Sialendoscopy is increasingly performed because of its minimal invasiveness. The major limitation of endoscopic laser lithotripsy of the salivary glands is the size of the stone. Often, for a stone larger than 4 mm, multiple fragmentations of the stone into small pieces is necessary before the pieces can be removed by wire basket or grasping forceps. Recently, the holmium:YAG laser has been reported as quite effective in removing larger salivary gland stones. However, sialoendoscopic laser lithotripsy is a very time-consuming procedure and in most cases, when there are multiple large stones in a single gland, entire gland excision is recommended. This report describes a male patient diagnosed with multiple large stones in his left submandibular gland who was successfully treated under sialendoscopy with holmium:YAG laser lithotripsy.

Efficacy of Office-Based Salivary Ductal Steroid Irrigation for Managing Post-Irradiation Xerostomia in Head and Neck Cancer Patients: A Retrospective Study.

Post-irradiation xerostomia remains a significant quality of life concern for patients with head and neck cancers. Conventional therapies offer limited effectiveness. This study aims to investigate the therapeutic potential of office-based salivary ductal steroid irrigation in patients with post-irradiation xerostomia. This single-center observational study recruited 147 head and neck cancer patients suffering from post-irradiation xerostomia between November 2020 and October 2022. All included subjects received at least one round of successful salivary ductal cannulation and irrigation. The primary measure of efficacy was improvement in subjective xerostomia and objective salivary amylase levels. A logistic regression was employed to evaluate factors affecting treatment responsiveness. The response rate among nasopharyngeal cancer (NPC) patients was 74.8%, and that among non-NPC cancer was 65.6%, without significant intergroup differences. The statistical analysis revealed no significant influence of age, gender, or disease stage on treatment responsiveness. Post-treatment salivary amylase levels were significantly higher in responsive non-NPC patients. In conclusion, salivary ductal steroid irrigation emerged as a promising therapeutic modality for the management of post-irradiation xerostomia in head and neck cancer patients. While no explicit factors were predictive of responsiveness, the high rate of symptom improvement suggests that this therapy may be a viable alternative for patients that are refractory to standard treatments.

Impact of Bacillus licheniformis-Fermented Products on Growth and Productivity in Heat-Stressed Laying Ducks.

The purpose of this study was to assess the impact of various concentrations of Bacillus licheniformis-fermented products (BLFP) on the growth and productivity of laying ducks (Anas platyrhynchos) subjected to heat stress during eight weeks of a feeding trial. A total of 150 one-day-old Brown Tsaiya ducks of both sexes were divided into five groups, with each group having three replicates and 10 ducks each for evaluation of growth performance. The treatment groups received dietary supplements of BLFP at levels of 0.1%, 0.2%, and 0.3%, along with a group receiving flavomycin (F) at 5 ppm, all over a 24-week period. The fermentation process in this study utilized a B. licheniformis strain (ATCC 12713) for the production of the spores through solid-state fermentation. The control group was given a basal diet consisting of yellow corn and soybean meal. The results showed that as compared to the flavomycin group, ducks in the 0.3% BLFP group had significantly higher body weights and better feed conversion rates. In addition, during the three weeks, the BLFP group showed higher feed consumption as compared to the control group. The jejunum villi length was significantly increased in the 0.2% BLPF group as compared to the control and flavomycin groups. This study also found that the flavomycin group had a significantly higher egg conversion rate, while the 0.1-0.3% BLFP groups had improved feed intake and the 0.3% group had significantly enhanced egg yolk color. Additionally, the 0.2% BLFP group showed substantial decreases in IL-1ß, TNF-α, IL-6, and IL-10 levels in the liver as well as an uptick in the tight junction protein Occludin gene expression in the colon when compared to the control group. Furthermore, the expression of the heat shock protein 70 in the gut upregulated in the 0.1% and 0.2% BLFP groups. In conclusion, these observations demonstrate that dietary supplementation of 0.2% BLFP is an ideal concentration to increase gut morphology, alleviate inflammatory response, and promote gut integrity in heat-stressed laying ducks.

A prospective study of transobturator tape as treatment for stress urinary incontinence after transvaginal mesh repair.

INTRODUCTION AND HYPOTHESIS: The transobturator suburethral sling is a common surgical treatment for stress urinary incontinence (SUI). In patients with incontinence after trocar-guided transvaginal mesh repair (Prolift), data on outcome remain limited. In the present study, we hypothesized that transobturator tape in such cases is assumed to be as effective as surgery alone. METHODS: This was a prospective analysis of outcomes of transobturator slings in women who had undergone transvaginal mesh repair and in those who underwent sling surgery alone (controls). Objective cure was defined as the absence of urinary leakage during the stress test at filling cystometry and a negative cough test during pelvic examination. The success rates were evaluated 3-6 months postoperatively. RESULTS: One hundred women were recruited for the study. Compared to the control group, women after transvaginal mesh repair had a significantly lower objective success rate (62 vs 86%, p = 0.005) and poorer bladder neck mobility (0.5 ± 0.8 vs 1.1 ± 0.5 cm, p = 0.001). CONCLUSIONS: The transobturator sling has lower objective success rate in women after transvaginal mesh that may be due to decreased bladder neck mobility. Patients with post-mesh repair SUI who opt for sling surgery should be informed of these less satisfactory outcomes during preoperative counseling.

Effect of all-trans retinoic acid on the growth of two nasopharyngeal cancer cell lines and its treatment potential in combination with cisplatin.

The purpose of this study was to determine the effect of all-trans retinoid acid (ATRA) on two nasopharyngeal cancer (NPC) cell lines and to evaluate the synergistic effect of ATRA used in combination with cisplatin, a standard chemotherapeutic agent for NPC. Two NPC cell lines (NPC-TW01 and NPC-TW04) were used, and the MTT assay was used to analyze cell growth inhibition under various concentrations of ATRA and cisplatin. Under low concentrations of ATRA, the growth of both cell lines was significantly inhibited. When ATRA was used in combination with cisplatin, the resulting synergistic effects were robust and significant. Only a low concentration of ATRA was required to produce a synergistic effect when combined with cisplatin, indicating the potential usefulness of a combination therapy regimen. Therefore, the combination of ATRA and cisplatin is a viable treatment option for NPC and should be further investigated.

Prognostic Factors for the Outcome of Salivary Gland Holmium: YAG Laser Intraductal Lithotripsy.

OBJECTIVES: Holmium: YAG laser has gained its popularity throughout the years and is used to treat sialolithiasis, which helps to overcome the limitations of traditional sialendoscopic lithotripsy for larger-sized salivary stones. However, little information is available regarding factors predicting the success rate of Holmium: YAG laser intraductal lithotripsy. The purpose of this study is to investigate the factors affecting the success rates of Holmium: YAG laser lithotripsy for salivary stones treatment in a tertiary care hospital. METHODS: A retrospective study conducted in patients receiving sialolithiasis surgery under sialendoscopy from May 2013 to March 2015 at Mackay Memorial Hospital, Taiwan. Data on various factors, including patients' age, gender, glands, size of largest stone, multiple stones (≥2 stones), location of the stone (distal duct, middle duct, proximal duct, and hilum), and operative time. The success of the surgery defined as patients without any complaints such as swelling or tenderness. Logistic regression and Fisher exact tests were employed to examine these factors on the success rate. RESULTS: Fifty-four patients who received sialendoscopy surgery with a mean age of 35.74 years old recruited. Logistic regression identified the operation time exceeding 210 minutes showed 23.497 folds higher odd ratio of having a result of operation failure (P < .05). CONCLUSION: The prolonged operation time is the sole independent factor affecting the successful outcome for salivary gland intraductal laser lithotripsy. We recommend operative time be no more than 210 minutes to increase the success rate in salivary gland Holmium: YAG laser intraductal lithotripsy.

Endoscopic and Image Analysis of the Airway in Patients with Mucopolysaccharidosis Type IVA.

Mucopolysaccharidosis (MPS) is a hereditary disorder arising from lysosomal enzymes deficiency, with glycosaminoglycans (GAGs) storage in connective tissues and bones, which may compromise the airway. This retrospective study evaluated patients with MPS type IVA with airway obstruction detected via endoscopy and imaging modalities and the effects of surgical interventions based on symptoms. The data of 15 MPS type IVA patients (10 males, 5 females, mean age 17.8 years) were reviewed in detail. Fiberoptic bronchoscopy (FB) was used to distinguish adenotonsillar hypertrophy, prolapsed soft palate, secondary laryngomalacia, vocal cord granulation, cricoid thickness, tracheal stenosis, shape of tracheal lumen, nodular deposition, tracheal kinking, tracheomalacia with rigid tracheal wall, and bronchial collapse. Computed tomography (CT) helped to measure the deformed sternal angle, the cross-sectional area of the trachea, and its narrowest/widest ratio (NW ratio), while angiography with 3D reconstruction delineated tracheal torsion, kinking, or framework damage and external vascular compression of the trachea. The NW ratio correlated negatively with age (p < 0.01), showing that airway obstruction progressed gradually. Various types of airway surgery were performed to correct the respiratory dysfunction. MPS type IVA challenges the management of multifactorial airway obstruction. Preoperative airway evaluation with both FB and CT is strongly suggested to assess both intraluminal and extraluminal factors causing airway obstruction.

Impaired spontaneous secretion as a potential factor in the development of sialolithiasis in the submandibular gland: A preliminary sialoscintigraphic study.

Objectives: The development of sialolithiasis is commonly related to local factors, such as the retrograde migration of foods, bacteria, or foreign bodies from the oral cavity. The association of sialolithiasis and saliva stasis resulting from decreased spontaneous secretion remains largely unexplored. The current study investigated the potential role of impaired spontaneous secretion in association with the formation of submandibular gland calculi. Study Design: A retrospective cohort study. Methods: Between September 2016 and December 2017, 11 patients with unilateral submandibular gland sialolithiasis confirmed with sialendoscopy were assigned to the experimental group. Another 35 patients clinically diagnosed with parotid obstructive sialadenitis were assigned as the control group. The slope changes of the isotope count curve of the unaffected submandibular gland in the experimental group and the bilateral submandibular glands in the control group were calculated and compared to estimate the spontaneous secretion differences. The degree of spontaneous secretion was defined as the slope changes in the steady ascending stage of the scintigraphic exam. Results: The slope decline (degree of spontaneous secretion) on the unaffected side in patients with single-gland submandibular obstructive sialadenitis was significantly lower than that in the control individuals (p = .002). In contrast, the between-group comparison in the unaffected parotid glands revealed no difference in the slope decline. Conclusion: The spontaneous secretion of the submandibular gland in patients with submandibular sialolithiasis was decreased compared to that in patients without submandibular sialolithiasis. This phenomenon might be associated with the development of sialolithiasis. Level of Evidence: 3.

Airway Management of the Deformed Trachea Using T-Tube Stents in Patients with Mucopolysaccharidosis Type IVA.

INTRODUCTION: Mucopolysaccharidosis (MPS) type IVA usually results in airway obstruction due to thoracic cage deformity and crowding of intrathoracic structures, causing tracheal compression by the tortuous innominate artery. OBJECTIVES: To offer an alternative and effective method in dealing with the challenged deformity of the airway in patients with MPS type IVA. METHODS: We present 3 patients with MPS type IVA who underwent airway stenting using Montgomery® T-tube stents. Three-dimensional reconstructed computed tomography was essential to design the T-tube and evaluate the anatomical relationship between the innominate artery and the trachea. The Y-shaped Montgomery® Pediatric Safe-T-Tube™ is more suitable for MPS type IVA. Regular follow-ups using fiberoptic bronchoscopy are necessary to evaluate the complications. RESULTS: All 3 patients had good outcomes during the follow-ups until present, despite the complication of granulation formation, which was resolved by revising the limbs of the T-tube. CONCLUSIONS: T-tube stents placed below the vocal cord may restore airway patency and preserve laryngeal function, including respiration, phonation, and swallowing, in patients with MPS type IVA.

Influence of Heat Stress on Poultry Growth Performance, Intestinal Inflammation, and Immune Function and Potential Mitigation by Probiotics.

Heat stress has emerged as a serious threat to the global poultry industry due to climate change. Heat stress can negatively impact the growth, gut health, immune function, and production and reproductive performances of poultry. Different strategies have been explored to mitigate heat stress in poultry; however, only a few have shown potential. Probiotics are gaining the attention of poultry nutritionists, as they are capable of improving the physiology, gut health, and immune system of poultry under heat stress. Therefore, application of probiotics along with proper management are considered to potentially help negate some of the negative impacts of heat stress on poultry. This review presents scientific insight into the impact of heat stress on poultry health and growth performance as well as the application of probiotics as a promising approach to alleviate the negative effects of heat stress in poultry.

Novel Multidisciplinary Salivary Gland Society (MSGS) Questionnaire: An International Consensus.

OBJECTIVES: First, establishment and validation of a novel questionnaire documenting the burden of xerostomia and sialadenitis symptoms, including quality of life. Second, to compare two versions regarding the answering scale (proposed developed answers Q3 vs. 0-10 visual analogue scale Q10) of our newly developed questionnaire, in order to evaluate their comprehension by patients and their reproducibility in time. STUDY DESIGN: The study is a systematic review regarding the evaluation of the existing questionnaire and a cohort study regarding the validation of our new MSGS questionnaire. MATERIALS AND METHODS: A Multidisciplinary Salivary Gland Society (MSGS) questionnaire consisting of 20 questions and two scoring systems was developed to quantify symptoms of dry mouth and sialadenitis. Validation of the questionnaire was carried out on 199 patients with salivary pathologies (digestive, nasal, or age-related xerostomia, post radiation therapy, post radioiodine therapy, Sjögren's syndrome, IgG4 disease, recurrent juvenile parotitis, stones, and strictures) and a control group of 66 healthy volunteers. The coherence of the questionnaire's items, its reliability to distinguish patients from healthy volunteers, its comparison with unstimulated sialometry, and the time to fill both versions were assessed. RESULTS: The novel MSGS questionnaire showed good internal coherence of the items, indicating its pertinence: the scale reliability coefficients amounted to a Cronbach's alpha of 0.92 for Q10 and 0.90 for Q3. The time to complete Q3 and Q10 amounted, respectively, to 5.23 min (±2.3 min) and 5.65 min (±2.64 min) for patients and to 3.94 min (±3.94 min) and 3.75 min (±2.11 min) for healthy volunteers. The difference between Q3 and Q10 was not significant. CONCLUSION: We present a novel self-administered questionnaire quantifying xerostomia and non-tumoral salivary gland pathologies. We recommend the use of the Q10 version, as its scale type is well known in the literature and it translation for international use will be more accurate. Laryngoscope, 132:322-331, 2022.

Outcome of tension-free obturator tape procedures in obese and overweight women.

INTRODUCTION AND HYPOTHESIS: Little data are available on the outcome of tension-free obturator tape (TVT-O) procedures in obese and overweight women. We hypothesized that the subjective and objective outcomes of TVT-O in women with a higher body mass index (BMI) would differ from those with a lower BMI. METHODS: We retrospectively reviewed the records of 129 patients who had undergone TVT-O, stratifying by BMI into normal weight (n = 39), overweight (n = 58), and obese (n = 32) groups. We compared pre- and postoperative evaluations, including subjective and objective outcome of TVT-O, complications, and quality of life assessed by validated questionnaires. RESULTS: The median follow-up was 24 months. There were no significant differences between groups in terms of objective cure rate and subjective success, quality of life scores, or postoperative complications. CONCLUSION: BMI did not influence the outcome of TVT-O procedures at a median of 24 months after surgery.

Correction: A sialoadenectomy is associated with an increased risk of coronary heart disease: A three-year follow-up study.

[This corrects the article DOI: 10.1371/journal.pone.0199135.].