Low Estimated Glomerular Filtration Rate Is Prevalent among North Korean Refugees in South Korea / 가정의학회지

BACKGROUND: The number of North Korean refugees entering South Korea is rising. Few studies have investigated the risk of non-communicable disease in North Korean refugees. Moreover, kidney insufficiency, a risk factor for cardiovascular disease, has not been studied in this population. We compared the prevalence of non-communicable disease and kidney function in North Korean refugees and South Koreans. METHODS: Our study was conducted using a case-control design. We enrolled 118 North Korean refugees from the Hana Center and selected 472 randomly sampled South Korean individuals as controls, who were age- and sex-matched with the North Korean refugees in a ratio of 1:4, from the 2014 Korea National Health and Nutrition Examination Survey database. RESULTS: The prevalence of non-communicable disease did not differ significantly between the groups; however, a low estimated glomerular filtration rate (eGFR; < 90 mL/min per 1.73 m2) was more prevalent in the North Korean refugees than in the South Korean population (52.1% vs. 29.9%, P < 0.001). After adjusting for covariates and weight gain after escape, the prevalence of a low eGFR was associated with the length of residence in South Korea (odds ratio, 2.84; 95% confidence interval, 1.02–7.89). CONCLUSION: The prevalence of non-communicable disease did not differ between North Korean refugees and the South Korean population, while a low eGFR was more prevalent in North Korean refugees than in South Koreans. Moreover, after adjusting for other covariates, the prevalence of a low eGFR in North Korean refugees was associated with the length of residence in South Korea.

Clinicopathologic Correlations of E-cadherin and Prrx-1 Expression Loss in Hepatocellular Carcinoma

BACKGROUND: Developing predictive markers for hepatocellular carcinoma (HCC) is important, because many patients experience recurrence and metastasis. Epithelial to mesenchymal transition (EMT) is a developmental process that plays an important role during embryogenesis and also during cancer metastasis. Paired-related homeobox protein 1 (Prrx-1) is an EMT inducer that has recently been introduced, and its prognostic significance in HCC is largely unknown. METHODS: Tissue microarray was constructed using surgically resected primary HCCs from 244 cases. Immunohistochemical staining of E-cadherin and Prrx-1 was performed. The correlation between E-cadherin loss and Prrx-1 expression, as well as other clinicopathologic factors, was evaluated. RESULTS: E-cadherin expression was decreased in 96 cases (39.4%). Loss of E-cadherin correlated with a higher recurrence rate (p 40%) were independent prognostic factors for shorter overall survival. CONCLUSIONS: Prrx-1 was expressed in small portions of HCCs but not in normal livers. Additional studies with a large number of Prrx-1-positive cases are required to confirm the results of this study.

High MicroRNA-370 Expression Correlates with Tumor Progression and Poor Prognosis in Breast Cancer / 한국유방암학회지

PURPOSE: Deregulation of microRNA-370 (miR-370) has been reported in various cancers, in which it can act as either an oncogene or a tumor suppressor gene. However, the clinicopathologic significance of miR-370 expression in breast cancer has not been studied. METHODS: The expression of miR-370 was determined with quantitative real-time polymerase chain reaction in 60 formalin-fixed, paraffin-embedded primary breast cancer tissues. Additionally, the protein expression levels of previously known targets of miR-370, such as FOXM1, FOXO1, and FOXO3a, were detected using immunohistochemistry. Finally, we analyzed its correlation with target protein expression, clinicopathologic features, and clinical outcome. RESULTS: High levels of miR-370 expression correlated with lymph node metastasis (p=0.009), advanced stage (p=0.002), and frequent perineural invasion (p=0.042). Moreover, patients with high miR-370 expression had poor disease-free survival compared with the low-expression group. However, no correlation was observed between miR-370 and its target protein expression. CONCLUSION: Our results indicate that upregulation of miR-370 in breast cancer is correlated with breast cancer progression and that it might be a potential biomarker for predicting clinical outcomes.

Significance of the Extracapsular Spread of Metastatic Lymph Nodes in Papillary Thyroid Carcinoma

OBJECTIVES: The extracapsular spread (ECS) of metastatic lymph nodes is associated with aggressive tumor behavior, and is regarded as a major risk factor for local recurrence in patients with head and neck squamous cell carcinoma. However, the significance of ECS of metastatic lymph nodes has not been well established in well-differentiated thyroid carcinoma. The purpose of this study was to examine this question. METHODS: A retrospective review was performed of 335 patients with papillary thyroid carcinoma who underwent total thyroidectomy with lymph node dissection from April 2001 to December 2009. We analyzed various clinical characteristics, pathologic factors, and the size, number, and ECS of foci in metastatic lymph nodes. RESULTS: On pathologic review, 201 of the patients (56.6%) had lymph node metastasis. This was significantly related to age and tumor size. ECS was noted in 64 of these 201 patients (31.8%), and was significantly related to male gender, tumor size, presence of extrathyroidal extension, metastatic lymph node size, and focus size. Recurrence occurred in 13 patients (3.9%), and the presence of ECS was significantly related to recurrence. CONCLUSION: ECS of metastatic lymph nodes is an important prognostic factor for loco-regional recurrence in papillary thyroid carcinoma.

A Case of Calcium Pyrophosphate Dihydrate Deposition Disease Associated with Primary Hyperparathyroidism

Calcium pyrophosphate dihydrate (CPPD) deposition disease is a heterogeneous group of diseases with CPPD crystal deposition. Aging is the most common risk factor for CPPD deposition, followed by osteoarthritis and previous injury. Occasionally, CPPD depositions are associated with familial predisposition and metabolic diseases, including hemochromatosis, primary hyperparathyroidism, hypophosphatasia, and hypomagnesemia. CPPD deposition diseases associated with primary hyperparathyroidism in Koreans have rarely been reported. Thus, we report a case of a relatively young female patient with CPPD deposition disease associated with primary hyperparathyroidism, which was diagnosed through a polarized microscopic examination of the synovial fluid and a subtotal parathyroidectomy.

A Case of Kaposi's Sarcoma Improved by Sirolimus Treatment in the Kidney Transplant Recipient / 대한신장학회지

The incidence of Kaposi's sarcoma (KS) increases in kidney transplant recipients who had the immunosuppressive therapy. The usual treatment of KS is to reduce the dosage of immunosuppressive agents, with chemotherapy and/or radiotherapy. Several studies have recently demonstrated that the conversion to proliferation signal inhibitors (PSIs) from calcineurin inhibitors (CNI) leads to the remission of some post-transplant tumors such as KS. PSIs were well tolerated with stable renal function and no episode of acute rejection was reported. On the basis of these findings, we report a case of Kaposi's sarcoma in the kidney transplant patient, who had multiple lymphadenopathy and hepatic involvement without skin lesions. This patient responded well to the change of the immunosuppressive treatment from cyclosporine to sirolimus, one of PSIs.

A Case of Multiple Myeloma with Ameliorated Bone Pain after Treatment of Adult Fanconi Syndrome / 대한신장학회지

Adult Fanconi syndrome is characterized by variable abnormalities caused by renal proximal transport defects, resulting in glycosuria, aminoaciduria, bicarbonaturia, uricosuria and phosphaturia. A 57-year-old man with kappa-light chain multiple myeloma, undergoing chemotherapy with prednisolone and melphalan for 17 month, was admitted with spontaneous femoral neck fracture and was consulted due to polyuria and refractory metabolic acidosis immediately after hemiarthroplasty. The laboratory values showed normal anion gap metabolic acidosis with normal urinary anion gap, hypokalemia, hypouricemia, hypophosphatemia at the time of consultation. After partial correction of acidemia, the fractional excretion of HCO3- was 11.9%, it was interpreted as proximal renal tubular acidosis. 24-hour urine collection showed increased level of excretion for most aminoacids. Diffuse osteopenia and multiple compression fractures on spine were detected on radiological examinations. Also, osteoporosis and osteomalacia was suggested during his clinical course. After the diagnosis of Fanconi syndrome was made, treatment was started with sodium bicarbonate, potassium citrate, calcitriol, calcium carbonate along with phosphate rich diet. Laboratory abnormalities were corrected and refractory multiple bone pain was ameliorated with these treatment.

Myxoma of the Larynx Presenting As a Nodule

We describe herein a rare case of a laryngeal myxoma presenting as a nodule. Laryngeal myxomas involving the neck region, especially the laryngeal area, are quite rare. A 36-year-old male patient presented with a 2 month history of hoarseness. On laryngoscopic examination, there was a myxoid homogeneous transparent mass on the right vocal cord. On microscopic examination, the lesion was hypocellular and myxoid. The lesion showed stellate or spindle cells which were evenly dispersed in the poorly vascularized myxoid stroma. Although the incidence is extremely rare, a laryngeal myxoma should be considered in the differential diagnosis of laryngeal masses.

The Expression of C4d and HLA-DR in Renal Allografts with the Histologic Features of Antibody-Mediated Rejection

BACKGROUND: Deposition of C4d along the peritubular capillaries is generally associated with an antibody-mediated response. We evaluated, with performing C4d immunostaining, the diagnostic accuracy of the cases that were previously diagnosed as antibody-mediated rejection (ABMR) when based only on the histologic findings, and we examined possible correlation of C4d with HLA-DR. METHODS: Forty-five renal transplantation biopsies, which showed ABMR-like histology, were obtained. The expressions of C4d and HLA-DR in the transplant rejection cases were investigated using immunofluorescent and/or immunohistochemical staining. RESULTS: There were 14 discordant cases among a total of 45 cases when C4d was used as a diagnostic marker and the original slides were reviewed. These total cases consisted of the C4d negative cases in two cases of hyperacute rejection and all the cases of ABMR and ABMR with chronic/sclerosing allograft nephropathy (CAN) and two C4d positive cases (one each of acute cellular rejection (ACR) and CAN according to their original diagnosis) and all these cases were then revised according to Banff 07. The expression of HLA-DR tended to be correlated with the log-transformed duration of grafts until three years after the transplantation. CONCLUSION: This study demonstrates that C4d together with the histologic findings should be used for making the diagnosis of ABMR. The tubular HLA-DR expression over time should be studied to further understand the mechanism of graft rejection.

Kikuchi's Disease of the Mesenteric Lymph Nodes Presenting as Acute Appendicitis

Kikuchi's disease is a benign self-limiting necrotizing lymphadenitis that occurs most commonly in young women, and is usually found in the cervical lymph nodes. When there is an unusual location of involved lymph nodes, the diagnosis can be difficult. We recently treated a patient with Kikuchi's disease who had ileocecal mesenteric lymph node involvement; the patient presented with symptoms of acute appendicitis in an 11-year old boy. Although mesenteric lymph node involvement of Kikuchi's disease is very rare, Kikuchi's disease should be added to the differential diagnosis of acute appendicitis in patients with enlarged ileocecal mesenteric lymph nodes on radiological evaluation.

Survival Analysis of Korean End-Stage Renal Disease Patients According to Renal Replacement Therapy in a Single Center

This study was to investigate clinical characteristics and any differential trends in survival among renal replacement therapy (hemodialysis [HD], peritoneal dialysis [PD], and kidney transplantation [KT]) in Korean end-stage renal disease (ESRD) population. We tried to analyze retrospectively the survival rate adjusted by risk factors and the relative risk stratified by key risk factors among 447 ESRD patients who began dialysis or had a kidney transplant at Ajou University Hospital from 1994 to 2004. In adjusted Cox survival curves, the KT patients had the best survival rate, and the HD patients had better survival than PD patients. The consistent trends in different subgroups stratified by age and diabetes were as following: 1) The risk of death for PD and HD was not proportional over time, 2) The relative risk of PD was similar or lower than that of HD for the first 12 months, but it became higher at later period. The significant predictors for mortality were age (over 55 yr), presence of diabetes, cerebrovascular accident at ESRD onset, and more than one time of hospitalization caused by malnutrition. Further large-scaled, multicenter-based comparative study is needed in Korean ESRD patients and more meticulous attention is required in high-risk patients.

The Intestinal Type of Florid Cystitis Glandularis Mimics Bladder Tumor: A Case Report

Cystitis glandularis is a benign metaplastic proliferative lesion of the urinary bladder which usually occurs in the setting of chronic irritation and infection or in some cases as a congenital process. Sometimes it presents as a tumor mass-like florid lesion, grossly mimicking malignancy. We report a case of 59-year-old man with multiple mass lesions around the trigone and the neck portion, which suggested the possibility of malignancy in clinical and radiological evaluations. Final diagnosis was confirmed by transurethral resection. The surface urothelial lining was intact. The submucosa showed von Brunn's nests, cystitis glandularis and cystitis cystica in the edematous lamina propria. There were numerous glands lined by tall columnar, mucin producing epithelium without atypia, conforming to the appearance of the intestinal variant of cystitis glandularis. The cystitis glandularis may mimic a neoplasm on gross evaluation. The intestinal variant of cystitis glandularis is particularly likely to be problematic when florid.

Circulating Endothelial Progenitor Cells and Vasculogenic Factors in Pterygium Pathogenesis

PURPOSE: We investigated whether endothelial progenitor cells (EPCs) and vasculogenic factors are involved in the pathogenesis of pterygium and the mechanism underlying the selective recruitment of EPCs during this process. METHODS: We studied 13 normal controls and 28 pterygium patients [ primary (n=15), recurrent (n=13)]. Substance-P, vascular endothelial growth factor (VEGF), and stem cell factor (SCF) were measured in plasma and tears using ELISA, and circulating CD34+ and c-kit+ mononuclear cells (MNCs) by flow cytometry. Anterior segment fluorescein angiography (FAG) was performed to evaluate hypoxic conditions in the early stage of pterygium. Surgically removed pterygial tissues were analyzed immunohistochemically using the progenitor cell markers, CD34, c-kit, VEGFR-1 and VEGFR-2. RESULTS: Anterior segment FAG findings showed an increase in non-perfusion areas and attenuated vessels in the nasal limbus during early stage pterygium. Circulating CD34+ MNCs and c-kit+ MNCs were increased in pterygium groups compared with normal controls. Systemic and local cytokines including SP, VEGF and SCF in pterygium groups were also elevated and showed positive correlations with CD34+ and c-kit+ MNC numbers. Immunohistochemical analysis of pterygium showed strong progenitor cell marker immunoreactivities. CONCLUSIONS: EPCs might be involved in pterygium development, and ocular hypoxia triggers this neovascualrization by recruiting EPCs derived from the bone marrow via the production of systemic and local cytokines.

Effects of Cyclooxygenase-2 Expression on Lymphangiogenesis and Lymph Node Metastasis in Gastric Cancer Tissues

PURPOSE: Many previous studies have suggested that cyclooxygenase-2 (COX-2) over expression is closely related to angiogenesis. However, few have reported the relationship between COX-2 and lymphangiogenesis which is still unclear. The aim of this study was to determine the relationship between COX-2 expression and lymphangiogenetic factor, VEGF-C, in human gastric cancer and to correlate COX-2 and VEGF-C expression with other clinocopathological features to investigate whether COX-2 contributes to lymphangiogenesis and enhances lymph node metastasis. MATERIALS AND METHODS: One hundred patients who underwent curative radical surgery in Hanyang University hospital from July 1998 to June 2001 were selected. The expression of COX-2 and VEGF-C were detected by using immunohistochemistry, and the relationships between these two parameters and several clinicopathological factors (gender, stage, lymph node status, tumor location, Lauren classification and angioinvasion) were determined. RESULTS: Increased COX-2 expression was found in 86 of 100 tumor samples (86%) and in 70 of 100 tumor samples (70%) with VEGF-C. A high correlation between VEGF-C expression and lymph node metastasis was observed (P=0.033) along as well as COX-2 expression (P=0.012). Also, there was a significant correlation between COX-2 and VEGF-C expression (P=0.026), yet no correlation were found between COX-2 and VEGF-C expression and other clinicopathological parameters. CONCLUSION: Our study suggests that COX-2 expression contributes to lymphangiogenesis by mediating VEGF-C and finally promoting lymph node metastasis.

Genotypes and Clinical Characteristics of BK Virus in Kidney Transplant Recipients / 대한신장학회잡지

BACKGOUND: BK virus has emerged as a major cause of allograft loss in kidney transplant recipients over the past decade. The presence of BK virus in urine or blood indicates reactivation of the virus not necessarily accompanied by BK virus associated nephropathy. BK virus genotypes have been described based on the DNA sequence of VP1 region, and no data have been published on BK virus genotypes in Korea. In this study, we sought to determine BK virus genotypes and clinical characteristics associated with BK virus reactivation. METHODS: We isolated BK virus DNA from urine and blood of 103 kidney transplant recipients, and amplified VP1 region using polymerase chain reaction (PCR). The PCR products were sequenced and genotypes of BK virus (I-IV) were determined based on the nucleotide sequence 1744-1812 of the VP1 region. In addition, the clinical characteristics of the patients were analyzed to determine the risk factors of BK virus reactivation. RESULTS: Of 103 patients examined, 16 and 5 patients were shown to have BK viruria and viremia, respectively. Eight viral strains were demonstrated to be genotype I, but the other 8 strains neither matched with the genotypes from I to IV, nor did they fit into any other variants identified in the Western countries. Of note, 3 of these 8 unclassified strains were shown to have the same type of mutations. With respect to the risk factors of BK virus, tacrolimus and mycophenolate mofetil when combined with tacrolimus were found to be significantly associated with BK viruria and viremia. CONCLUSION: It appears that different variants of BK virus are prevalent in Korea compared with the Western countries, and that the reactivation of BK virus is significantly associated with tacrolimus.

Is it Possible to Predict the Progression Rate in Korean IgA Nephropathy Patient? / 대한신장학회잡지

BACKGOUND: The progression rate of IgA nephropathy is known to be variable. We tried to draw an equation that can predict the interval till end stage renal disease (ESRD). METHODS: We retrospectively checked the risk factors of the progression such as demographic, clinical, laboratory, and histologic data by using simple linear regression in eighty eight (M:F=53:35) patients with biopsy-proven IgA nephropathy from Oct 1994 to Aug 2004. By multiple linear regression, a semiquantitative equation estimating the rate of progression was developed. We also evaluated whether there is a "point of no return" that progresses to ESRD which was shown by D'Amico ('93) and Scholl ('99) by receiver operating characteristic (ROC) curve analysis. RESULTS: Mean age and follow-up period were 34.1+/-13.6 years and 55.7+/-31.4 months. Among the risk factors, spot urine protein to creatinine ratio and mean arterial pressure during the follow-up period were significantly associated with the rate of progression (p<0.05). A semiquantitative equation estimating the rate of progression using the two factors was developed as follow. (delta)CCr=2.206-(0.128 x PCR(follow-up))-(0.023 x MAP(follow-up)) (MAPfollow-up:mean arterial pressure; regression coefficient=-0.023, PCRfollow-up:spot urine protein/creatinine; regression coefficient=-0.128). By ROC curve analysis, all patients with maximum serum creatinine over 4.1 mg/ dL during follow-up were found to progress to ESRD. CONCLUSION: We conclude that in Korean IgA nephropathy patients we could predict the rate of decline in renal function for individual patients semiquantitatively and we could confirm the existence of a "point of no return" during the course of IgA nephropathy.

Arterial Stiffness, Malnutrition and Inflammation in Chronic Hemodialysis Patients / 대한신장학회잡지

BACKGROUND: In ESRD patients, malnutrition and atherosclerosis are strongly associated with inflammation resulting in MIA (Malnutrition-Inflammation-Atherosclerosis) syndrome. As compared with atherosclerosis, arteriosclerosis or arterial stiffening is another important cardiovascular risk factor. Therefore, we speculated on the presence of new MIA syndrome, which is composed of malnutrition, inflammation and arteriosclerosis, and evaluated causal relations among them in 70 chronic hemodialysis patients (age 53+/-13 years, male 53%, diabetes 40%). METHODS: As an indicator of arterial stiffness, brachial-ankle pulse wave velocity (PWV) was measured using a plethysmography. PWV index (measured PWV/nomogram based theoretical PWV) was then calculated to adjust confounding effects of age, blood pressure, and gender by using the PWV nomogram obtained in nonuremic population with same age, blood pressure, and gender. Nutritional status was assessed by serum albumin level, subjective global assessment (SGA) and normalized protein catabolic rate (nPCR). Extracellular fluid and intracellular fluid volume ratio (ECF/ICF) were determined using bioimpedance analysis. The presence of an inflammation was assessed by serum high sensitivity C-reactive protein (CRP) level. RESULTS: PWV index correlated positively with log transformed CRP (LnCRP) level, ECF/ICF and negatively with SGA, nPCR and serum albumin level. Serum albumin level correlated positively with nPCR, BUN, hemoglobin level and negatively with LnCRP level, age and ECF/ICF. Diabetic patients had higher PWV index and lower albumin level than non-diabetic patients. In multiple regression analysis, only LnCRP level was a significant common determinant of the both PWV index (R2=0.419; p >0.001) and serum albumin level (R2=0.543; p<0.001). CONCLUSION: Increased CRP levels are independently associated with arterial stiffening and hypoalbuminemia. Inflammation might be a linking mechanism of arterial stiffening and malnutrition in chronic hemodialysis patients.

Vancomycin-Induced Agranulocytosis and Rhinocerebral Mucormycosis in a Patient with Continuous Ambulatory Peritoneal Dialysis-Associated Peritonitis / 대한신장학회잡지

Vancomycin-induced agranulocytosis is a rare side effect, but the increased use of vancomycin may disclose a more frequent occurrence. And it is a life-threatening complication, especially in end stage renal disease (ESRD) patients. We describe a 62-year-old patient with continuous ambulatory peritoneal dialysis (CAPD), who developed agranulocytosis after 3 weeks intraperitoneal administration of vancomycin for treatment of peritonitis caused by methicillin-resistant Staphylococcus haemolyticus. The agranulocytosis was resolved with granulocyte colony-stimulating factor (G-CSF) therapy and by the discontinuation of vancomycin. But, the patient developed subsequent rhinocerebral mucormycosis with invasion to skull base associated prolonged neutropenic period and expired in spite of surgical resection and intravenous administration of amphotericin. This case serves as a reminder to clinicians that patients receiving long-term treatment with vancomycin should have their white blood cell count monitored and vancomycin-induced agranulocytosis should be corrected promptly.

Congenital Nephrogenic Diabetes Insipidus Presented with Bilateral Hydronephrosis: Genetic Analysis of V2R Gene Mutations

Most cases of hydronephrosis are caused by urinary tract obstruction. However, excessive polyuric syndrome rarely gives rise to non-obstructive hydronephrosis, megaureter, and a distended bladder. The authors report here on two cases of congenital nephrogenic diabetes insipidus (NDI) with severe bilateral hydronephrosis and megaureter. It is Interesting that the patients were symptomless except for their polyuria, and they both presented with bilateral hydronephrosis. Fluid deprivation testing revealed the presence of AVP resistant NDI. Gene analysis for these patients showed the AVP receptor 2 (V2R) missense mutations (Q225X and S126F), which have previously been reported on in other studies. We made the diagnosis of NDI by using a physiologic test, and we confirmed it by mutation analysis of the V2R gene.

Progression of Diabetic Nephropathy in Type 1 Diabetes in Korea / 대한신장학회잡지

BACKGROUND: Diabetic nephropathy is the main cause of the end-stage renal disease in Korea. This study was performed to evaluate the progression pattern and risk factors of diabetic nephropathy in type 1 diabetes patients. METHODS: Total 64 patients who were registered in Ajou University Hospital since April 1994 till April 2004 were enrolled. We retrospectively analyzed the influence of systolic and diastolic blood pressure, serum creatinine, total cholesterol, albumin, HbA1c and urine albumin excretion on the rate of decline in creatinine clearance (CCr) by Cockcroft- Gault equation. RESULTS: The patients (27 males/37 females), aged 32.8+/-9.1 (mean+/-SD) years, with a mean duration of diabetes of 9.5+/-4.9 years, were followed more than 6 months. CCr were 113.0+/-20 mL/min/1.73m2 at diagnosis and a mean decrease rate was 3.8+/-3.6 mL/ min/1.73m2/year. Doubling time of serum creatinine was 13.1+/-3.2 year in patients who developed doubling of their creatinine (26.6%). Microalbuminuria and overt proteinuria developed at 8.1+/-2.5 year and at 11.4+/-1.5 year after the diagnosis of type 1 diabetes respectively. A mean decrease rate of CCr was 6.1+/-2.9 mL/min/1.73m2/year in patients who develop ESRD after 14.2+/-2.8 years. During the follow up, systolic and diastolic blood pressure, serum total cholesterol were significantly higher and the mean serum albumin and creatinine clearance were significantly lower in chronic renal failure (CRF) group compared to non-renal failure (non-CRF) group (p< 0.05). There was no significant difference in HbA1c between CRF and non-CRF groups. CONCLUSION: The results may suggest that Korean type 1 diabetes patients with diabetic nephropathy in Ajou hospital have a rather faster decline in kidney function compared with other reports. But we need further prospective study to confirm this findings.