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A study on oral discomfort in gynecological cancer patients undergoing chemotherapy (화학요법을 받는 부인암환자의 구강불편감에 관한 연구)

  • 정재원
    • Journal of Korean Academy of Nursing
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    • v.25 no.2
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    • pp.372-389
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    • 1995
  • The frequency with which administration of chemotherapy for gynecological cancer treatment is used has increased along with the use of surgery and radiotherapy Among the various side effects of chemotherapy, stomatitis causes a problem of function and sensation in the oral cavity. This oral discomfort can be categorized into two components ; perceived oral symptoms and observed oral symptoms. If the oral problem continues, it may cause infection, bleeding and nutritional deficiencies. As a result of this condition, compliance with the treatment process can be affected as well as the prognosis for the cancer patients. But as the oral discorrfort usually appears after chemotherapy, it is often not reported to the health care personnel as a patient problem. Without problem identification of the oral discomfort and ability to assess the problem, effective intervention cannot be planned. Therefore, this study was conducted to identify the pattern and the degree of oral discomfort due to cancer chemotherapy and thus to provide data for identification of the patient problem and for nursing assessment. The design of this study was a longitudinal de-scriptive study The subjects were in - patients who received chemotherapy under the diagnosis of gynecological cancer between Mar. 15, 1994 and May 15, 1994 at a general hospital in Seoul, Korea. The number of subjects was 64 and they were divided into two groups, one of 41 (A : 5FU & Neoplatin), the other of 23(B : Neoplatin, Cytoxan, Adriamycin), according to the treatment regimen. The data were collected for 24 days using self-re-port instruments. The instruments were the 「Perceived Oral Symptom Assessment Tool」 and 「Observed Oral Symptom Assessment Tool」 developed by this researcher. Data were analyzed using the SPSS-PC program, ANOVA, t-test, paired t-test and the Pearson Correlation Coefficient were applied. The results of this study are as follows : 1. In A regimen the peak time for perceived oral symptom scores was the fifth day after chemotherapy, and the tenth day for observed oral symptom scores. Both of the problems started on first day of chemotherapy and were not resolved completely until the 24th day after treatment. 2. In B regimen, the peak time for perceived oral symptom scores was on the seventh day after chemotherapy, and the eighth day for observed oral symptom scores. It was noted that perceived oral symptom scores were higher than observed oral symptom scores consistently for 24 days. Both also started on first day of chemotherapy, and were not resolved completely until the 24th day after chemotherapy. 3. There were no differences statistically in perceived oral symptom scores between A and B regimen. The loss of appetite and xerostomia caused the most severe discomfort in both of these two groups. 4. The were no differences statistically in observed oral symptom scores between the A and B regi moil. In the A regimen, the highest observed symptom scores were the lips, gingiva, tongue and buccal membrane in that order. But in the B regimen, the highest observed symptom scores were tongue, lips, buccal membrane and gingiva in that order. 5. In A regimen, the patients who had gingival edema and dentures had significantly higher perceived oral symptom scores. And those who had gingival edema and bleeding, foul odor and aphthous stomatitis had significantly higher observed oral symptom scores. 6. In B regimen, the patients who had the experience of stomatitis in the last course of chemotherapy had significantly higher perceived oral symptom scores. Those who had gingival edema had significantly higher observed oral symptom scores. 7. In the A regimen there was no correlation between lab values for lymphocytes and albumin with perceived oral symptom scores and observed oral symptom scores. In the B regimen, there was a significant negative correlation between lymphocytes and albumin with the observed oral symptom scores, but not between perceived oral symptom scores and lymphocytes and albumin values. In conclusion, the nurse should expect that the patient undergoing chemotherapy will complain severely about subjective discomfort and before objective physical change is observed. Also the patients who have chronic oral problems such as dentures, gingival edema and bleeding, foul odor, aphthous stomatitis will complain of severe oral discomfort due to chemotherapy.

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Evaluation of Etiological Factors for Injuries at Oral and Maxillofacial Area (구강악안면부 외상발생의 역학적 평가)

  • Bae, Sung-Suk;Hwang, Soon-Jung
    • Journal of dental hygiene science
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    • v.12 no.4
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    • pp.310-319
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    • 2012
  • In this study, 1,495 cases of computerized data collected as disease entities of oral and maxillofacial injuries among patient visiting S university hospital located in Seoul in 2009 were analyzed and following results were obtained. It was found that the injury incidence in male was greater than in female (1.49:1), it occurred most frequently in the age of 7~14 years old (19.6%), and its most frequent cause was falling down (25.9%). Injuries occurred in other place including beach and open-air (24.7%) most frequently, often developed in anterior teeth (43.2%) and posterior teeth (43.1%), their incidence was relatively higher between 15:00~17:00 (10.4%) and 19:00~23:00 (7.1%) O'clock. In the relationship between causes of the injury and the diagnosis based on the international classification of disease), falling, fall, impingement, violence, traffic accident, sports and own making accident caused most frequently lip and oral open injuries (S01.5), open fracture of tooth (S02.51), close fracture of tooth (S02.50), close fracture of mandible (S02.60), close fracture of tooth (S02.50), respectively. From the above results, it is necessary to understand general characteristics of oral and maxillofacial injuries and to consider their trends for the establishment of systematic complement policies and for the performing safety training and public relations activities.

Arthroscopic Treatment of Metallic Suture Anchor Failures after Bankart Repair (Bankart 수술 후 발생한 금속 봉합 나사못 합병증의 관절경적 치료)

  • Shin, Sang-Jin;Jung, Jae-Hoon;Kim, Sung-Jae;Yoo, Jae-Doo
    • Journal of the Korean Arthroscopy Society
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    • v.10 no.1
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    • pp.70-76
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    • 2006
  • Purpose: This study presents 5 patients who had metallic anchor protrusion on glenoid after Bankart repair in anterior shoulder instability and reviewed the cause, clinical feature and arthroscopic removal technique. Method and Materials: 5 male with average age of 22 years (range 19 to 25 years) were included. 4 patients had arthroscopic Bankart repair and 1 patient had open repair for anterior shoulder instability. They had protruded metallic suture anchors on glenoid and the protruded suture anchors were removed arthroscopically using larger suture anchor empty inserter. Results: 4 patients had painful clicking sound with motion of abduction and external rotation and 1 patient showed shoulder instability. The ROM showed normal except mild degrees loss of external rotation. The position of protruded metallic anchor was 2, 3 and 5 O'clock in three patients and 4 O'clock in 2 patients. In 2 patients, the metallic suture anchor was malpositioned about 5mm off on the medial side from the anterior glenoid edge. All had Outerbrige classification Grade II-III chondral damage on humeral head and 1 patient showed glenoid cartilage destruction. None had shoulder instability after 2 years of follow-up. Constant score was 65 preoperatively and 89 postoperatively. ASES score was 67 preoperatively and 88 postoperatively. Conclusion: Symptoms of protruded suture anchor are not combined with instability. Most of symptoms were revealed from the rehabilitation period and confused with postoperative pain. Prompt diagnosis and early arthroscopic removal or impaction of protruded metallic suture anchor is recommended because of serious glenohumeral cartilage destruction. This is easy and simple and reproducible method to remove protruded metallic suture anchor arthroscopically.

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Clinical Characteristics, Histology and Prognosis of Autoimmune Hepatitis in Korean Children (소아 자가면역성 간염: 임상적 특성, 조직 소견 및 예후)

  • Chung, Dae-Lim;Seo, Jeong Kee;Yang, Hye Ran;Ko, Jae Sung;Park, Sung Hye
    • Pediatric Gastroenterology, Hepatology & Nutrition
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    • v.7 no.2
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    • pp.186-196
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    • 2004
  • Purpose: Autoimmune hepatitis is a chronic inflammatory liver disease with unknown cause that is characterized by liver histology, circulating autoantibodies and increased levels of immunoglobulin G. Only sporadic reports are available on autoimmune hepatitis in children. The aim of this study was to evaluate the clinical, biochemical, and histological features, and the long-term outcome of autoimmune hepatitis in Korean children. Methods: We reviewed the medical records of 14 children diagnosed as having autoimmune hepatitis at Seoul National University Children's Hospital from 1990 to 2004, and analyzed clinical, biochemical, and histological features, and clinical outcomes. Results: Mean age at diagnosis was 9 years and 11 of the 14 children were female. Six children presented with acute hepatitis-like manifestations. Jaundice and fatigue were the most common symptoms. Other autoimmune diseases accompanied in 6 children. Anti-nuclear antibody was detected in 13 patients and anti-smooth muscle antibody was positive in 8. All 14 patients were type 1 autoimmune hepatitis. The main histologic findings were interface hepatitis, rosette formation, and cirrhosis. Clinical and biochemical features were improved in six patients treated with ursodeoxycholic acid. Eight patients were treated with corticosteroid alone or in combination with azathioprine and five of them are in biochemical remission. Conclusion: Autoimmune hepatitis is an inflammatory liver disease, which has a favorable long-term outcome if it is diagnosed and treated promptly. Therefore, autoimmune hepatitis should be suspected in children with chronic hepatitis of unknown etiology, especially in female patients who show hypergammaglobulinemia or some clinical features of autoimmune disease.

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일부 농촌지역의 결핵 치료 환자에 대한 실태 조사에 관한 연구

  • 이재희
    • Journal of Korean Academy of Nursing
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    • v.1 no.1
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    • pp.85-94
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    • 1970
  • This is a study of 21 tuberculosis patients receiving medical treatment at the Public Health Center in Kyongi Do, Pu Chun Gun and at the General Hospital. The results cover the findings of the period from May, 1969 to November 1970. The information obtained is based on personal interviews with the patients, and symptomatic diagnosis made from observations. The following statistics when not equalling 100% contain only the responses of the two extremes in each case. The findings of the research are as follows: 1. 52.3% of the patients in the study are males and 47.7% are females. 28.6% of the subjects are between 20 and 29 years of age and an equal percent are between 30 and 39 years. 2. 47.5% of the subjects had graduated from primary school, while only 4.8% had graduated from high school. 3. 57.1% of the patients said they had no religions beliefs, while 4.8% professed to being Buddhists or believing in superstition. 4. 47.3% of the people said they were unemployed, while 4.8% classified themselves as labourers. 5. In response to how tuberculosis was first detected in their respective cases, 52.6% became aware of their disease through X-ray results, while 4.8% were discovered to have tuberculosis when being treated for other diseases at the hospital. 6. When asked how many of the patients knew anything about their disease when treated, 57.1% knew nothing about tuberculosis when they received treatment, while 42.9% had some knowledge of the disease. 7. Of those who knew something about tuberculosis, 61.9% learned about from doctors and nurses, while 4.8% learned from other people. 8. 57.1% of the patients knew that tuberculosis is a communicable disease, while 42.9% did not know. 9. 52.4% of the patients did not know the cause of tuberculosis while 4.9% believed the disease was caused by a curse. 10. When asked about the extent of treatment, 52.4% responded that they had undergone continuous treatment, while 4.8% had not received treatment. 11.The reasons given for not continuing treatment were the following: economic factors 55.6%; side reactions to the treatment, lack of knowledge of how to get treatment, of the need for treatment, or of the positive effects of treatment 11.1%. 12. 61.9% of the subjects usually took the medical treatment at home, 9.5% took it in the mountains or at the beach. 13. 42.9% of the patients received drugs for treatment at the local public health center, while 4.8% received them at the hospital 14. 33.3% of the patients received P.A.S+I.N.H.+S.M. for treatment of tuberculosis, while 4.8% received P.A.S.+S.M.. and some secondary drug. 15. Of the patients who took some extra medicine for tuberculosis, 38.1% took a Chinese drug, while 9.5% took herb medicine. 16. 38.1% of the patients had continued treatment for three years, 4.8% had interrupted the treatment. 17. When asked about the development of the disease after treatment, the patients gave the following information: after one month, 90.5% thought the treatment helped, while 9.5% weren't sure; after one year, 55.6% thought it was good, while 5.5% thought it was not; after three years, 63.6% had a very bad condition. while 4.8% didn't know. 18. 61.9% of the patients were unconcerned about covering their mouths when they coughed, while 38.1% covered their mouths. 19. 57.2% were unconcerned they spit, while 23.8% spit into a waste basket. 20. 66.7% were unconcerned about sterilizing tableware, while 9.5% handled it separately. 21. 66.7% were unconcerned about ventilating their room, while 9.5% ventilated the room twice a week.

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A Study on the Prevalence Rate of Hypertension and the Actual Conditions of Control (일 지역 성인의 고혈압 유병률 및 관리 실태)

  • Kim, Hyeon-Ok
    • Research in Community and Public Health Nursing
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    • v.10 no.1
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    • pp.154-172
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    • 1999
  • In order to analyse the prevalence rate of hypertension and the actual conditions of control, we selected five districts out of eleven eups and myuns in Chinan Country. We administered structured questionaries to 309 adults above the age of 40, computerized the data using SPSS - PC+. More than 40.1% of adults over 40 in Chinan County have health disorders ranging from high blood pressure to hypertension including alert high blood pressure at 36.2%, relatively high. Among general characteristics, differences in the rate of hypertension were influenced by age, occupation and places of residence. Over 71 who are engaged in agriculture, who don't have jobs, who reside in Sungsu, Jungchun, Chinan-eup all have higher hypertension rates than other groups. Accordingly, the control of hypertension should be focused on these people. As a result of the control of blood pressure, the survey showed 93.0% of the subjects were checked mainly at hospitals clinics, health centers subhealth centers and community health posts more than once a year, relatively high level of blood pressure management. However, the difference between their blood pressure measurements at ordinary times and the level of blood pressure at the time of research was quite considerable. Only 47.3% of the subjects diagnosed with high blood pressure and 70.3% of the subjects with normal blood pressure recognized their blood pressure accurately 52.7% of the subjects diagnosed with high blood pressure showed errors in understanding their blood pressure at normal times. Because these errors can cause problems in the control of blood pressure, proper management should be executed through a systematic examination. As a result of the high blood pressure control condition, the average period of hypertension was 74.5( ${\pm}92.8$) months, 92.3% of the subjects were diagnosed with high blood pressure at hospitals clinics, health centers subhealth centers community health posts, but only 29.5% were examined after a general check up on high blood pressure was completed. 70.5% were diagnosed with high blood pressure only after measuring their blood pressure. 14.1% of the subjects were hospitalized because of falls influenced by high blood pressure. 33.3% attended hospitals and health centers regularily for medical treatment and this shows how low the rate of the control of blood pressure. Most people did not undergo medical treatment, because they had no painful symptoms (46.7%), they didn't need to take the medicine(28.9%), or they forget to take the medicine(20.0%). These problems in the control of hypertension were discovered in the process of diagnosing high blood pressure at health medical institutions. Many people did not recognize the need for consistent control of blood pressure. That is, although the diagnosis for high blood pressures performed at hospitals clinics, health centers subhealth centers and community health posts, was 92.3%, more than 70.5% of the subjects were not examined completely with regard to blood pressure. Accordingly, heath medical institutions must diagnose high blood pressure not only by only measuring blood pressure but also by using systematic process of examination. As for the people diagnosed with high blood pressure, one should perform consistent medical approaches and help them to recognize the importance of the continuous control of blood pressure through subject-oriented education. Problems the subjects experienced were the following numbness in the limbs easily paralyzed stitches in their shoulders which felt painful, stiff necks, occiputs felt heavy, headaches when they got up in the morning, felt dizzy when standing and moving their heads and poor eyesight. The rate of knowledge related to high blood pressure was 78.7 points, comparatively low. Whether they had normal blood pressure or hypertension made no difference. These results are not desirable. Adult-oriented education forgot the prevention and management of high blood pressure should be implemented. Hypertensive-oriented education should be especially reinforced. Because there was a difference in the level of knowledge according to age, academic career, occupation or place of residence, education related to hypertension should be intensified and focused on those over the age of 71 those who did not attend school, those who do not have jobs and are engaged in agriculture and residents living in Bugui, Jungchun regions. The degree of healthy life practice in hypertensives is poor, particularly weight control, as opposed to people who have normal blood pressure. It makes no difference in smoking, the amount of daily smoking, drinking, the control of salt because each result means that they are not practicing healthy life or modifying their life-style. The development and programs to improve a healthy life should be executed.

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Isolation of Nontuberculous Mycobacteria by DNA Probe and Clinical Characteristics of Patients with NTM Pulmonary Disease (DNA probe를 이용한 비결핵항산균의 분리 및 폐질환자들의 임상적 특징)

  • Kim, Hee Kyoo;Kim, Yu Ri;Park, Jung Pil;Kim, Nang Hee;Ok, Chul Ho;Jung, Maan Hong;Jang, Tae Won;Jeong, Seok Hoon;Kim, Cheol Min;Park, Hee Kyung
    • Tuberculosis and Respiratory Diseases
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    • v.58 no.3
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    • pp.248-256
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    • 2005
  • Background : Nontuberculous mycobacterial (NTM) infections are increasingly being recognized as a cause of chronic pulmonary disease. This study describes the prevalence of NTM species from clinical specimens and the clinical characteristics of NTM pulmonary disease. Material and Methods : The NTM isolated from March 2003 to December 2003 at the Kosin Medical Center were identified using an oligonucleotide chip containing the internal transcribed space (ITS) sequence. The medical records of the patients with the NTM isolates, who fulfilled the 1997 ATS diagnostic criteria for NTM pulmonary disease, were analyzed, retrospectively. Results : Twenty four species (24.2%) of NTM were isolated from 99 cultured AFB specimens. M. avium complex (MAC) (13 isolates), M. szulgai (3), M. kansasii (2), M. malmoense (2), M. abscessus (1), M. chelonae (1), M. scrofulaceum (1), and unclassified (1). Of the 23 patients with isolated NTM, 11 patients were found to be compatible with a NTM pulmonary infection according to the ATS criteria; MAC was found in 6 cases (54.5%), M. szulgai in 2 cases (18.2%), and M. abscessus, M. szulgai, M. kansasii and M. malmoense in 1 case each (9.1%). Ten patients (91%) were male and the median age at diagnosis was 61 years. In the pre-existing diseases, malignant disease was found in 6 cases including 5 patients with lung cancer, and history of old pulmonary tuberculosis was identified in 4 cases. The radiological patterns showed lung destruction lung in 3 cases, a cavitary mass in 3 cases, a nodular pattern in 2 cases, and reticulonodular, consolidation and a bronchiectasis pattern were in 1 case each. Conclusion : Various types of NTM pulmonary diseases were found in a tertiary hospital at Busan, Korea. The NTM pulmonary diseases were caused by MAC, M. szugai, M. kansasii, M. malmoense, M. abscessus, M. chelonae, and M. scrofulaceum in the order of frequency.

Clinical Characteristics of Chronic Cough in Korea

  • An, Tai Joon;Kim, Jin Woo;Choi, Eun Young;Jang, Seung Hun;Lee, Hwa Young;Kang, Hye Seon;Koo, Hyeon-Kyoung;Lee, Jong Min;Kim, Sung-Kyung;Shin, Jong-Wook;Park, So Young;Rhee, Chin Kook;Moon, Ji-Yong;Kim, Yee Hyung;Lee, Hyun;Kim, Yong Hyun;Kim, Je Hyeong;Lee, Sang Haak;Kim, Deog Kyeom;Yoo, Kwang Ha;Kim, Dong-Gyu;Jung, Ki-Suck;Kim, Hui Jung;Yoon, Hyoung Kyu;Cough Study Group of the Korean Academy of Tuberculosis and Respiratory Diseases
    • Tuberculosis and Respiratory Diseases
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    • v.83 no.1
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    • pp.31-41
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    • 2020
  • Background: Chronic cough is defined as a cough lasting more than 8 weeks and socio-economic burden of chronic cough is enormous. The characteristics of chronic cough in Korea are not well understood. The Korean Academy of Tuberculosis and Respiratory Diseases (KATRD) published guidelines on cough management in 2014. The current study evaluated the clinical characteristics of chronic cough in Korea and the efficacy of the KATRD guidelines. Methods: This was a multi-center, retrospective observational study conducted in Korea. The participants were over 18 years of age. They had coughs lasting more than 8 weeks. Subjects with current pulmonary diseases, smokers, exsmokers with more than 10 pack-years or who quit within the past 1 year, pregnant women, and users of cough-inducing medications were excluded. Evaluation and management of cough followed the KATRD cough-management guidelines. Results: Participants with chronic cough in Korea showed age in the late forties and cough duration of more than 1 year. Upper airway cough syndrome was the most common cause of cough, followed by cough-variant asthma (CVA). Gastro-esophageal reflux diseases and eosinophilic bronchitis were less frequently observed. Following the KATRD cough-management guidelines, 91.2% of the subjects improved after 4 weeks of treatment. Responders were younger, had a longer duration of cough, and an initial impression of CVA. In univariate and multivariate analyses, an initial impression of CVA was the only factor related to better treatment response. Conclusion: The causes of chronic cough in Korea differed from those reported in other countries. The current Korean guidelines proved efficient for treating Korean patients with chronic cough.

Treatment Outcome of Langerhans Cell Histocytosis (랑게르한스 세포 조직구증의 치료 결과)

  • Chung, So Hak;Kim, Jae Do;Jo, Hyun Ik
    • The Journal of the Korean bone and joint tumor society
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    • v.20 no.1
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    • pp.14-21
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    • 2014
  • Purpose: To analyze the clinical features and treatment outcome of Langerhans' cell histocytosis. Materials and Methods: From August 1996 to June 2013, 28 patients who histologically proven with LCH were analyzed of medical records, radiography, pathologic character retrospectively. Results: A total of 28 cases of LCH including 22 child has been reported. Onset age was 0.6 to 51 years old, occurred in the average age was 14.8 years. Follow-up period was 6 months to 134 months average was 44.6 months. The M:F ratio was 2.5:1. The initial symptoms was pain in 18 cases, 5 cases of pathologic fracture, 3 case of palpable mass, 1 case of discovered by accident in radiography, 1 case of torticollis. In radiological examination osteolysis was seen all cases, 7 cases showed a periosteal reaction, 1 case showed soft tissue extension. Clinical type of all cases were eosinophilic granuloma. 25 cases were classified as unifocal disease and 3 cases were multifocal single systemic diseases. In all cases, incisional biopsy was performed. After histologic confirmed, 14 cases was treated with curettage or surgical excision of the lesion and the other 14 cases were followed up without treatment. There is no death during follow up period. 11 cases has no radiological improvement after 3-6 months observation, intralesional steroid injection was performed. Conclusion: Patients with LCH who has rapid systemic onset is very rare, so if you meet the young children who suspected LCH, you shoulder avoid the examination which cause excessive radiation exposure to the young patient. In order to confirm the diagnosis of disease, biopsy is needed. Close observation after confirmed by histological method will bring the satisfactory results. But the patients who had pathologic fracture or wide bone destruction already may need curettage and bone grafting to lesion or internal fixation. The lesion which has no radiological improvement after 3-6 months observation or appear with pain interferes daily life may need local steroid injection as a good treatment.

A Clinicopathological Study of Rapidly Progressive Glomerulonephritis in Children (소아 급속 진행성 사구체 신염의 임상-병리학적 고찰)

  • Cho Hee-Yeon;Chung Dae-Lim;Kang Ju-Hyung;Ha Il-Soo;Choi Yong;Cheong Hae-Il
    • Childhood Kidney Diseases
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    • v.8 no.2
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    • pp.176-185
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    • 2004
  • Purpose: Rapidly progressive glomerulonephritis (RPGN) is a clinicopathologic entity characterized by extensive crescent formation and rapid deterioration of renal function within few months. For better understanding of its clinical course and designing better treatment strategies, a clinicopathological study of childhood RPGN was performed. Methods: The clinical manifestations and pathological findings were reviewed retrospectively in 12 children who were diagnosed as having RPGN by clinical manifestations and renal biopsy during a period from 1991 to 2003. Several clinicopathological parameters were analyzed as prognostic factors. Results: Among a total of 12 patients, 4 were male and 8 were female. The median onset age was 11.5 years(range 5.5-14.6 years), and the median period of follow-up was 25 months(range 7 months-6.6 years). According to the pathological classification, 10 patients (83%) were type II RPGN(immune-complex mediated glomerulonephritis), 2 patients were type III RPGN(pauci-immune glomerulonephritis), and none was type I RPGN(anti-glomerular basement membrane nephritis). All patients were treated with oral steroid in various combinations with methylprednisolone pulse therapy(10 patients, 83%), cyclophosphamide(8 patients, 67%), or plasmapheresis(4 patients, 33%). Clinical outcomes of 12 patients were complete remission in 1(8%), end-stage renal disease in 2(17%), chronic renal insufficiency with persistent proteinuria in 2(17%), and normal renal function with persistent proteinuria in 7(58%) at the last follow-up. Poor prognosis is associated with increased serum creatinine level, severe anemia and younger age at the time of diagnosis. Conclusion: Immune-complex mediated glomerulonephritis is the major cause RPGN in children and most cases showed improvement of renal function with aggressive management. For better understanding of this rare disease, a prospective multicenter study should be done.

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