Korean Center Research Articles

Chronological changes in epidemiologic features of patients with gallstones over the last 20 years in a single large-volume Korean center

PurposeSouth Korea has a high prevalence of gallstones, the type of which could be influenced by changes in diet and socioeconomic status. Here we aimed to investigate the epidemiological characteristics and changing patterns of gallstones over the past 20 years in Korea.MethodsA total of 5,808 patients who underwent cholecystectomy due to gallstones at Seoul National University Hospital between 1996 and 2015 were analyzed. Patients were divided into 4 subgroups: period 1 (1996–2000, n = 792), period 2 (2001–2005, n = 1,215), period 3 (2006–2010, n = 1,525), period 4 (2011–2015, n = 2,276). Gallstones were classified by type: pure cholesterol (PC), mixed cholesterol (MC), calcium bilirubinate (CB), black pigment (BP), and combination (COM).ResultsThe female to male ratio was 1.16 with mean ages of 53.6 and 55.3 years old, respectively. The ratio of cholesterol stones to pigment stones was 0.96:1. The mean age and male to female ratio of the patients increased over time. The proportion of cholesterol vs pigment stone did not differ significantly. Proportions of PC and MC stone subtypes did not change notably, whereas proportion of BP stones increased (34.0% to 45.5%), and CB stones decreased (20.7% to 5.3%).ConclusionGallstone types and occurrences were affected by environmental changes, and pigment stones remained common in Korea. Although no distinct increase in cholesterol stones was noted, the proportion of CB stones decreased. As the mean age at gallstone presentation increases, BP stones could become more prevalent.

국내 혈액 센터에서의 혈액 적정 재고량 유지를 고려한 이동식 헌혈 시설의 운영 최적화 사례 연구

The inventory management in the blood center is still challenging due to the uncertainties related to blood supply and perishability of the blood products. In particular, the uncertainty originated from blood supply is hard to mitigate because blood can only be obtained from voluntary donation from blood donors. To increase blood donation, mobile blood donation facilities such as blood donation buses have widely been used all over the world since they can attract potential blood donors. However, the systematic scheduling of such mobile donation facilities is not yet adequately applied in practice. In this paper, we propose a mixed integer programming formulation that determines optimal schedules of mobile blood donation facilities while taking into account the inventory management in the blood center. Our case study is conducted on real-world instances of a Korean blood center. The results show that optimized schedules obtained from our model can significantly reduce total costs compared to two heuristic scheduling algorithms.

Comparison of ACUITY, CRUSADE, and GRACE Risk Scales for Predicting Clinical Outcomes in Patients Treated with Dual-Antiplatelet Therapy

Several reliable scales have been proposed for the management and prognosis in patients with acute coronary syndromes (ACS) treated with dual-antiplatelet therapy (DAPT). We sought to compare the performance of three conventional risk scores to predict major bleeding (MB; such as ACUITY or CRUSADE), or major adverse cardiovascular event (MACE for GRACE). This study included 904 consecutive post-ACS patients from the single Korean study center who underwent coronary interventions, and were treated with DAPT. All three scores were calculated based on admission data. MB and MACE were collected at 30-day and 1-year follow-ups. MB was defined according to the Bleeding Academic Research Consortium (BARC) criteria (types 3–5), and MACE included all-cause death, myocardial infarction, target vessel revascularization, and stroke. MB occurred in 114 patients (12.6%) during 30 days, and 65 patients (7.2%) from 30 days till 1-year follow-up. MACE occurred in 28 (3.1%) and 72 (8.0%) patients during 30 and 30 days till 1 year, respectively. For 30 days MB, the discriminatory ability of ACUITY (AUC: 0.83, 95% CI: 0.81–0.86) and CRUSADE (AUC: 0.82, 95% CI: 0.79–0.84) was similar, and more reliable than GRACE (AUC: 0.74, 95% CI: 0.71–0.77; p < 0.0001 and p = 0.002, respectively). The predictive value for 1-year MB was similar between ACUITY (AUC: 0.75, 95% CI: 0.72–0.78, p < 0.0001), CRUSADE (AUC: 0.70, 95% CI: 0.70–0.73, p < 0.0001), and GRACE (AUC: 0.70, 95% CI: 0.67–0.73, p < 0.0001) classifications. All three risk scales exhibited similar prediction for 30-day and 1-year MACE. We conclude that ACUITY and CRUSADE scores were superior to GRACE in predicting 30-day MB. However, all three risk scales were similarly useful for long-term MB, and MACE assessment.

The Epidemiological Influence of Climatic Factors on Shigellosis Incidence Rates in Korea.

Research has shown the effects of climatic factors on shigellosis; however, no previous study has evaluated climatic effects in regions with a winter seasonality of shigellosis incidence. We examined the effects of temperature and precipitation on shigellosis incidence in Korea from 2002–2010. The incidence of shigellosis was calculated based on data from the Korean Center for Disease Control and Prevention (KCDC, Cheongju, Korea), and a generalized additive model (GAM) was used to analyze the associations between the incidence and climatic factors. The annual incidence rate of shigellosis was 7.9 cases/million persons from 2002–2010. During 2007–2010, high incidence rates and winter seasonality were observed among those aged ≥65 years, but not among lower age groups. Based on the GAM model, the incidence of shigellosis is expected to increase by 13.6% and 2.9% with a temperature increase of 1 °C and a lag of two weeks and with a mean precipitation increase of 1 mm and a lag of five weeks after adjustment for seasonality, respectively. This study suggests that the incidence of shigellosis will increase with global climate change despite the winter seasonality of shigellosis in Korea. Public health action is needed to prevent the increase of shigellosis incidence associated with climate variations.

Phase Angle Using Bioelectrical Impedance Analysis for Predicting Survival in Patients with Metastatic Cancer

Objectives The aim of this study was to identify the validity of phase angle as a prognostic factor for survival in patients with metastatic cancer. Methods Data of patients with metastatic cancer who visited the Korean medicine cancer center at Kyung Hee University Hospital in Gangdong from April 2016 to February 2018 were collected for this study. The values of phase angle (PhA) and blood hemoglobin (Hb), C-reactive protein (CRP), and serum albumin levels were also investigated by bioelectrical impedance analysis (BIA). Results In total, 86 patients were analyzed. The cut-off value of the phase angle was determined as 5.0. Univariate and multivariate analysis revealed that phase angle (HR 3.15, 95% CI 1.79-5.54) and CRP (HR 2.15, 95% CI 1.24-3.73) predicted survival with statistical significance. The median overall survival of the low PhA group (PhA≤5.0) was 1.8 months (95% CI 0.6-2.9 months) and 7.2 months (95% CI 5.2-9.2 months) in the high PhA group (PhA>5.0)(p<0.001). Conclusions The phase angle could be an independent prognostic factor for patients with metastatic cancer. Further research is required to confirm these findings and their correlation with other indexes. Keywords: bioelectrical impedence analysis (BIA), phase angle, palliative care, prognostic factor, metastatic cancer

P3584Long term outcome of unprotected left main coronary artery disease: comparison between CABG and pci in korean single center

P3584Long term outcome of unprotected left main coronary artery disease: comparison between CABG and pci in korean single center

Characterization of congenital myopathies at a Korean neuromuscular center.

Congenital myopathies are muscle diseases characterized by specific histopathologic features, generalized hypotonia from birth, and perinatal complications, although some cases develop during childhood or, rarely, in adulthood. We undertook this study to characterize congenital myopathies among patients registered at our institution. Clinical, histopathologic, and genetic features were evaluated in 34 patients recruited for this study. The majority of patients experienced a childhood onset, and no disease-related mortality was recorded during follow-up. Functional outcomes were no better for those with late-onset disease, indicating later disease progression can be significant. Nemaline myopathy was the most frequent pathology, followed by central core disease and centronuclear myopathy. Among the 18 (54.5%) genetically confirmed patients, NEB and RYR1 mutations were the most common, followed by DNM2 mutations. This study shows features not previously reported and suggests that congenital myopathy should be considered an important issue among adult patients. Muscle Nerve 58: 235-244, 2018.

Validation of prediction models for risk stratification of incidentally detected pulmonary subsolid nodules: a retrospective cohort study in a Korean tertiary medical centre

ObjectivesTo validate the performances of two prediction models (Brock and Lee models) for the differentiation of minimally invasive adenocarcinoma (MIA) and invasive pulmonary adenocarcinoma (IPA) from preinvasive lesions among subsolid...

Temporal Changes in Care Processes and Outcomes for Endovascular Treatment of Acute Ischemic Stroke: Retrospective Registry Data from Three Korean Centers.

Background and PurposeThe purpose of the current study is to evaluate the influence of temporal patterns related to the availability of new endovascular treatment (EVT) devices on care processes and outcomes among patients with AIS.Materials and MethodsWe enrolled 720 consecutive patients (January 2011 to May 2016) in a retrospective registry, ASIAN KR, from three Korean hospitals, who received EVT for acute ischemic stroke (AIS) caused by cervicocephalic arterial occlusions. We performed period-to-period analyses based on stent retriever reimbursement and the availability of second-generation direct-aspiration devices (Period 1: January 2011–July 2014 vs. Period 2: August 2014–May 2016); time metrics and outcomes were compared when the onset-to-puncture time was <720 min among patients with EVT for intracranial occlusion.ResultsPeriod 2 had better post-EVT outcomes (3-month modified Rankin Scale 0–2 or equal to prestroke score, 48.3% vs. 60.2%, P=0.004), more successful reperfusion rates (modified Treatment In Cerebral Ischemia 2b–3, 74.2% vs. 82.2%, P=0.019), fewer subarachnoid hemorrhages (modified Fisher grade 3–4, 5.5% vs. 2.0%, P=0.034) and lower hemorrhagic transformation rates (any intracerebral hemorrhage, 35.3 vs. 22.7%, P=0.001) than Period 1. Compared to Period 1, Period 2 had a shorter door-to-puncture time (median 109 vs. 90 min, P<0.001), but longer onset-to-door time (129 vs. 143 min, P=0.057).ConclusionRecent temporal improvements in post-EVT AIS outcomes in Korea are likely due to a combination of enhanced hospital care processes and administration of newer thrombectomy devices.

Low- versus Standard-Dose Intravenous Alteplase in the Context of Bridging Therapy for Acute Ischemic Stroke: A Korean ENCHANTED Study.

Background and PurposeFollowing the positive results from recent trials on endovascular therapy (EVT), bridging therapy (intravenous alteplase plus EVT) is increasingly being used for the treatment of acute ischemic stroke. However, the optimal dose of intravenous alteplase remains unknown in centers where bridging therapy is actively performed. The optimal dose for eventual recanalization and positive clinical outcomes in patients receiving bridging therapy also remains unknown.MethodsIn this prospective Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED) sub-study, we explored the outcomes following treatment with two different doses (low- [0.6 mg/kg] or standard-dose [0.9 mg/kg]) of intravenous alteplase across 12 Korean centers where EVT is actively performed. The primary endpoint was a favorable outcome at 90 days (modified Rankin Scale scores 0 to 1). Secondary endpoints included symptomatic intracerebral hemorrhage (ICH) in all patients, and the recanalization rate and favorable outcome in patients who underwent cerebral angiography for EVT (ClinicalTrials.gov, number NCT01422616).ResultsOf 351 patients, the primary outcome occurred in 46% of patients in both the standard-(80/173) and low-dose (81/178) groups (odds ratio [OR], 1.14; 95% confidence interval [CI], 0.72 to 1.81; P=0.582), although ICHs tended to occur more frequently in the standard-dose group (8% vs. 3%, P=0.056). Of the 67 patients who underwent cerebral angiography, there was no significant difference in favorable functional outcome between the standard- and low-dose groups (39% vs. 21%; OR, 2.39; 95% CI, 0.73 to 7.78; P=0.149).ConclusionsThere was no difference in functional outcome between the patients receiving different doses of alteplase in centers actively performing bridging therapy.

Pancreatic fistula and mortality after surgical management of pancreatic trauma: analysis of 81 consecutive patients during 11 years at a Korean trauma center.

PurposePancreatic trauma is infrequent because of its central, deep anatomical position. This contributes to a lack of surgeon experience and many debates exist about its standard care. This study aimed to investigate the postoperative pancreatic fistula (POPF) and mortality of pancreatic trauma after operation.MethodsWe reviewed records in the trauma registry of our institution submitted from January 2006 to December 2016. The grade of pancreatic injury, surgical management, morbidity, mortality, and other clinical variables included in the analyses.ResultsData from a total of 26,072 trauma patients admitted to the Emergency Department were analyzed. Pancreatic trauma was observed in 114 of these patients (0.44%). Laparotomy was performed in 81 patients (2 pan creatico duodenectomies, 2 pancreaticogastrostomies, peripancreatic drainage in 41 patients, distal pancreatectomies in 34 patients, and 9 patients who underwent surgery for damage control). The incidence of POPF was 38.3%. The overall mortality was 8.8% (7 of 81). In multivariate analysis, pancreas injury grade IV (≥4) (adjusted odds ratio [AOR], 4.071; P = 0.029) and preoperative peritonitis signs (AOR, 2.903; P = 0.039) were independent risk factors for POPF. All patients who died had also another major abdominal injury (≥grade 3). Multiorgan failure was a major cause of death (6 of 7, 85.7%). The mortality rate of isolated pancreas injury was 0%.ConclusionThe pancreas injury grade and preoperative peritonitis were significant risk factors of POPF. The mortality rate of isolated pancreatic trauma was very low.

A cross-sectional retrospective study to analyze the underlying causes and clinical characteristics of children with reactive thrombocytosis at a Korean tertiary medical center.

BackgroundReactive thrombocytosis (RT) is a common condition among children, although no studies have examined the etiology or clinical characteristics of RT among Korean children.MethodsThis retrospective study evaluated children with RT at a single Korean tertiary center during a 10-year period.ResultsRT accounted for 13.5% of children who were admitted to the pediatric ward (4,113/30,355): mild RT, 82.7%; moderate RT, 14.1%; severe RT, 1.1%; and extreme RT, 2.1%. There was a negative correlation between platelet count and Hb level (P=0.008). There were positive correlations between platelet count and WBC (P=0.001), erythrocyte sedimentation rate (ESR) (P=0.007), and admission duration (P=0.006). The most common cause of RT was infection and the second most common was Kawasaki disease (KD). The highest proportion of lower respiratory tract infection was observed in extreme RT (P<0.001). The proportion of KD was highest in extreme RT (P<0.001) and in children aged 1–7.9 years (P<0.001). The proportion of refractory KD was highest in extreme RT (P=0.005). In cases of KD, there was a positive correlation between platelet count and fever duration (P=0.006). Non-KD autoimmune inflammation was only observed in mild/moderate RT, and its proportion was highest in children aged 8–18 years (P<0.001).ConclusionIn children, more severe RT was associated with lower Hb, increased WBC, ESR, and prolonged admission. With respiratory infection or KD, extreme RT was associated with more severe disease course.

Quantitative and Qualitative Evaluations of the Enhanced Logo-autobiography Program for Korean-American Women

ABSTRACT This study extends Bernstein et al.'s (2016) investigation of the effects of the Enhanced Logo-autobiography Program on Korean-American women's depressive symptoms, coping strategies, purpose in life, and posttraumatic growth by analyzing quantitative and qualitative data. This study's participants significantly improved on quantitative measures of depression, coping strategies, purpose in life, and post-traumatic growth at eight weeks post-intervention and follow-up. The qualitative content analysis revealed 17 themes with five essential themes. The program's activity to promote purpose in life through posttraumatic growth facilitated participants' recovery from traumatic experiences. Standardized guidelines are needed to conduct this program in Korean community centers.

1491P - Primary cardiac sarcoma: A retrospective study in two Korean tertiary centers

1491P - Primary cardiac sarcoma: A retrospective study in two Korean tertiary centers

Investigation of a nosocomial outbreak offungemia caused by Candida pelliculosa (Pichia anomala) in a Korean tertiary care center.

Candida pelliculosa is a rare pathogen of fungemia. There have been a few nosocomial outbreaks of C. pelliculosa fungemia in nurseries and pediatric intensive care units (ICU), hematologic units, and surgical ICU. We describe an epidemiologic outbreak investigation, including case findings of C. pelliculosa fungemia in South Korea. This outbreak investigation conducted in a 940-bed, tertiary referral center, Ulsan, South Korea and included active microbial surveillance and a case-control study. A patient in the trauma intensive care unit (ICU) with multiple trauma developed C. pelliculosa fungemia, and 10 patients in the trauma ICU, medical ICU, and 2 general wards subsequently contracted C. pelliculosa fungemia during the next 24 days (November 16 and December 9, 2015). The 16s rRNA sequencing of 4 isolates showed that C. pelliculosa was verified with 99-100% similarity (GenBank accession number: KF317892.1), and these isolates were identical in the randomly amplified polymorphic DNA (RAPD) assay. A case-control study showed that medical staff and staying in the interventional radiology procedure room were risk factor for development of C. pelliculosa fungemia. After intervention including strict hand washing, disinfecting medical equipment, and contact precautions, there have been no new C. pelliculosa infections since December 10, 2015. This is the first report of a nosocomial outbreak involving 11 patients in 2 ICUs and 2 general wards caused by C. pelliculosa in South Korea. Infection control measures are important for decreasing transmission of C. pelliculosa in the hospital.

Urinary tract infection caused by community‐acquired extended‐spectrum β‐lactamase‐producing bacteria in infants

ObjectiveUrinary tract infection (UTI) caused by resistant strains of bacteria is increasingly prevalent in children. The aim of this study was to investigate the clinical characteristics and risk factors for UTI caused by community‐acquired extended‐spectrum β‐lactamase (CA‐ESBL)‐producing bacteria in infants. MethodsThis was a retrospective study performed over 5 years in a single Korean center. Hospitalized infants with febrile UTI were enrolled and divided into two groups (CA‐ESBL vs. CA non‐ESBL UTI). The yearly prevalence was calculated. Baseline characteristics and clinical course such as fever duration, laboratory and radiological findings were compared between the two groups. Risk factors associated with the CA‐ESBL UTI were investigated. ResultsAmong the enrolled infants (n=185), 31 (17%) had CA‐ESBL UTI. The yearly prevalence of ESBL of CA‐ESBL UTI increased during the study (0% in 2010, 22.2% in 2015). Infants with CA‐ESBL UTI had a longer duration of fever after initiating antibiotics (2.0±1.1 vs. 1.5±0.6 days, p=0.020). Cortical defects on renal scan and early treatment failure were more frequent in CA‐ESBL (64.5 vs. 42.2%, p=0.023; 22.6 vs. 4.5%, p=0.001). A logistic regression analysis revealed that urinary tract abnormalities and previous UTI were independent risk factors for CA‐EBSL UTI (odds ratio, 2.7; p=0.025; 10.3; p=0.022). ConclusionThe incidence of UTI caused by ESBL‐producing bacteria has increased in Korean infants. Recognition of the clinical course and risk factors for ESLB‐producing UTI may help to determine appropriate guidelines for its management.

Delivery and feeding mode affects fecal calprotectin levels in infants < 7 months old

BackgroundElevated fecal calprotectin (FC) is a non-invasive marker of inflammation indicating bowel disease. However, healthy infants have displayed high FC levels, with large variation. We sought to determine what factors might affect FC levels in children <6months old. MethodsWe recruited 133 healthy infants aged 0–6months from four Korean day care centers. Stool samples were analyzed by immunosorbent assay. All infants completed a questionnaire related to clinical characteristics including birth and feeding history. ResultsThe mean FC concentration of all of participants was 237.40μg/g (range 11.5–1330.6μg/g). FC levels between 0 and 6months reduced with increasing age and the differences were statistically significant. The mean FC value according to feeding mode was 354.67μg/g for those fed breast milk and 149.44μg/g for those fed formula milk (p<0.001). Mean FC values were 319.69μg/g vs. 130.97μg/g for normal spontaneous vaginal delivery (NSVD) vs. caesarean section births, respectively (p<0.001). In addition, delivery mode affected the FC level at 0–6months regardless of feeding mode. ConclusionThe FC levels of infants aged 0–6months reduced with age and were higher than the normal levels observed in healthy older infants. The FC value at <7months was higher in infants who were fed breast milk and born by NSVD.

Genetic diversity and population structure of Korean wild soybean (Glycine soja Sieb. and Zucc.) inferred from microsatellite markers

Korea is considered one of the centers of genetic diversity for cultivated as well as wild soybeans. Natural habitats of wild soybeans are distributed across the Korean mainland and the islands surrounding the Korean peninsula. In this study, the genetic diversity of 100 mainland Korean wild soybean accessions was evaluated by using 42 simple sequence repeat markers covering 17 soybean chromosomes. All analyzed loci were polymorphic and a total of 114 alleles were found. The observed average genetic diversity was low (0.4). The results showed that the 100 selected accessions did not exactly follow the geographical distribution. These results were further confirmed by the phylogeny inferred from five morphological characteristics (i.e., leaf shape, leaf area, plant shape, seed area, and 100-seed weight). Together, the genetic and morphological evaluations suggested conclusively that the selected population did not follow the geographical distribution pattern. The present study could provide useful information for the ex situ conservation and exploitation of wild soybean accessions in soybean improvement stratagems, and will aid in further understanding about the phylogeography of the species in the Korean center of diversity.

한국 신장이식 대기자의 심리사회적 평가 및 영향 요인

Purpose: The purpose of this study was to assess the psychosocial status of candidates for deceased donor kidney transplantation (DDKT) in South Korea and identify factors associated with high-risk psychosocial status. Methods: The descriptive cross-sectional design included application of a standardized transplantation-specific assessment tool, the Psychosocial Assessment Candidacy Transplantation (PACT) instrument, and review of candidates’ medical records. A total of 157 patients awaiting DDKT were recruited from a Korean organ transplantation center. The collected data were analyzed using descriptive statistics and binary logistic regression. Candidates were divided into high- and low-psychosocial risk groups using 3 as the cutoff point of PACT. Results: The mean score for the PACT final rating was 2.10, and the lowest average subscale score was 2.30 for understanding the processes of transplantation and follow up. Poor physical candidacy, especially due to comorbidities, and older age were associated with high psychosocial risk. Conclusion: The results of this study showed that the psychosocial status of Korean DDKT candidates was problematic. Development of systematic management programs for effective clinical strategies in the care of candidates is crucial to maintain their desirable psychosocial status in case of an emergency DDKT operation and improve post-transplantation outcomes. Continuous education is absolutely necessary to enhance understanding of the transplantation process for high-risk psychosocial candidates. Additionally, nurses and transplantation professionals should screen candidates with high-risk psychosocial status early in the process using transplantation-specific assessment tools and provide intensive interventions, particularly for poor physical candidacy patients and older candidates. Key Words: Kidney transplantation; Waiting lists; Psychology; Nursing assessments 국문주요어: ì‹ ìž¥ì´ì‹, 대기자, ì‹¬ë¦¬ì‚¬íšŒì  요인, ê°„í˜¸ì‚¬ì •

Safety and efficacy of tenofovir in chronic hepatitis B-related decompensated cirrhosis

AIMTo evaluate the safety and efficacy of tenofovir disoproxil fumarate (TDF) as a first-line therapy in decompensated liver disease.METHODSWe enrolled 174 chronic hepatitis B-related liver cirrhosis patients treated with 300 mg/d TDF at six Korean centers. Of the 174 cirrhosis patients, 57 were assigned to the decompensated cirrhosis group and 117 were assigned to the compensated cirrhosis group. We followed the patients for 12 mo and evaluated clinical outcomes, including biochemical, virological, and serological responses. We also evaluated changes in hepatic and renal function and compared the decompensated and compensated cirrhosis groups.RESULTSThe 1-year complete virological response (CVR) and Hepatitis B e antigen (HBeAg) seroconversion were seen in 70.2% and 14.2% in the decompensated cirrhosis group, respectively. The rates of HBeAg seroconversion/loss and ALT normalization at month 12 were similar in both groups. TDF treatment was also effective for decreasing the level of hepatitis B virus (HBV) DNA in both groups, but CVR was higher in the compensated group (88.9% vs 70.2%, P = 0.005). Tenofovir treatment for 12 mo resulted in improved Child-Turcotte-Pugh (CTP) and model for end-stage liver disease (MELD) scores in decompensated group (P < 0.001). Of the 57 decompensated patients, 39 (68.4%) achieved CTP class A and 27 (49.1%) showed improvement in the CTP score of 2 points after 12 mo of TDF. The observed rate of confirmed 0.5 mg/dL increases in serum levels of creatinine in the decompensated and compensated cirrhosis group were 7.0% and 2.5%, respectively (P < 1.000).CONCLUSIONTDF therapy in decompensated cirrhosis patients was effective for decreasing HBV DNA levels and improving hepatic function with relatively lower CVR than in compensated cirrhosis. Thus, physicians should carefully monitor not only renal function but also treatment responses when using TDF in decompensated cirrhosis patients.