Factors contributing to the stigma of epilepsy

      Summary

      Purpose:

      To evaluate the factors, including personality and coping styles, likely to be influential in enhancing the social stigma of epilepsy.

      Methods:

      Data were collected from 400 adults with epilepsy recruited from 10 epilepsy centers in Korea. Clinical information about seizures was obtained by neurologists, and other information was collected from self-completed questionnaires, including those measuring stigma scales.

      Results:

      Thirty-one percent of people with epilepsy felt stigmatized by their condition and in 9% of these the stigma was severe. Multivariate analysis identified experiences of actual discrimination from society, introverted personality, problem solving controllability, and emotional subscale of QOLIE-31 as being independently associated with the social stigma of epilepsy.

      Conclusions:

      Episodes of discrimination, coping strategies, and personality may be important in feeling the stigma of epilepsy. These findings may provide a basis for further studies to clarify the causative factors generating the stigma of epilepsy.

      Keywords

      Introduction

      Stigma has been conceptualized as “an attribute that is deeply discrediting”.
      • Goffman E.
      Stigma: notes on the management of spoiled identity.
      The stigmatizing nature of epilepsy and its associated psychological distress have been reported to have a significant impact on the quality of life of individuals with epilepsy; however, the degree of the felt stigma and its consequences are not equal in every individual with epilepsy.
      • Schneider J.W.
      • Conrad P.
      Medical and sociological typologies: the case of epilepsy.
      The factors influencing the development and maintenance of feelings of stigma are not fully known.
      • Jacoby A.
      Felt versus enacted stigma: a concept revisited. Evidence from a study of people with epilepsy in remission.
      • Baker G.A.
      • Brooks J.
      • Buck D.
      • Jacoby A.
      The stigma of epilepsy: a European perspective.
      Seizure frequency is considered a factor significantly related to felt stigma.
      • Jacoby A.
      • Baker G.A.
      • Steen N.
      • Potts P.
      • Chadwick D.W.
      The clinical course of epilepsy and its psychosocial correlates: findings from a U.K. community study.
      Medical Research Council Antiepileptic Drug Withdrawal Study Group
      Prognostic index for recurrence of seizures after remission of epilepsy.
      • Jacoby A.
      Epilepsy and the quality of everyday life. Findings from a study of people with well-controlled epilepsy.
      People with well-controlled seizures were less likely to express feelings of stigma if they had been seizure-free for 6 months, but even individuals with infrequent seizures had higher scores on the stigma scale compared with seizure-free patients and 14% of those who were seizure-free for at least 2 years reported feelings of stigma.
      • Jacoby A.
      Felt versus enacted stigma: a concept revisited. Evidence from a study of people with epilepsy in remission.
      A recent multivariate analysis showed that impact of epilepsy, age of onset, country of origin, feelings about life, and injuries associated with epilepsy were significantly related to scores on the stigma scale, but seizure frequency was not.
      • Baker G.A.
      • Brooks J.
      • Buck D.
      • Jacoby A.
      The stigma of epilepsy: a European perspective.
      The methods by which individuals with epilepsy cope with their disorder are complex and as yet relatively under-researched.
      • Scambler G.
      Coping with epilepsy.
      An individual's personality and problem solving style, which have not been evaluated with regard to the stigma of epilepsy, may have importance in developing and/or maintaining the felt stigma. Stable personality traits are important, and a person with a more introverted personality may be more vulnerable to trivial emotional stress and may experience more negative effects than a more extraverted individual.
      • Eysenck H.J.
      The biological basis of personality.
      • Eysenck H.J.
      • Eysenck M.W.
      Personality and individual differences.
      In addition, problems have been found to be strongly related to psychological symptomatology,
      • Nezu A.M.
      • Ronan G.F.
      Life stress, current problems, problem solving, and depressive symptoms: an integrative model.
      in that daily problems can lead to psychological distress and poor quality of life.
      • Nezu A.
      • Nezu C.M.
      • Friedman S.H.
      • Faddis S.
      • Houts P.S.
      A problem-solving approach: helping cancer patients cope.
      These problems may have a different degree of impact depending on the problem solving style of each individual. We hypothesized that persons with a predisposition to stress vulnerability would be more affected by trivial stress and would be less able to appropriately cope with their chronic illness. The purpose of our study was to investigate whether an individual's personality or problem solving style was related to the felt stigma of epilepsy.

      Methods

       Subjects

      Individuals aged 19–65 years, who had been diagnosed with any type of epilepsy for a minimum of one year, and who were seizure-free for the previous 24 h, were recruited from 10 epilepsy centers in Korea. Subjects were excluded if they had focal neurological deficits, progressive neurological disorders, or active psychiatric or medical disorders that would impair their judgment or have a negative impact on their quality of life beyond the effects caused by epilepsy. Subjects were also excluded if their regimen of antiepileptic drugs had been changed during the past month, if they had brain surgery during the past year, or if they used a concomitant medication with central nervous system effects. Written informed consent was obtained from all subjects.

       Data collection

      All subjects were asked to fill out questionnaires on the day they visited their neurologist at the outpatient clinic. Those who agreed to participate were seated by themselves or with accompanying relatives in a quiet room. Subjects rated the questionnaires in person, and the completed questionnaires were checked for missing values. Demographic and clinical data were collected by interviews and from information in their medical files. Seizure-related variables included age at seizure onset, epilepsy classification, duration of epilepsy, seizure frequency, number of antiepileptic drugs, and history of seizure-related injuries (burn, head trauma, teeth injury, and others) in the previous year.

       Questionnaires

       Stigma scale

      Felt stigma was assessed using a scale developed originally to measure patients’ perception of the stigma of stroke and that was subsequently adapted for epilepsy.
      • Jacoby A.
      Felt versus enacted stigma: a concept revisited. Evidence from a study of people with epilepsy in remission.
      Each of the three items requires a simple yes/no response. Subjects were asked to say whether, because of their epilepsy, they felt that other people were uncomfortable with them, treated them as inferior, and preferred to avoid them. Patients scored one for each item with which they agreed. Their overall score was the sum of their positive responses. Thus, the higher the score is, the patient is more likely to feel stigmatised.

       Self-esteem scale

      We administered the Rosenberg Self-esteem Scale, which is composed of 10 items, 5 positive and 5 negative and scored on a 4-point Likert scale.
      • Rosenberg M.
      Society and the adolescent self-image.
      The Cronbach alpha coefficient of this scale was 0.83.

       Eysenck Personality Questionnaire

      We used the Korean version of the Eysenck Personality Questionnaire

      Eysenck HJ, Eysenck SBG. Manual of the Eysenck Personality Questionnaire (Junior and adult). Hodder & Stroughton; 1975.

      short-form, which is composed of 48 items, consisting of four scales (psychoticism, extraversion-introversion, neuroticism, and lie) with 12 items each. The Cronbach alpha coefficients for these four scales were 0.67, 0.81, 0.84, and 0.81, respectively.

       Problem solving style

      We used the Korean version of the Problem Solving Style,
      • Cassidy T.
      • Long C.
      Problem-solving style, stress and psychological illness: development of a multifactorial measure.
      which is composed of 24 items in six scales, helplessness (alpha = 0.73), problem-solving control (alpha = 0.58), creative style (alpha = 0.73), problem-solving confidence (alpha = 0.72), avoidance style (alpha = 0.62), and approach style (alpha = 0.71).

       Hospital anxiety and depression scale

      This scale consists of 14 items, 7 related to anxiety and 7 related to depression. Each item has a 4-point response set, ranging from 0 for no distress to 3 for significant distress.
      • Zigmond A.S.
      • Snaith R.P.
      The hospital anxiety and depression scale.
      Individuals are identified as not clinically depressed/anxious (total score on each sub-scale < 8), borderline depressed/anxious (score 8–10), or clinically depressed/anxious (score ≥ 11). The Cronbach alpha coefficients were 0.82 for anxiety and 0.77 for depression.

       The QOLIE-31

      We completed the adaptation of the QOLIE-31
      • Cramer J.A.
      • Perrine K.
      • Devinsky O.
      • Bryant-Comstock L.
      • Meador K.
      • Hermann B.
      Development and cross-cultural translations of a 31-item quality of life in epilepsy inventory..
      into a Korean version,
      • Yoo H.J.
      • Lee S.A.
      • Heo K.
      • Kang J.K.
      • Ko R.W.
      • Yi S.D.
      • et al.
      The reliability and validity of Korean QOLIE-31 in patients with epilepsy.
      which consisted of subscales for seizure worry (alpha = 0.86), overall QOL (alpha = 0.69), emotional well-being (alpha = 0.68), energy-fatigue (alpha = 0.62), cognitive functioning (alpha = 0.85), medication effects (alpha = 0.82), and social functioning (alpha = 0.81). Higher scores in the QOLIE-31 are indicative of a better QOL.

       Questionnaire for episodes of discrimination against people with epilepsy

      Subjects were asked to say whether, because of their epilepsy, they experienced actual discrimination in their daily life from other people. The questionnaire consisted of 10 items, three job-related (getting a job, being treated unfairly at work, and getting fired), 3 related to discrimination by members of the opposite sex (being rejected from dating, getting separated or divorced, or being treated unfairly by a spouse), and 4 related to friends, neighborhood acquaintances, and close relatives (being shunned or avoided, being refused a meeting, being broken off from a meeting, and being insulted). Each item required a simple yes/no response. Subjects scored one for each item with which they agreed, and their overall score was the sum of their positive responses. Higher scores indicate more episodes of discrimination experienced by each subject.

       Statistical analyses

      Data were analyzed by SPSS version 10.0. All independent variables were correlated with the dependent variable: the presence or absence of stigma of epilepsy as assessed by the stigma scale. The chi-square test was used for univariate analysis of these categorical variables: gender, seizure remission, seizure frequency, type of epilepsy, nocturnal tendency of seizure recurrence (more than 90% of seizures during sleep), medical treatment (monotherapy or polytherapy), history of generalized tonic-clonic seizures, history of seizure-related injuries, level of education, marital status, economic status, and employment. Student's T-test and the Pearson correlation test were used to evaluate these continuous variables: age at seizure onset, age at surgery, duration of epilepsy, episodes of actual discrimination, and scores on the QOLIE-31, Eysenck Personality Questionnaire, Problem Solving Style Questionnaire, Self-esteem Scale, and Hospital Anxiety and Depression Scale. Multivariate analysis using logistic regression was performed on variables that were significant (p < 0.05) in univariate analysis.

      Results

       Subject characteristics

      Demographic and clinical characteristics of the 400 subjects in the study are shown in Table 1. There were 204 men and 196 women, of mean age 32.9 years (range 19–64 years). About 89% of patients had symptomatic or cryptogenic partial epilepsy. About 20% of the participants had been seizure free for at least 2 years, with 14% having fewer than one seizure per year, 45% having 1–11 seizures per year, and the remaining 21% having one or more seizures per month. About 43% had generalized seizures in the previous 2 years, and about 9% had sustained injuries directly associated with their seizures. With regard to antiepileptic drug regimen, 55.5% were on polytherapy and 44.5% were on monotherapy.
      Table 1Demographic and clinical features of 400 Korean epileptics.
      Gender (M/F)204/196
      Age (year)32.9 (19–64)
      Age at onset (year)19.7 (1–61)
      Duration (year)13.2 (1–44)
      Medical treatment
       Monotherapy222 (55.5%)
       Polytherapy178 (44.5%)
      Epilepsy type
       Idiopathic generalized34 (8.5%)
       Crypto/symptomatic partial355 (88.8%)
       Undetermined and others11 (2.8%)
      Seizure frequency
       Remission81 (20.3%)
       <1/year56 (14.0%)
       1–11/year180 (45.0%)
       ≥1/month83 (20.8%)
      Generalized tonic clonic seizures in the last 2 years
       Presence173 (43.3%)
       Absence224 (56.0%)
       Missing value3 (0.8%)
      More than 90% of seizures during sleep
       Yes49 (12.3%)
       No344 (86.0%)
       Missing value7 (1.8%)
      Injuries in the last year
       Yes35 (8.8%)
       No359 (89.8%)
       Missing value6 (1.5%)
      Marital status
       Married179 (44.8%)
       Unmarried188 (47.0%)
       Others21 (5.3%)
       Missing value12 (3.0%)
      Employment status
       Employed174 (43.5%)
       Unemployed75 (18.6%)
       Housewife/student141 (35.3%)
       Missing value10 (2.5%)
      Education status
       Primary or middle school88 (22.0%)
       High school177 (44.3%)
       University134 (33.5%)
       Missing value1 (0.3%)
      Economic status
       High43 (10.8%)
       Middle205 (51.3%)
       Low130 (32.5%)
       Missing value22 (5.5%)

       Felt stigma of epilepsy

      About 31% of the study participants reported feelings of stigma, with 9% answering “yes” to all three items, indicating that they felt highly stigmatized by their disorder (Table 2).
      Table 2Social stigma of epilepsy and its relationship to categorical variables.
      Scores on stigma scalep value
      0123
      Total patients69.2
      Data in table represent the calculated percentages on numbers in brackets.
      13.38.59.0
      Gender
       Male70.112.38.39.3
       Female68.414.38.78.70.790
      Seizure remission
       Yes79.012.34.93.7
       No66.813.59.410.30.046
      Seizure frequency
       <1/year77.413.15.83.6
       1–11/year68.313.97.810.0
       >1/month57.812.014.515.70.009
      Generalized tonic clonic seizures in the last 2 years
       Yes62.413.310.413.9
       No74.612.97.15.40.013
      Timing of seizure recurrence
       Nocturnal75.514.36.14.1
       Not nocturnal68.313.48.49.90.392
      Treatment
       Monotherapy72.513.18.16.3
       Polytherapy65.213.59.012.40.140
      History of injuries in the last year
       Yes31.414.314.340.0
       No73.012.88.16.10.000
      Epilepsy type
       Simple partial73.67.511.37.5
       Complex partial68.114.58.98.5
       Idiopathic generalized64.717.65.911.80.643
      Discrimination
       Experienced52.914.814.218.1
       Not experienced80.112.14.92.90.000
      Education level
       Primary/middle school53.412.518.215.9
       High school73.414.13.49.0
       University73.912.79.04.50.001
      Economic status
       High79.19.39.32.3
       Middle72.211.78.87.3
       Low62.315.47.714.60.057
      Marital status
       Single68.611.211.78.5
       Married72.614.55.67.30.467
      Employment status
       Unemployed61.312.09.317.3
       Employed74.110.99.25.70.060
      a Data in table represent the calculated percentages on numbers in brackets.
      Univariate analyses showed that several variables were significantly associated with the presence of stigma of epilepsy, including high seizure frequency (p < 0.01), a history of generalized tonic-clonic seizures (p < 0.05), low level of education (p = 0.001), and a history of seizure-related injuries (p < 0.001). Higher scores on the stigma scale were significantly correlated with longer duration of epilepsy (r = 0.144, p < 0.01), more episodes of discrimination (r = 0.444, p = 0.000), lower scores on the QOLIE-31 (r = −0.408, p = 0.000), more introverted (r = −0.196, p = 0.000) or more neurotic (r = 0.288, p = 0.000) personality, a greater degree of helplessness (r = 0.201, p = 0.000) or a lower degree of problem-solving control (r = −0.275, p = 0.000) and problem-solving confidence (r = −0.141, p = 0.000), higher degrees of anxiety (r = 0.278, p = 0.000) and depression (r = 0.300, p = 0.000), and a lower degree of self-esteem (r = −0.312, p = 0.000) (Table 2, Table 3). Other variables were not significant, including sex, age, age at onset, type of medical treatment, type of epilepsy, timing of seizure occurrence, economic status, marital status, employment status, the psychoticism and lie subscales on the Eysenck Personality Questionnaire, and problem-solving creative, avoidance, or approach style.
      Table 3Relationships of social stigma of epilepsy to various parameters.
      Not stigmatisedStigmatisedp value
      MeanS.D.MeanS.D.
      Age (year)32.69.433.510.00.375
      Age at onset (year)20.110.318.710.10.209
      Duration of epilepsy (year)12.68.714.710.30.050
      Number of AEDs1.40.51.50.50.114
      Total score on QOLIE-3163.115.849.718.00.000
       Seizure worry63.315.849.718.00.000
       Overall QOL58.816.049.221.20.000
       Emotional63.218.053.919.10.000
       Energy/fatigue50.119.940.519.50.000
       Cognitive74.419.661.422.90.000
       Medication effects61.428.849.026.90.000
       Social68.223.250.525.40.000
      Eysenck Personality Scale-Adult
       Psychoticism1.81.71.91.70.557
       Introversion/extraversion5.83.24.63.20.000
       Neuroticism5.83.57.83.10.000
       Lie6.62.86.42.90.541
      Problem solving style
       Helplessness9.82.810.83.20.004
       Controllable12.12.710.53.10.000
       Creative12.52.912.63.30.746
       Confidence12.42.611.62.80.007
       Avoidance10.12.810.23.00.877
       Approach13.02.712.43.10.051
      Hospital Anxiety and Depression Scale
       Anxiety8.03.810.04.00.000
       Depression5.33.47.43.90.000
      Self-esteem Scale28.04.225.64.40.000
      Degree of discrimination0.81.42.02.30.00
      S.D., standard deviation; AEDs, antiepileptic drugs; QOL, quality of life.
      Logistic regression analysis revealed that several factors were independently associated with feelings of stigma, including experience of actual discrimination (p = 0.005; odds ratio (OR) = 1.3 [95% CI = 1.1–1.6]); introverted personality (p < 0.05; OR = 0.9 [95% CI = 0.8–1.0]); problem solving controllability (p < 0.05; OR = 0.9 [95% CI = 0.8–1.0]); and emotional subscale of the QOLIE-31 (p < 0.05; OR = 1.0 [95% CI = 1.0–1.1]) (Table 4).
      Table 4Multivariate analysis of significant factors associated with social stigma of epilepsy.
      FactorsOdds ratio95% CIp value
      Discrimination from society1.311.09–1.590.005
      Introverted personality0.890.80–0.980.024
      Problem solving control0.870.76–0.990.038
      Emotional subscale of QOLIE-311.031.00–1.070.046
      CI, confidence interval.

      Discussion

      In our study, 31% of the participants reported feeling stigmatized by their epilepsy, 9% of them highly so. This contrasts with the findings of a recent European study,
      • Baker G.A.
      • Brooks J.
      • Buck D.
      • Jacoby A.
      The stigma of epilepsy: a European perspective.
      which reported that 51% of participants reported feeling stigmatized, 18% highly so. Significant cross-cultural differences were noted between levels of stigma reported by people with epilepsy across Europe, with Spanish respondents reporting the lowest levels, and French respondents the highest. Our result of 31% was similar to that of Spanish respondents. We found this percentage to be unexpectedly low, based on the observation that stigmatization and psychological problems for people with epilepsy are more common in developing countries
      • Van Ree F.
      Epilepsy in Varanasi (India).
      • Walker A.E.
      Current status of epilepsy in some developing countries.
      and based on the more negative public attitude toward epilepsy in Korean society
      • Lee Y.
      • Kim S.S.
      • Lim J.G.
      • Yi S.D.
      • Park Y.C.
      Knowledge and attitude toward epilepsy in some Taegu-kyungbook residents.
      • Park S.J.
      • Jeong X.K.
      • Kim M.K.
      • Cho K.H.
      • Choi J.S.
      • Kim S.J.
      Public attitude toward epilepsy in Chonnam rural areas—baseline data for interventional trial.
      compared with Western societies.
      The RESt-1 Group
      Social aspects of epilepsy in the adult in seven European countries.
      • Canger R.
      • Cornaggia C.
      Public attitudes toward epilepsy in Italy: results of a survey and comparison with U.S.A. and West German data.
      The reason for the low level of stigmatization observed here need to be explored.
      We found that 21% of individuals with epilepsy in remission for a minimum of two years reported feelings of stigma, suggesting that factors other than those related to seizures are important in generating and maintaining the stigma of epilepsy. Our logistic regression analyses revealed that experiences of actual discrimination, introverted personality, problem solving controllability, and emotional subscale of QOLIE-31 were independently correlated with feelings of stigma.
      About 44% of the participants in our study reported having suffered some form of discrimination due to epilepsy, and about 50% of those who had experience of discrimination said they felt stigmatized. The proportion who felt highly stigmatized was six times higher in those who experienced discrimination than in those who did not. In proposing a sociopsychological model for the stigma of epilepsy, employment discrimination was emphasized as a cause of stigma.
      • Ryan R.
      • Kempner K.
      • Emlen A.C.
      The stigma of epilepsy as a self-concept.
      In contrast, felt stigma of epilepsy was found to have no direct relationship to episodes of discrimination (enacted stigma) against people with epilepsy.
      • Scambler G.
      • Hopkins A.
      Being epileptic: coming to terms with stigma.
      In Scambler and Hopkins’ study,
      • Scambler G.
      • Hopkins A.
      Being epileptic: coming to terms with stigma.
      felt stigma was far more prevalent than enacted stigma. The authors commented that the simple experience of being discriminated did not necessarily make individual patients feel shameful that they have epilepsy. This was supported by findings that only 3% of unemployed individuals with epilepsy cited epilepsy as the cause, whereas 32% of subjects believed that their epilepsy made it more difficult for them to get a job.
      • Jacoby A.
      Felt versus enacted stigma: a concept revisited. Evidence from a study of people with epilepsy in remission.
      These inconsistent results regarding the relationship between felt and enacted stigma may be related to significant cross-cultural differences in public perceptions and attitudes towards epilepsy and people with epilepsy. The perception of the general public towards epilepsy has been much more negative in Korean society
      • Lee Y.
      • Kim S.S.
      • Lim J.G.
      • Yi S.D.
      • Park Y.C.
      Knowledge and attitude toward epilepsy in some Taegu-kyungbook residents.
      • Park S.J.
      • Jeong X.K.
      • Kim M.K.
      • Cho K.H.
      • Choi J.S.
      • Kim S.J.
      Public attitude toward epilepsy in Chonnam rural areas—baseline data for interventional trial.
      than in Western societies.
      The RESt-1 Group
      Social aspects of epilepsy in the adult in seven European countries.
      • Canger R.
      • Cornaggia C.
      Public attitudes toward epilepsy in Italy: results of a survey and comparison with U.S.A. and West German data.
      About 15% of the participants in our study reported having been refused a job because of their epilepsy. When they revealed their epilepsy to their prospective employers, however, this figure rose to 55%. In a 1996 survey in Korea,
      • Park S.J.
      • Jeong X.K.
      • Kim M.K.
      • Cho K.H.
      • Choi J.S.
      • Kim S.J.
      Public attitude toward epilepsy in Chonnam rural areas—baseline data for interventional trial.
      58% of the members of the general public surveyed said that individuals with epilepsy should not be employed as would a normal person. Consequently, most Koreans with epilepsy have tried to conceal their condition. We found that about 75% of the individuals in our survey never disclosed their disease when applying for a job.
      People with epilepsy are generally considered to be at greater risk of psychopathology than those without the disorder. Increased levels of anxiety and depression
      • Jacoby A.
      Felt versus enacted stigma: a concept revisited. Evidence from a study of people with epilepsy in remission.
      • Jacoby A.
      • Baker G.A.
      • Steen N.
      • Potts P.
      • Chadwick D.W.
      The clinical course of epilepsy and its psychosocial correlates: findings from a U.K. community study.
      • Betts T.A.
      Depression, anxiety, and epilepsy.
      and poor self-esteem
      • Levin R.
      • Banks S.
      • Berg B.
      Psychosocial dimensions of epilepsy: a review of the literature.
      • Collings J.A.
      Psychosocial well-being and epilepsy: an empirical study.
      have been reported to be common psychological problems in people with epilepsy. This psychological dysfunction was also known to be associated with the stigma of epilepsy. This is in good agreement with our results of univariate analyses. Also the emotional subscale of the QOLIE-31, which represented the psychological domain, was independently associated with feelings of stigma in our multivariate analysis. Although it is still not known whether feelings of stigma due to epilepsy are precursors to the development of additional psychosocial problems,
      • Arnston P.
      • Droge D.
      • Norton R.
      • Murray E.
      The perceived psychosocial consequences of having epilepsy.
      • Lennox W.G.
      • Lennox M.A.
      Epilepsy and related disorders.
      it is evident that the psychological dysfunction in people with epilepsy has the significant impact on their quality of life.
      Our study population was taken from epilepsy centers throughout Korea and did not include people with epilepsy spread throughout the population. Due to this sampling bias, some of our data, including those related to the prevalence of the stigma of epilepsy, cannot be generalized to people with epilepsy throughout Korea. Our results regarding the factors likely to be influential in the stigma of epilepsy, which was the main focus of this study, may be generally applicable to people with epilepsy, although these results should be interpreted with some caution.

      Acknowledgment

      The study was financially supported by a grant of Janssen Korea Limited.

      Appendix A.

      The Korean QoL in Epilepsy Study Group comprised the following: Sang-Ahm Lee, M.D. (P.I.). Hee-Jung Yoo, Ph.D.: University of Ulsan College of Medicine (Seoul); Kyoung Heo, M.D., Sung-Soo Lee, M.D., and Byung -In Lee, M.D.: Yonsei University College of Medicine (Seoul); Hyung-Kook Park, M.D.: Soonchunhyang University College of Medicine (Chunan); Dong-Jin Shin, M.D.: Gachon Medical School, Gil Medical Center (Incheon); Hong-Ki Song, M.D.: Hallym University College of Medicine (Seoul); Won-Young Jung, M.D.: Chosun University Medical College (Gwangju); Oh-Young Kwon, M.D.: Gyeongsang National University College of Medicine (Jinju); Yo-Sik Kim, M.D.: Wonkwang University School of Medicine (Iksan); Sung-Eun Kim, M.D.: Inje University Paik Hospital (Pusan).

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