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Sowah LA, Smeaton L, Brates I, Bhattacharya D, Linas B, Kreter B, Wagner-Cardoso S, Solomon S, Sulkowski M, Robbins GK. Perspectives on Adherence From the ACTG 5360 MINMON Trial: A Minimum Monitoring Approach With 12 Weeks of Sofosbuvir/Velpatasvir in Chronic Hepatitis C Treatment. Clin Infect Dis 2023; 76:1959-1968. [PMID: 36694361 PMCID: PMC10249990 DOI: 10.1093/cid/ciad034] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 01/10/2023] [Accepted: 01/19/2023] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND With the advent of efficacious oral direct-acting antivirals (DAAs) for hepatitis C virus (HCV), identification of characteristics associated with adherence is critical to treatment success. We examined correlates of sub-optimal adherence to HCV therapy in a single-arm, multinational, clinical trial. METHODS ACTG A5360 enrolled HCV treatment-naive persons without decompensated cirrhosis from 5 countries. All participants received a 12-weeks course of sofosbuvir/velpatasvir at entry. In-person visits occurred at initiation and week 24, sustained virologic response (SVR) assessment. Adherence at week 4 was collected remotely and was dichotomized optimal (100%, no missed doses) versus sub-optimal (<100%). Correlates of sub-optimal adherence were explored using logistic regression. RESULTS In total, 400 participants enrolled; 399 initiated treatment; 395/397 (99%) reported completing at week 24. Median age was 47 years with 35% female. Among the 368 reporting optimal adherence at week 4 SVR was 96.5% (95% confidence interval [CI] [94.1%, 97.9%]) vs 77.8% (95% CI [59.2%, 89.4%]) P value < .001. In the multivariate model age <30 years and being a US participant were independently associated with early sub-optimal adherence. Participants <30 years were 7.1 times more likely to have early sub-optimal adherence compared to their older counterparts. CONCLUSIONS Self-reported optimal adherence at week 4 was associated with SVR. Early self-reported adherence could be used to identify those at higher risk of treatment failure and may benefit from additional support. Younger individuals <30 years may also be prioritized for additional adherence support. Clinical Trials Registration. NCT03512210.
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Affiliation(s)
- Leonard A Sowah
- Therapeutic Research Program, Division of AIDS, National Institute of Allergy and Infectious Diseases, Rockville, Maryland, USA
| | - Laura Smeaton
- Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Irena Brates
- Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Debika Bhattacharya
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Benjamin Linas
- Boston University School of Medicine, Boston, Massachusetts, USA
| | - Bruce Kreter
- Gilead Sciences Inc, Foster City, California, USA
| | - Sandra Wagner-Cardoso
- Instituto Nacional de Infectologia—Laboratorio de Pesquisa Clínica em HIV/AIDS, Rio de Janeiro, Brazil
| | - Sunil Solomon
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mark Sulkowski
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Gregory K Robbins
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Haque LY, Fiellin DA, Tate JP, Esserman D, Bhattacharya D, Butt AA, Crystal S, Edelman EJ, Gordon AJ, Lim JK, Tetrault JM, Williams EC, Bryant K, Cartwright EJ, Rentsch CT, Justice AC, Lo Re V, McGinnis KA. Association Between Alcohol Use Disorder and Receipt of Direct-Acting Antiviral Hepatitis C Virus Treatment. JAMA Netw Open 2022; 5:e2246604. [PMID: 36515952 PMCID: PMC9856353 DOI: 10.1001/jamanetworkopen.2022.46604] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 10/19/2022] [Indexed: 12/15/2022] Open
Abstract
Importance Direct-acting antiviral (DAA) treatment for hepatitis C virus (HCV) infection is associated with lower mortality and is effective in individuals with alcohol use disorder (AUD). However, despite recommendations, patients with AUD may be less likely to receive DAAs. Objective To assess the association between alcohol use and receipt of DAA treatment among patients with HCV within the Veterans Health Administration (VHA). Design, Setting, and Participants This cohort study included 133 753 patients with HCV born from 1945 to 1965 who had completed the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) questionnaire and had at least 1 outpatient visit in the VHA from January 1, 2014, through May 31, 2017, with maximal follow-up of 3 years until May 31, 2020; DAA receipt; or death, whichever occurred first. Exposures Alcohol use categories generated using responses to the AUDIT-C questionnaire and International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnoses: current AUD, abstinent with AUD history, at-risk drinking, lower-risk drinking, and abstinent without AUD history. Demographic, other clinical, and pharmacy data were also collected. Main Outcomes and Measures Associations between alcohol use categories and DAA receipt within 1 and 3 years estimated using Cox proportional hazards regression stratified by calendar year. Results Of 133 753 patients (130 103 men [97%]; mean [SD] age, 60.6 [4.5] years; and 73 493 White patients [55%]), 38% had current AUD, 12% were abstinent with a history of AUD, 6% reported at-risk drinking, 14% reported lower-risk drinking, and 30% were abstinent without a history of AUD. Receipt of DAA treatment within 1 year was 7%, 33%, 53%, and 56% for patients entering the cohort in 2014, 2015, 2016, and 2017, respectively. For patients entering in 2014, those with current AUD (hazard ratio [HR], 0.72 [95%, CI, 0.66-0.77]) or who were abstinent with an AUD history (HR, 0.91 [95% CI, 0.84-1.00]) were less likely to receive DAA treatment within 1 year compared with patients with lower-risk drinking. For those entering in 2015-2017, patients with current AUD (HR, 0.75 [95% CI, 0.70-0.81]) and those who were abstinent with an AUD history (HR, 0.76 [95% CI, 0.68-0.86]) were less likely to receive DAA treatment within 1 year compared with patients with lower-risk drinking. Conclusions and Relevance This cohort study suggests that individuals with AUD, regardless of abstinence, were less likely to receive DAA treatment. Improved access to DAA treatment for persons with AUD is needed.
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Affiliation(s)
- Lamia Y. Haque
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
| | - David A. Fiellin
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Janet P. Tate
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Veterans Affairs Connecticut Health Care System, West Haven
| | - Denise Esserman
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Debika Bhattacharya
- Department of Internal Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles
- Veterans Affairs Greater Los Angeles Health Care System, Los Angeles, California
| | - Adeel A. Butt
- Department of Medicine, Weill Cornell Medicine, New York, New York
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Stephen Crystal
- Center for Health Services Research, Rutgers University, New Brunswick, New Jersey
| | - E. Jennifer Edelman
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, Connecticut
| | - Adam J. Gordon
- Informatics, Decision-Enhancement, and Analytic Sciences Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy, Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Joseph K. Lim
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Jeanette M. Tetrault
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Emily C. Williams
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington, Seattle
| | - Kendall Bryant
- HIV/AIDS and Alcohol Research Program, National Institute on Alcohol Abuse and Alcoholism, Bethesda, Maryland
| | - Emily J. Cartwright
- Department of Medicine, Emory School of Medicine, Atlanta, Georgia
- Veterans Affairs Atlanta Health Care System, Atlanta, Georgia
| | - Christopher T. Rentsch
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Veterans Affairs Connecticut Health Care System, West Haven
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Amy C. Justice
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
- Veterans Affairs Connecticut Health Care System, West Haven
| | - Vincent Lo Re
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, Philadelphia, Pennsylvania
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, Philadelphia, Pennsylvania
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Côco LT, Silva GF, Romeiro FG, Cerqueira ATDAR. Factors associated with hepatitis C treatment adherence: an integrative review. CIENCIA & SAUDE COLETIVA 2022; 27:1359-1376. [PMID: 35475818 DOI: 10.1590/1413-81232022274.06942021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 05/13/2021] [Indexed: 11/21/2022] Open
Abstract
This integrative review examined factors associated with hepatitis C treatment adherence. The articles included were published in English, Spanish and Portuguese in the Lilacs, Medline, PsycINFO, Web of Science, Scopus and CINAHL databases, between 2000 and 2019. Initially, 540 publications were found and, after applying the study inclusion criteria, 22 articles were selected. Percentage non-adherence to treatment ranged from 12% to 32%. The variables identified as facilitating adherence were: receiving treatment for psychiatric disorders identified during treatment; knowing about medications and disease; receiving less complex treatment with greater likelihood of cure; fewer adverse events; social support; doctor-patient communication; and/or being in relationships. Barriers to adherence identified were: presence of depressive symptoms and other mental disorders; abuse of alcohol and psychoactive substances; education; age; ethnicity; unemployment; not having a steady partner; stigma; distance from health services; and the complexity and adverse effects of treatment. This review identified gaps in research on adherence.
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Affiliation(s)
- Layla Tatiane Côco
- Departamento de Neurologia, Psicologia e Psiquiatria, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista Júlio de Mesquita Filho (UNESP). Av. Prof. Mário Rubens Guimarães Montenegro s/n, Distrito de Rubião Júnior. 18618-970 Botucatu SP Brasil.
| | - Giovanni Faria Silva
- Departamento de Clínica Médica, Faculdade de Medicina de Botucatu, UNESP. Botucatu SP Brasil
| | - Fernando Gomes Romeiro
- Departamento de Clínica Médica, Faculdade de Medicina de Botucatu, UNESP. Botucatu SP Brasil
| | - Ana Teresa de Abreu Ramos Cerqueira
- Departamento de Neurologia, Psicologia e Psiquiatria, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista Júlio de Mesquita Filho (UNESP). Av. Prof. Mário Rubens Guimarães Montenegro s/n, Distrito de Rubião Júnior. 18618-970 Botucatu SP Brasil.
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Evon DM, Kim HP, Edwards A, Carda-Auten J, Reeve BB, Golin CE, Fried MW. "If I Get Cured, My Whole Quality of Life Will Change": Patients' Anticipated and Actualized Benefits Following Cure from Chronic Hepatitis C. Dig Dis Sci 2022; 67:100-120. [PMID: 33528686 PMCID: PMC8326296 DOI: 10.1007/s10620-021-06829-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 01/07/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Patients' motivations for undergoing direct-acting antiviral (DAA) therapy for chronic hepatitis C may include anticipation of treatment benefits not well described in the literature. AIMS Evaluate patients' anticipated and actualized improvements in several domains of functioning before and after viral cure. METHODS Pre-post-study utilizing in-depth interviews with 28 patients prior to, and several months after, DAA therapy. Interviews were audio-recorded, transcribed, coded, and analyzed by two qualitative experts. RESULTS Patients had a median age of 54 years, 43% were male, 57% white, 25% had cirrhosis, and 71% were treated with sofosbuvir/ledipasvir. Pre-treatment, patients hoped for improvements in several domains including psychological, emotional, physical, social, and occupational functioning. After viral cure, increased energy and less fear of transmission were pathways to better quality of life. Psychological and emotional improvements positively affected physical, social, and occupational functioning. Social improvements were due to better mood and motivation, fewer symptoms, and reduced fear of stigma and transmission. Occupational benefits were linked to increased stamina, self-confidence, and less pain, anxiety, and stigma. Reduced fear of stigma had a pervasive impact on all life improvements after cure. Patient characteristics such as the presence of cirrhosis or psychiatric issues influence treatment motivations. Qualitative data correspond with change in pre-post-survey scores. CONCLUSIONS Tremendous hope is placed on the ability of DAA therapy to bring about substantial improvements in life functioning after viral cure. Highly interconnected effects on quality of life worked synergistically through improved physical and psychological well-being. Stakeholders should appreciate the multi-dimensional benefits that viral eradication bestows upon individuals and society.
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Affiliation(s)
- Donna M. Evon
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Burnett-Womack Building CB #7584, Chapel Hill, NC 27599
| | - Hannah P. Kim
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, 130 Mason Farm Road, Bioinformatics Building CB #7080, Chapel Hill, NC 27599
| | - Angela Edwards
- Division of Global Health and Infectious Disease, Department of Medicine, University of North Carolina, 130 Mason Farm Road, Bioinformatics Building, Chapel Hill, NC 27599
| | - Jessica Carda-Auten
- Institute for Global Health and Infectious Diseases, Connected Health Applications and Interventions Core, University of North Carolina, 130 Mason Farm Road, Bioinformatics Building CB #7030, Chapel Hill, NC 27599
| | - Bryce B. Reeve
- Department of Population Health Sciences and Department of Pediatrics, Duke University School of Medicine, 215 Morris Street, Suite 230 DUMC 104023, Durham, NC 27701
| | - Carol E. Golin
- Division of General Medicine and Clinical Epidemiology, Department of Medicine, Department of Health Behaviors, University of North Carolina, 135 Dauer Drive CB #7440, Chapel Hill, NC 27599
| | - Michael W. Fried
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Burnett-Womack Building CB #7584, Chapel Hill, NC 27599
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Aas CF, Vold JH, Skurtveit S, Odsbu I, Chalabianloo F, Økland JM, Leiva RAM, Vickerman P, Johansson KA, Fadnes LT. On the path towards universal coverage of hepatitis C treatment among people receiving opioid agonist therapy (OAT) in Norway: a prospective cohort study from 2013 to 2017. BMJ Open 2020; 10:e036355. [PMID: 32847908 PMCID: PMC7451452 DOI: 10.1136/bmjopen-2019-036355] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES We aimed to calculate cumulative hepatitis C virus (HCV) treatment coverage among individuals enrolled in opioid agonist therapy (OAT) in Norway between 2013 and 2017 and to document the treatment transition to direct-acting antiviral (DAA) agents. Moreover, we aimed to describe adherence to DAAs in the same cohort. DESIGN Prospective cohort, registry data. SETTING Specialist healthcare service (secondary) PARTICIPANTS AND OUTCOMES: This observational study was based on data from The Norwegian Prescription Database. We studied dispensed OAT and HCV treatment annually to calculate the cumulative frequency, and employed secondary sources to calculate prevalence, incidence and HCV treatment coverage from 2013 to 2017, among the OAT population. Factors associated with adherence to DAAs were identified a priori and subject to logistic regression. RESULTS 10 371 individuals were identified with dispensed OAT, 1475 individuals of these were identified with dispensed HCV treatment. Annual HCV treatment coverage increased from 3.5% (95% CI: 3.2 to 4.4) in 2013 to 17% (95% CI: 17 to 20) in 2017, giving a cumulative HCV coverage among OAT patients in Norway of 38.5%. A complete shift to interferon-free treatment regimens occurred, where DAAs accounting for 32% of HCV treatments in 2013 and 99% in 2017. About two-thirds of OAT patients were considered adherent to their DAA regimens across all genotypes. High level of OAT continuity was associated with improved adherence to DAAs (adjusted OR 1.4, 95% CI: 1 to 2, p=0.035). CONCLUSIONS A large increase in HCV treatment coverage attributed by a complete shift to interferon-free regimens among the Norwegian OAT population has been demonstrated. However, treatment coverage is inadmissibly too low and a further substantial scale-up in HCV treatment is required to reach the universal targets of controlling and eliminating the HCV endemic.
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Affiliation(s)
- Christer Frode Aas
- Department of Addiction Medicine, Helse Bergen HF, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Jørn Henrik Vold
- Department of Addiction Medicine, Helse Bergen HF, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Svetlana Skurtveit
- Department of Mental Disorders, Norwegian Institute of Public Health, Oslo, Norway
- Norwegian Centre for Addiction Research, University of Oslo, Oslo, Norway
| | - Ingvild Odsbu
- Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Fatemeh Chalabianloo
- Department of Addiction Medicine, Helse Bergen HF, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Jan Magnus Økland
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | | | - Peter Vickerman
- London School of Hygiene and Tropical Medicine, London, UK
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Kjell Arne Johansson
- Department of Addiction Medicine, Helse Bergen HF, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Lars T Fadnes
- Department of Addiction Medicine, Helse Bergen HF, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
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Yen HH, Su PY, Zeng YH, Liu IL, Huang SP, Hsu YC, Chen YY, Yang CW, Wu SS, Chou KC. Glecaprevir-pibrentasvir for chronic hepatitis C: Comparing treatment effect in patients with and without end-stage renal disease in a real-world setting. PLoS One 2020; 15:e0237582. [PMID: 32790715 PMCID: PMC7425913 DOI: 10.1371/journal.pone.0237582] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 07/29/2020] [Indexed: 12/12/2022] Open
Abstract
Introduction Chronic hepatitis C virus (HCV) infection is increasingly observed in patients with renal disease. With the introduction of glecaprevir/pibrentasvir (GLE/PIB) as a pan-genotype therapy for HCV, treatment efficacy is expected to rise. Materials and methods This retrospective study evaluated the efficacy and safety of GLE/PIB treatment in adults with HCV infection and end-stage renal disease (ESRD). The primary end point was sustained virological response (SVR) observed 12 weeks after completed treatment. Results We enrolled 235 patients, including 44 patients with ESRD. Median age was 60 years, and 48% were males. Twenty-two percent had cirrhosis. HCV genotypes 1 (43%) and 2 (41%) were the most common. The overall SVR rate was 96.6%. Patients with ESRD were older than those without (67.6 years vs 58.3 years, p < 0.001) and trended toward having a higher prevalence of cirrhosis (32% vs 19%, p = 0.071). A significant proportion of patients with ESRD complained of skin itching during treatment (61% vs 26%, p < 0.001), and the SVR rate were similar between these two groups (95.45% vs 96.86%, p = 0.644). Conclusions Despite a higher rate of pruritus among patients with ESRD, GLE/PIB-based therapy achieved similarly high SVR rates among patients with and without ESRD.
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Affiliation(s)
- Hsu-Heng Yen
- Division of Gastroenterology, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- General Education Center, Chienkuo Technology University, Changhua, Taiwan
- * E-mail: , (HHY); (KCC)
| | - Pei-Yuan Su
- Division of Gastroenterology, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Ya-Huei Zeng
- Division of Gastroenterology, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - I-Ling Liu
- Division of Gastroenterology, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Siou-Ping Huang
- Division of Gastroenterology, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Yu-Chun Hsu
- Division of Gastroenterology, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Yang-Yuan Chen
- Division of Gastroenterology, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Chia-Wei Yang
- Division of Gastroenterology, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Shun-Sheng Wu
- Division of Gastroenterology, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Kun-Ching Chou
- Division of Gastroenterology, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
- * E-mail: , (HHY); (KCC)
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