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Pan J, Wang H, Yao T, Liao X, Cheng H, Liangpunsakul S, Wang Y, Zhang M, Zhang Z. Clinical Predictors of Functional Cure in Children 1-6 Years-old with Chronic Hepatitis B. J Clin Transl Hepatol 2022; 10:405-411. [PMID: 35836765 PMCID: PMC9240240 DOI: 10.14218/jcth.2021.00142] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 08/31/2021] [Accepted: 09/15/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND AND AIMS Hepatitis B surface antigen (HBsAg) clearance is significantly more common in children with chronic hepatitis B (CHB) than in adults; however, the possible influencing factors related to HBsAg loss have yet to be found. This study aimed to explore the efficacy of long-term interferon (IFN)α therapy in treating children with CHB and analyzed the factors influencing functional cure after treatment. METHODS A total of 236 children aged 1-6 years and diagnosed with CHB via liver biopsy were included in the study, all receiving IFNα treatment (IFNα-2b monotherapy, IFNα-2b followed by lamivudine [LAM] or IFNα-2b combined with LAM) and followed up for 144 weeks. A comprehensive analysis was conducted on clinical data, including biochemical items, serum markers of hepatitis B virus (HBV) and immunological indexes, and logistic regression analysis was used to screen the influencing factors related to HBsAg loss. RESULTS The cumulative loss rates of HBsAg were 79.5%, 62.1% and 42.1% at 144 weeks after the start of treatment in the 1-3 years-old group, 3-5 years-old group and 5-7 years-old group, respectively (p<0.05). IFNα-2b combined with LAM treatment displayed the highest HBsAg loss rates compared with monotherapy and sequential treatment (p=0.011). Younger baseline age and lower HBsAg levels were independent factors for the prediction of HBsAg loss (p<0.05). The baseline PreS1 and hepatitis B core antibody levels in the HBsAg loss group were lower than those in the HBsAg non-loss group. In addition, the PreS1 level was positively corelated with the level of HBsAg, HBV DNA and liver inflammation. CONCLUSIONS Long-term treatment with IFNα was effective in achieving HBsAg loss in CHB children aged 1-6 years-old. Age less than 3 years-old and lower HBsAg levels are independent predictors of functional cure in children with CHB.
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Affiliation(s)
- Jing Pan
- Department of Infectious Disease, Peking University First Hospital, Beijing, China
- Liver Disease Department of The Fifth Medical Center of the General Hospital of PLA, Beijing, China
| | - Haiyan Wang
- Institute for Hepatology, National Clinical Research Center for Infectious Disease, Shenzhen Third People’s Hospital; The Second Affiliated Hospital, School of Medicine, Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Tiantian Yao
- Department of Infectious Disease, Peking University First Hospital, Beijing, China
| | - Xuejiao Liao
- Institute for Hepatology, National Clinical Research Center for Infectious Disease, Shenzhen Third People’s Hospital; The Second Affiliated Hospital, School of Medicine, Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Hao Cheng
- Department of Infectious Disease, Peking University First Hospital, Beijing, China
| | - Suthat Liangpunsakul
- Division of Gastroenterology and Hepatology, Department of Medicine; Department of Biochemistry and Molecular Biology, Indiana University, Indianapolis, IN, USA
| | - Yan Wang
- Department of Infectious Disease, Peking University First Hospital, Beijing, China
| | - Min Zhang
- Liver Disease Department of The Fifth Medical Center of the General Hospital of PLA, Beijing, China
- Correspondence to: Zheng Zhang, Institute of Hepatology, Shenzhen 3 People’s Hospital, Shenzhen, Guangdong 518112, China. ORCID: https://orcid.org/0000-0002-3544-1389. Tel/Fax: +86-755-8123-8983, E-mail: ; Min Zhang, Liver Disease Department of The Fifth Medical Center of the General Hospital of PLA, 100 Western 4 Ring Middle Road, Beijing 100039, China. Tel/Fax: +86-10-6693-3129, E-mail:
| | - Zheng Zhang
- Institute for Hepatology, National Clinical Research Center for Infectious Disease, Shenzhen Third People’s Hospital; The Second Affiliated Hospital, School of Medicine, Southern University of Science and Technology, Shenzhen, Guangdong, China
- Correspondence to: Zheng Zhang, Institute of Hepatology, Shenzhen 3 People’s Hospital, Shenzhen, Guangdong 518112, China. ORCID: https://orcid.org/0000-0002-3544-1389. Tel/Fax: +86-755-8123-8983, E-mail: ; Min Zhang, Liver Disease Department of The Fifth Medical Center of the General Hospital of PLA, 100 Western 4 Ring Middle Road, Beijing 100039, China. Tel/Fax: +86-10-6693-3129, E-mail:
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Zhou X, Zhang F, Ao Y, Lu C, Li T, Xu X, Zeng H. Diagnosis experiences from 50 hepatitis B patients in Chongqing, China: a qualitative study. BMC Public Health 2021; 21:2195. [PMID: 34852813 PMCID: PMC8638347 DOI: 10.1186/s12889-021-11929-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 09/28/2021] [Indexed: 11/23/2022] Open
Abstract
Background The aim of this study was to provide recommendations for reducing the impact of hepatitis B infection on patients with chronic hepatitis B by describing their experiences during the diagnosis process. Methods We conducted face-to-face interviews with 50 hepatitis B patients recruited by convenient sampling from an infectious diseases department of a teaching hospital in Chongqing, China from July to August 2019. Thematic analysis framework included interviewees’ social demographic characteristics, diagnosis approach, signs and symptoms before diagnosis, feelings after diagnosis, and doctor’s instructions. Results Most patients first detected hepatitis B through various types of physical examinations when the patients were asymptomatic or had only mild symptoms. Most patients were shocked, scared, or overwhelmed when they were diagnosed with hepatitis B. They were able to remember the doctor’s instructions about maintaining a healthy lifestyle, but not impressed by the doctor’s advice about regular follow-up liver function tests. The lack of regular follow-up has caused irreversible damage to some patients. Conclusions Most patients are passively diagnosed with hepatitis B due to their lack of awareness on active hepatitis B prevention. Patients need professional mental health care to overcome the negative emotions that following the diagnosis. Physicians’ instruction should emphasize the importance of regular follow-up liver function tests in addition to a healthy lifestyle.
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Affiliation(s)
- Xiangxi Zhou
- School of Public Health and Management, Chongqing Medical University, No. 1 Yixueyuan Road, Yuzhong District, Chongqing, 400016, China
| | - Fan Zhang
- School of Public Health and Management, Chongqing Medical University, No. 1 Yixueyuan Road, Yuzhong District, Chongqing, 400016, China.,Research Center for Medicine and Social Governance in Health, Chongqing Medical University, Chongqing, China.,The Innovation Center for Social Risk Governance in Health, Chongqing Medical University, Chongqing, China
| | - Yongping Ao
- School of Public Health and Management, Chongqing Medical University, No. 1 Yixueyuan Road, Yuzhong District, Chongqing, 400016, China
| | - Chunli Lu
- School of Public Health and Management, Chongqing Medical University, No. 1 Yixueyuan Road, Yuzhong District, Chongqing, 400016, China
| | - Tingting Li
- Centers for Disease Control and Prevention of Chongqing, Chongqing, China
| | - Xianglong Xu
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia.,Melbourne Sexual Health Centre, Alfred Health, Melbourne, Australia.,China Australia Joint Research Center for Infectious Diseases, School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi'an, Shaanxi, People's Republic of China
| | - Huan Zeng
- School of Public Health and Management, Chongqing Medical University, No. 1 Yixueyuan Road, Yuzhong District, Chongqing, 400016, China. .,Research Center for Medicine and Social Governance in Health, Chongqing Medical University, Chongqing, China. .,The Innovation Center for Social Risk Governance in Health, Chongqing Medical University, Chongqing, China.
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Kang B, Yi DY, Choe BH. Translational Strategies to Eliminate Chronic Hepatitis B in Children: Prophylaxis and Management in East Asian Countries. Front Pediatr 2021; 9:809838. [PMID: 35186829 PMCID: PMC8854863 DOI: 10.3389/fped.2021.809838] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 12/27/2021] [Indexed: 12/14/2022] Open
Abstract
Translational medical research on hepatitis B virus (HBV) infection and chronic hepatitis B (CHB) pathogenesis provides guidance on strengthening the treatment and prevention strategies of CHB. Preventing vertical transmission is the key to eliminating HBV infection in children. The understanding of HBV replication, hepatocyte turnover, and the fate of covalently closed circular DNA (cccDNA) would help establish a personalized application of the guidelines, especially concerning the discontinuation of nucleos(t)ide analog (NA) treatment in children. Transplacental leakage of HBV-infected maternal blood is suggested as the leading cause of vertical transmission. Prenatal maternal prophylaxis could diminish maternal HBV viremia at delivery, to reduce the risk of neonatal HBV infection. The meaning of the expression "no additional risk of breast milk feeding" is thereby explained. Understanding the untreated natural course of CHB in children and the course changeable by treatment is important to apply individualistic strategies and avoid the immoral selection of treatment indications. NAs with potent efficacy and a high barrier to drug resistance should be used as first-line treatment to reduce the likelihood of NA-resistant HBV development because the rate of mutant HBV emergence might count on the infected hepatocyte turnover rate in chronic HBV infection. Although elimination of intranuclear cccDNA is difficult by NAs alone, a cure is possible by human immunity and hepatocyte turnover. The reduction of intranuclear cccDNA occurs after the destruction of HBV-infected hepatocytes, non-cytolytic immune response, apoptosis of hepatocytes, and compensatory cell proliferation. Therefore, consolidation therapy after NA-induced hepatitis B e-antigen seroconversion must be necessary for a sufficient period. This review also summarizes the treatment strategies of CHB in children based on the practical application of translational research.
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Affiliation(s)
- Ben Kang
- Department of Pediatrics, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Dae Yong Yi
- Department of Pediatrics, College of Medicine, Chung-Ang University Hospital, Chung-Ang University, Seoul, South Korea
| | - Byung-Ho Choe
- Department of Pediatrics, School of Medicine, Kyungpook National University, Daegu, South Korea
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Choe BH. What Are the Main Differences in the Treatment of Chronic Hepatitis B between Korean Children and Adults? J Korean Med Sci 2018; 33:e69. [PMID: 29441758 PMCID: PMC5809755 DOI: 10.3346/jkms.2018.33.e69] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 01/15/2018] [Indexed: 12/02/2022] Open
Affiliation(s)
- Byung Ho Choe
- Department of Pediatrics, Kyungpook National University School of Medicine, Daegu, Korea.
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Choe JY, Ko JS, Choe BH, Kim JE, Kang B, Lee KJ, Yang HR. Antiviral Efficacy of Tenofovir Monotherapy in Children with Nucleos(t)ide-naive Chronic Hepatitis B. J Korean Med Sci 2018; 33:e11. [PMID: 29215820 PMCID: PMC5729652 DOI: 10.3346/jkms.2018.33.e11] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 10/14/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The purpose was to compare the efficacy between tenofovir disoproxil fumarate (TDF) and lamivudine (LMV) in children with nucleos(t)ide-naive chronic hepatitis B (CHB) infection. Patients with CHB were treated with TDF in the immune-reactive phase and compared with a historical control group of patients treated with LMV before the TDF era. METHODS Hepatitis B virus (HBV) DNA titer decrements (> 3 log₁₀ IU/mL) were monitored after treatment initiation. The treatment duration for HBV DNA clearance (< 357 IU/mL) and complete response (HBeAg loss and HBV DNA clearance) were analyzed. The follow-up period was 96 weeks. RESULTS Sixteen patients were treated with TDF and compared with a historical control group of 24 patients treated with LMV. HBV DNA decrement (> 3 log₁₀ IU/mL) was achieved in 100% (16/16) of the TDF group but in only 62.5% (15/24) of the LMV group (P = 0.005) at 48 weeks. The HBV DNA clearance (< 357 IU/mL) in the TDF and LMV groups was, respectively, as follows: 62.5% (10/16) and 25.0% (6/24) at 12 weeks (P = 0.018), 81.3% (13/16) and 37.5% (9/24) at 24 weeks (P = 0.006), 93.8% (15/16) and 50.0% (12/24) at 48 weeks (P = 0.004), and 100% (16/16) and 54.2% (13/24) at 96 weeks (P = 0.001). Complete response occurred in 41.7% (5/12) of HBeAg-positive patients in the TDF group and 28.6% (6/21) of the LMV group at 96 weeks (P = 0.443). CONCLUSION TDF monotherapy for 96 weeks produced a significantly more effective virologic response than LMV monotherapy in children with nucleos(t)ide-naive CHB.
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Affiliation(s)
- Jae Young Choe
- Department of Pediatrics, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jae Sung Ko
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Byung Ho Choe
- Department of Pediatrics, Kyungpook National University School of Medicine, Daegu, Korea.
| | - Jung Eun Kim
- Department of Pediatrics, Kyungpook National University School of Medicine, Daegu, Korea
| | - Ben Kang
- Department of Pediatrics, Kyungpook National University School of Medicine, Daegu, Korea
| | - Kyung Jae Lee
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Hye Ran Yang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
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Defresne F, Sokal E. Chronic hepatitis B in children: Therapeutic challenges and perspectives. J Gastroenterol Hepatol 2017; 32:368-371. [PMID: 27262164 DOI: 10.1111/jgh.13459] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/15/2016] [Indexed: 02/06/2023]
Abstract
Chronic hepatitis B virus (HBV) infection and HBV-related hepatitis in children remains an unmet medical need, as current treatments are only partially effective, and only in a limited number of affected children. So-called "immunotolerant" children have not shown increased serological responses to available treatments. In cases involving more active disease, serological response has only been obtained in approximately one-third of patients when using interferon, while other cases exhibited virological response solely under continuous treatment with nucleoside analogs. Guidelines have recently been established to aid pediatricians in effectively managing this condition. With the available medications, no treatment is so far indicated for immunotolerant children, but only for cases presenting increased alanine aminotransferase levels to over 1.5-2 times the upper limit of normal for over 6 months, and without spontaneous HB envelope antigen to antibody seroconversion. The therapeutic arsenal approved by the Food and Drugs Administration and European Medicines Agency for children remains limited because of the lack of large-scale clinical trials validating treatments already approved for the adult population. Yet, the recent discovery of a specific HBV-cell surface receptor, NTCP, allows for new treatment perspectives regarding the future.
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Affiliation(s)
- Florence Defresne
- Department of Paediatrics, Saint Luc University Clinics, and Paediatric Research Unit, Institute of Experimental and Clinical Research, Catholic University of Louvain, Brussels, Belgium
| | - Etienne Sokal
- Department of Paediatrics, Saint Luc University Clinics, and Paediatric Research Unit, Institute of Experimental and Clinical Research, Catholic University of Louvain, Brussels, Belgium
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Clemente MG, Vajro P. An update on the strategies used for the treatment of chronic hepatitis B in children. Expert Rev Gastroenterol Hepatol 2017; 10:649-58. [PMID: 26752166 DOI: 10.1586/17474124.2016.1139450] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Chronic hepatitis B (CHB) in children shows a variety of clinical presentations, which influence its natural course and treatment options. This report provides an overview of the ongoing strategies in pediatric CHB management. Interferon-α represents the first choice of treatment in children showing HBV replication and hepatic inflammation (immune active CHB), while the recommendation is to monitor inactive/immune-tolerant children (normal transaminases and low/absent viral replication). When circumstances preclude the use of Interferon-α and in cases of compensated/decompensated cirrhosis, entecavir for children above 2 years of age or tenofovir for children above 12 years of age are the nucleos(t)ide analogues recommended by the most recent guidelines.
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Affiliation(s)
- Maria Grazia Clemente
- a Pediatric Clinic, Department of Surgical, Microsurgical and Medical Sciences , University of Sassari , Sassari , Italy
| | - Pietro Vajro
- b Pediatrics Unit, Department of Medicine and Surgery , University of Salerno , Baronissi (Salerno) , Italy
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Kramvis A. The clinical implications of hepatitis B virus genotypes and HBeAg in pediatrics. Rev Med Virol 2016; 26:285-303. [PMID: 27139263 PMCID: PMC5084815 DOI: 10.1002/rmv.1885] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Revised: 04/02/2016] [Accepted: 04/04/2016] [Indexed: 12/12/2022]
Abstract
Although a successful vaccine against HBV has been implemented in 184 countries, eradication of hepatitis B virus (HBV) is still not on the horizon. There are over 240 million chronic carriers of HBV globally. The risk of developing chronic hepatitis ranges from >90% in newborns of hepatitis Be antigen (HBeAg)‐positive mothers, 25%–35% in children under 5 years of age and <5% in adults. HBeAg, a non‐particulate viral protein, is a marker of HBV replication. This is the only HBV antigen to cross the placenta, leading to specific unresponsiveness of helper T cells to the capsid protein and HBeAg in newborns. HBeAg is tolerated in utero and acts as a tolerogen after birth. Perinatal transmission is frequent when mothers are HBeAg‐positive, whereas it occurs less frequently when mothers are HBeAg‐negative. Sequence heterogeneity is a feature of HBV. Based on an intergroup divergence >7.5% across the complete genome, HBV is classified phylogenetically into at least nine genotypes. With between ~4% and 8% intergroup nucleotide divergence, genotypes A–D, F, H and I are classified further into subgenotypes. HBV genotypes/subgenotypes may have distinct geographical distribution and can develop different mutations in the regions of the HBV genome that code for HBeAg. These differences can be related to the role of HBV genotypes to the natural history of infection and mode of transmission. Thus genotypes/subgenotypes of HBV can be responsible for the different natural history of infection and modes of transmission in children, found in various regions of the world, where different genotypes/subgenotypes prevail. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Anna Kramvis
- Hepatitis Virus Diversity Research Unit (HVDRU), Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Kasırga E. Lamivudine resistance in children with chronic hepatitis B. World J Hepatol 2015; 7:896-902. [PMID: 25937866 PMCID: PMC4411531 DOI: 10.4254/wjh.v7.i6.896] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 10/31/2014] [Accepted: 01/20/2015] [Indexed: 02/06/2023] Open
Abstract
Currently, although lamivudine (LAM) has a low genetic barrier, only interferon-alpha and LAM are available as a first-line treatment in children with chronic hepatitis B (CHB). LAM is a potent inhibitor of hepatitis B virus-deoxyribonucleic acid (HBV-DNA) polymerase replication by termination of the proviral HBV-DNA chain. LAM has a good safety and tolerability profile in CHB patients with hepatic decompensation. However, the main disadvantages of this HBV reverse transcriptase inhibitor are: (1) pre-existing covalently closed circular DNA cannot be eradicated by LAM, thus relapse after therapy withdrawal is frequent; and (2) although the longer LAM treatment induced the higher seroconversion rate, the risk of viral resistance increased through the selection of YMDD (tyrosine, methionine, aspartate, aspartate) motif. Insufficient suppression of viral replication leads to the emergence of resistant strains that could result in virological breakthrough which is usually followed by biochemical breakthrough. Mutant strains affects additional resistance and cross resistance, leading to drug resistance in a significant number of CHB patients. In this case, efficacy of more powerful anti-viral agents with higher genetic barrier against development of resistance is diminished. Furthermore, strains that are resistant to LAM could bring about vaccine escape mutants, decreasing the efficacy of HBV vaccine. A more potent drug with a high genetic barrier to resistance needs to be approved as the first-line treatment option for CHB in children.
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Abstract
BACKGROUND Hepatitis B e antigen (HBeAg) seroconversion is an important event in patients with chronic hepatitis B virus (HBV) infection. This study aimed to clarify the outcome of long-term follow-up of chronic HBV infection and the factors affecting HBeAg seroconversion in children in Japan. METHODS Patients who were first examined at our institution between 1980 and 2012, who were <20 years of age at the time of this initial visit, and who were positive for hepatitis B surface antigen for at least 6 months were identified retrospectively. Sex, age at diagnosis, HBV genotype, maximum serum alanine aminotransferase (ALT) level, occurrence of hepatitis flare-ups (yes/no), and transmission route were evaluated to identify the predictors of HBeAg seroconversion. RESULTS A total of 205 children with chronic HBV were enrolled. Among them, 192 were positive for HBeAg upon diagnosis of chronic HBV infection. Out of this group, 95 (49%) achieved HBeAg seroconversion and 43 (21%) received treatment during the follow-up period. Only the maximum serum ALT level was significantly associated with the achievement of HBeAg seroconversion by multivariate analysis (P < 0.05). Kaplan-Meier analysis showed that the median times to HBeAg seroconversion (50% achievement of HBeAg seroconversion) of the treated and untreated children were 10.2 and 12.0 years, respectively. The cumulative proportion of HBeAg seroconversion was significantly higher in the treated children than in the untreated children (P = 0.02). CONCLUSIONS A higher serum ALT level was a predictor for HBeAg seroconversion. Antiviral treatment could accelerate the achievement of HBeAg seroconversion in HBV-infected children.
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Choe BH. A disappearing vertical infection: will hepatitis B be a forgotten disease in children? Korean J Intern Med 2014; 29:296-300. [PMID: 24851062 PMCID: PMC4028517 DOI: 10.3904/kjim.2014.29.3.296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Accepted: 04/18/2014] [Indexed: 11/27/2022] Open
Affiliation(s)
- Byung-Ho Choe
- Department of Pediatrics, Kyungpook National University School of Medicine, Daegu, Korea
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