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Breidbart E, Ilkowitz J, Regelmann MO, Ashraf AP, Gourgari E, Kamboj MK, Kohn B, Lahoti A, Mehta S, Miller R, Raman V, Khokhar A, Brar PC. Precocious Puberty and GnRH Analogs: Current Treatment Practices and Perspectives among US Pediatric Endocrinologists. Horm Res Paediatr 2024:1-12. [PMID: 38718766 DOI: 10.1159/000539011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 04/10/2024] [Indexed: 07/30/2024] Open
Abstract
INTRODUCTION Gonadotropin releasing hormone analogs (GnRHas) are used for treatment of precocious puberty. Over the last decade, several new formulations have been approved. METHODS The Drugs and Therapeutics Subcommittee of the Pediatric Endocrine Society (PES) undertook a review to ascertain the current treatment options, prescribing behaviors, and practices of GnRHas among pediatric endocrinologists practicing within the USA. The survey consisted of four main subsections: (1) description of clinical practice; (2) self-assessment of knowledge base of pediatric and adult GnRHa formulations; (3) current practice for treating central precocious puberty (CPP); and (4) utilization of healthcare resources. RESULTS There were 223 survey respondents. Pediatric endocrine practitioners were most familiar with the pediatric one-monthly preparation, the 3-month preparation, and the histrelin implant (Supprelin®) (88%, 96%, and 91%, respectively), with lower familiarity for 24-week triptorelin intramuscular (Triptodur®) (65%) and 6-month subcutaneous leuprolide (Fensolvi®) (45%). Only 23% of the respondents reported being extremely familiar with the availability of adult formulations, and 25% reported being completely unaware of cost differences between pediatric and adult GnRHa preparations. The implant was the most preferred therapy (44%), but in practice, respondents reported a higher percentage of patients treated with the 3-month preparation. While family preference/ease of treatment (87%) was the key determinant for using a particular GnRHa preparation, insurance coverage also played a significant role in the decision (64%). Responses regarding assessment for efficacy of treatment were inconsistent, as were practices and criteria for obtaining an MRI. CONCLUSIONS The survey indicated there is more familiarity with older, shorter acting GnRHas, which are prescribed in greater numbers than newer, longer acting formulations. There is lack of consensus on the need for central nervous system (CNS) imaging in girls presenting with CPP between 6 and 8 years of age and use of laboratory testing to monitor response to treatment. Insurance requirements regarding CNS imaging and laboratory monitoring are highly variable. Despite having similar constituents and bioavailability, there are substantial cost differences between the pediatric and adult formulations and lack of evidence for safe use of these formulations in children. The survey-based analysis highlights the challenges faced by prescribers while reflecting on areas where further research is needed to provide evidence-based practice guidelines for pediatric endocrinologists.
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Affiliation(s)
- Emily Breidbart
- Division of Pediatric Endocrinology and Diabetes, NYU School of Medicine, New York, New York, USA
| | - Jeniece Ilkowitz
- Division of Pediatric Endocrinology and Diabetes, NYU School of Medicine, New York, New York, USA
| | - Molly O Regelmann
- Division of Endocrinology and Diabetes, Children's Hospital at Montefiore, Bronx, New York, USA
| | - Ambika P Ashraf
- Division of Pediatric Endocrinology and Diabetes, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Evgenia Gourgari
- Division of Pediatric Endocrinology, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Manmohan K Kamboj
- Division of Pediatric Endocrinology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Brenda Kohn
- Division of Pediatric Endocrinology and Diabetes, NYU School of Medicine, New York, New York, USA
| | - Amit Lahoti
- Division of Pediatric Endocrinology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Shilpa Mehta
- Division of Pediatric Endocrinology and Diabetes, New York Medical College, Valhalla, New York, USA
| | - Ryan Miller
- Division of Pediatric Endocrinology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Vandana Raman
- Division of Pediatric Endocrinology, University of Utah, Salt Lake City, Utah, USA
| | - Aditi Khokhar
- Division of Pediatric Endocrinology, Goryeb Children's Hospital, Morristown, New Jersey, USA
| | - Preneet C Brar
- Division of Pediatric Endocrinology and Diabetes, NYU School of Medicine, New York, New York, USA
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Yoo E, Kim S, Jung HL, Shim JY, Shim JW, Kim DS, Kwak JH, Kim ES, Yang A. Impact of 6-month triptorelin formulation on predicted adult height and basal gonadotropin levels in patients with central precocious puberty. Front Endocrinol (Lausanne) 2023; 14:1134977. [PMID: 36875449 PMCID: PMC9982112 DOI: 10.3389/fendo.2023.1134977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 02/03/2023] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND Triptorelin, a long-acting gonadotropin-releasing hormone (GnRH) agonist, is available in 1-, 3-, and 6-month formulations to treat central precocious puberty (CPP). The triptorelin pamoate 22.5-mg 6-month formulation recently approved for CPP offers greater convenience to children by reducing the injection frequency. However, worldwide research on using the 6-month formulation to treat CPP is scarce. This study aimed to determine the impact of the 6-month formulation on predicted adult height (PAH), changes in gonadotropin levels, and related variables. METHODS We included 42 patients (33 girls and nine boys) with idiopathic CPP treated with a 6-month triptorelin (6-mo TP) formulation for over 12 months. Auxological parameters, including chronological age, bone age, height (cm and standard deviation score [SDS]), weight (kg and SDS), target height (TH), and Tanner stage, were evaluated at baseline, and after 6, 12, and 18 months of treatment. Hormonal parameters, including serum luteinizing hormone (LH), follicle-stimulating hormone (FSH), and estradiol for girls or testosterone for boys, were analyzed concurrently. RESULTS The mean age at treatment initiation was 8.6 ± 0.83 (8.3 ± 0.62 for girls, 9.6 ± 0.68 for boys). The peak LH level following intravenous GnRH stimulation at diagnosis was 15.47 ± 9.94 IU/L. No progression of the modified Tanner stage was observed during treatment. Compared to baseline, LH, FSH, estradiol, and testosterone were significantly reduced. In particular, the basal LH levels were well suppressed to less than l.0 IU/L, and the LH/FSH ratio was less than 0.66. The bone age/chronological age ratio remained stable with a decreasing trend (1.15 at the start of treatment, 1.13 at 12 months, 1.11 at 18 months). PAH SDS increased during treatment (0.77 ± 0.79 at baseline, 0.87 ± 0.84 at the start of treatment, 1.01 ± 0.93 at six months, and 0.91 ± 0.79 at 12 months). No adverse effects were observed during treatment. CONCLUSION The 6-mo TP suppressed the pituitary-gonadal axis stably and improved the PAH during treatment. Considering its convenience and effectiveness, a significant shift to long-acting formulations can be expected.
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Affiliation(s)
- Eunjoo Yoo
- Department of Pediatrics, Kangbuk Samsung Hospital, School of Medicine, Sungkyunkwan University, Seoul, Republic of Korea
| | - Sinae Kim
- Biostatistics Collaboration Team, Research Core Center, National Cancer Center, Goyang, Republic of Korea
| | - Hye Lim Jung
- Department of Pediatrics, Kangbuk Samsung Hospital, School of Medicine, Sungkyunkwan University, Seoul, Republic of Korea
| | - Jung Yeon Shim
- Department of Pediatrics, Kangbuk Samsung Hospital, School of Medicine, Sungkyunkwan University, Seoul, Republic of Korea
| | - Jae Won Shim
- Department of Pediatrics, Kangbuk Samsung Hospital, School of Medicine, Sungkyunkwan University, Seoul, Republic of Korea
| | - Deok Soo Kim
- Department of Pediatrics, Kangbuk Samsung Hospital, School of Medicine, Sungkyunkwan University, Seoul, Republic of Korea
| | - Ji Hee Kwak
- Department of Pediatrics, Kangbuk Samsung Hospital, School of Medicine, Sungkyunkwan University, Seoul, Republic of Korea
| | - Eun Sil Kim
- Department of Pediatrics, Kangbuk Samsung Hospital, School of Medicine, Sungkyunkwan University, Seoul, Republic of Korea
| | - Aram Yang
- Department of Pediatrics, Kangbuk Samsung Hospital, School of Medicine, Sungkyunkwan University, Seoul, Republic of Korea
- *Correspondence: Aram Yang,
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Ni MM, Yang ST, Wu WW, Wang SS, Li M, Liu QQ, Ji X. Benefits from the first year of GnRHa therapy in boys with idiopathic central precocious puberty when initiating treatment after age 9 years: findings from a real-world retrospective study. BMC Endocr Disord 2022; 22:299. [PMID: 36456936 PMCID: PMC9716691 DOI: 10.1186/s12902-022-01207-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 11/09/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND GnRHa treatment was established for improving final adult height (FAH) in children presenting with Idiopathic central precocious puberty (ICPP) up to age 8, while several controversies remained for older age groups. The primary objective was to evaluate whether boys diagnosed with ICPP over 9 years of chronological age (CA) could achieve a height benefit from GnRHa treatment. METHODS We retrospectively evaluated the medical records of 23 boys treated for idiopathic central precocious puberty between January 2018 and January 2021 at Jiangsu Children's Medical Center. All patients started treatment with intramuscular depot GnRHa at a dose of 80-100 μg/kg, followed by continuous intramuscular injection every 28 days at a dose of 60-80 μg/kg. The hormonal parameters, bone age/chronological age ratio, FAH, growth velocity (GV), tanner staging and body mass index (BMI) were assessed during the treatment period. RESULTS After one course of treatment (3 months), the basal FSH and testosterone levels were reduced, while the basal LH value was not significantly changed compared with those before treatment. Furthermore, the mean BA/CA ratio reduction was statistically significant at month 12. The mean PAH following administration of GnRHa after 12 months was statistically improved compared with those at baseline. In addition, the clinical sign of puberty and GV were significantly improved and the BMI remained unchanged as desired at month 12. CONCLUSIONS This analysis highlighted the positive outcome on the decrease in the rate of bone maturation, with a favorable effect on progression of clinical signs of puberty. Furthermore, our study confirmed PAH was improved even in the older children at onset of treatment (ages 9-10), emphasizing the importance of personalized treatment in such population.
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Affiliation(s)
- Ming-Ming Ni
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, 72 Guangzhou Rd, Nanjing, 210008, People's Republic of China
| | - Shu-Ting Yang
- School of Pharmacy, Nanjing Medical University, Nanjing, 210029, China
- Nanjing Medical University, Nanjing, China
| | - Wen-Wen Wu
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, 72 Guangzhou Rd, Nanjing, 210008, People's Republic of China
| | - Shan-Shan Wang
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, 72 Guangzhou Rd, Nanjing, 210008, People's Republic of China
| | - Man Li
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, 72 Guangzhou Rd, Nanjing, 210008, People's Republic of China
| | - Qing-Qing Liu
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, 72 Guangzhou Rd, Nanjing, 210008, People's Republic of China
| | - Xing Ji
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, 72 Guangzhou Rd, Nanjing, 210008, People's Republic of China.
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Zhou Y, Jia R, Kong FS, Chen M, Ren F, Xu Z, Ma Y. A single blood sample for stimulated LH assayed by ICMA is useful for monitoring the treatment efficacy of triptorelin depot in girls. Scand J Clin Lab Invest 2022; 82:588-594. [PMID: 36421059 DOI: 10.1080/00365513.2022.2148120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND There is still no consensus on the optimal monitoring method to evaluate the hypothalamic-pituitary-gonadal axis (HPGA) inhibition. METHODS There were 124 girls treated with triptorelin depot due to puberty disorders, including 77 central precocious puberty and 47 early puberty. After treatment, triptorelin stimulation tests were performed, and blood samples were collected at 0, 20, 40 and 60 min. Luteinizing hormone (LH) and follicle-stimulating hormone (FSH) were measured by immunochemiluminometric assay (ICMA). RESULTS Peak LH (PLH), peak FSH and estradiol in 124 girls were significantly decreased after treatment, while 2 cases had inadequate treatment efficacy. Areas under the receiver operating characteristic curves (AUC) of PLH and peak FSH after stimulation for the diagnosis of HPGA suppression were 0.984 and 0.121. When the cut-off value of PLH was ≤ 2.25 IU/L, the sensitivity was 96.7% and specificity was 100.0%. There was no difference in AUC between PLH and a single LH at 20, 40, or 60 min (p > 0.05). When LH were ≤ 2.34 IU/L, ≤ 2.21 IU/L and ≤ 2.00 IU/L at 20, 40 and 60 min, respectively, the sensitivity were 99.1%, 96.7% and 98.4%, and the specificity were all 100.0%. The correlation coefficients between PLH and LH at 20, 40 or 60 min were 0.947, 0.975 and 0.961. CONCLUSION A single blood sample for stimulated LH at 20 min, 40 min, or 60 min assayed by ICMA during triptorelin stimulation test is useful for monitoring the treatment efficacy of triptorelin depot in girls with puberty disorders.
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Affiliation(s)
- Yuan Zhou
- Department of Pediatrics, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Ruofan Jia
- Department of Pediatrics, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Fan-Sheng Kong
- Department of Pediatrics, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Min Chen
- Department of Clinical Laboratory, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Feng Ren
- Department of Clinical Laboratory, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Zhuangjian Xu
- Department of Pediatrics, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Yaping Ma
- Department of Pediatrics, Affiliated Hospital of Jiangnan University, Wuxi, China
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Vukovic R, Milenkovic T, Soldatovic I, Pekic S, Mitrovic K, Todorovic S. Triptorelin stimulated luteinizing hormone concentrations for diagnosing central precocious puberty: study of diagnostic accuracy. Endocrine 2022; 75:934-941. [PMID: 34826116 PMCID: PMC8616750 DOI: 10.1007/s12020-021-02947-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 11/13/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE Gonadotropin-releasing hormone (GnRH) stimulation test is the gold standard for diagnosing central precocious puberty (CPP). However, intravenous GnRH is not always readily available. The aim of the present study was to evaluate the diagnostic accuracy of triptorelin-stimulated luteinizing hormone (LH) concentrations in the diagnosis of CPP among girls presenting with premature thelarche compared to the gold standard GnRH test. METHODS A prospective, case-control (CPP vs isolated premature thelarche), clinical study evaluating the diagnostic accuracy of triptorelin-stimulated LH concentrations in 60 girls with premature thelarche was performed. All girls underwent stimulation with subcutaneous triptorelin injection and intravenous GnRH in a randomized order. During the stimulation test with triptorelin, LH and FSH were measured at time 0, 30, 60, 90, 120, and 180 min after the injection. Estradiol was sampled 24 h after the injection. During the GnRH test, LH and FSH were measured at time 0, 30, 45, and 60 min. Girls with peak GnRH-stimulated LH concentrations ≥5.0 IU/L were classified as having CPP. Area under the curve (AUC) for triptorelin-stimulated LH concentrations was assessed using the receiver operating characteristic (ROC) analysis. RESULTS Triptorelin-stimulated LH concentrations were significantly higher in girls who had CPP according to the GnRH test (53.3%). LH peaked at 180 min after the triptorelin injection. The highest diagnostic accuracy for CPP (AUC = 0.973, sensitivity 96.9%, specificity 89.3%) at 180 min was at a LH concentration ≥3.4 IU/L. The 24 h estradiol concentration did not improve the predictive model. CONCLUSIONS Measuring LH concentrations 180 min after triptorelin injection with a cut-off value of ≥3.4 IU/L demonstrated a high diagnostic accuracy compared to the GnRH test. Thus, stimulation with triptorelin can be used as a reliable alternative for diagnosing CPP in girls with premature thelarche.
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Affiliation(s)
- Rade Vukovic
- Department of Endocrinology, Mother and Child Health Care Institute of Serbia "Dr Vukan Cupic", Radoja Dakica 8, 11070, Belgrade, Serbia.
- School of Medicine, University of Belgrade, Dr Subotica 8, 11 000, Belgrade, Serbia.
| | - Tatjana Milenkovic
- Department of Endocrinology, Mother and Child Health Care Institute of Serbia "Dr Vukan Cupic", Radoja Dakica 8, 11070, Belgrade, Serbia
| | - Ivan Soldatovic
- School of Medicine, University of Belgrade, Dr Subotica 8, 11 000, Belgrade, Serbia
| | - Sandra Pekic
- School of Medicine, University of Belgrade, Dr Subotica 8, 11 000, Belgrade, Serbia
- Neuroendocrinology Department, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Dr Subotica 13, 11 000, Belgrade, Serbia
| | - Katarina Mitrovic
- Department of Endocrinology, Mother and Child Health Care Institute of Serbia "Dr Vukan Cupic", Radoja Dakica 8, 11070, Belgrade, Serbia
- School of Medicine, University of Belgrade, Dr Subotica 8, 11 000, Belgrade, Serbia
| | - Sladjana Todorovic
- Department of Endocrinology, Mother and Child Health Care Institute of Serbia "Dr Vukan Cupic", Radoja Dakica 8, 11070, Belgrade, Serbia
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Zhan S, Huang K, Wu W, Zhang D, Liu A, Dorazio RM, Shi J, Ullah R, Zhang L, Wang J, Dong G, Ni Y, Fu J. The Use of Morning Urinary Gonadotropins and Sex Hormones in the Management of Early Puberty in Chinese Girls. J Clin Endocrinol Metab 2021; 106:e4520-e4530. [PMID: 34160619 PMCID: PMC8530706 DOI: 10.1210/clinem/dgab448] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Indexed: 11/29/2022]
Abstract
CONTEXT Although gonadotropin-releasing hormone stimulation test (GnRHST) is the gold standard in diagnosing central precocious puberty (CPP), it is invasive, expensive, and time-consuming, requiring multiple blood samples to measure gonadotropin levels. OBJECTIVE We evaluated whether urinary hormones could be potential biomarkers for prepuberty or postpuberty, aiming to simplify the current diagnosis and prognosis procedure. METHODS We performed a cross-sectional study of a total of 355 girls with CPP in National Clinical Research Center for Child Health in China, including 258 girls with positive and 97 girls with negative results from GnRHST. Twenty patients received GnRH analogue (GnRHa) treatment and completed a 6-month follow up. We measured luteinizing hormone (LH), follicle-stimulating hormone (FSH), estradiol, prolactin, progesterone, testosterone, and human chorionic gonadotropin in the first morning voided urine samples. RESULTS Their urinary LH levels and the ratios of LH to FSH increased significantly with the advancement in Tanner stages. uLH levels were positively associated with basal and peak LH levels in the serum after GnRH stimulation. A cutoff value of 1.74 IU/L for uLH reached a sensitivity of 69.4% and a specificity of 75.3% in predicting a positive GnRHST result. For the combined threshold (uLH ≥ 1.74 + uLH-to-uFSH ratio > 0.4), the specificity reached 86.6%. After 3 months of GnRHa therapy, the uLH and uFSH levels decreased accordingly. CONCLUSION uLH could be a reliable biomarker for initial CPP diagnosis and screening; uLH could also be an effective marker for evaluating the efficacy of clinical treatment.
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Affiliation(s)
- Shumin Zhan
- The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou 310052, China
| | - Ke Huang
- The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou 310052, China
| | - Wei Wu
- The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou 310052, China
| | - Danni Zhang
- The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou 310052, China
| | - Ana Liu
- The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou 310052, China
| | - Robert M Dorazio
- The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou 310052, China
| | - Jianrong Shi
- The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou 310052, China
| | - Rahim Ullah
- The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou 310052, China
| | - Li Zhang
- The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou 310052, China
| | - Jinling Wang
- The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou 310052, China
| | - Guanping Dong
- The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou 310052, China
| | - Yan Ni
- The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou 310052, China
| | - Junfen Fu
- The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou 310052, China
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