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Giannouchos TV, Ukert B, Pirrallo RG, Smith J, Kum HC, Wright B, Dietrich A. Determinants of Persistent, Multi-Year, Frequent Emergency Department Use Among Children and Young Adults in Three US States. Acad Pediatr 2024; 24:442-450. [PMID: 37673206 DOI: 10.1016/j.acap.2023.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 07/11/2023] [Accepted: 08/28/2023] [Indexed: 09/08/2023]
Abstract
OBJECTIVE This study examines the factors associated with persistent, multi-year, and frequent emergency department (ED) use among children and young adults. METHODS We conducted a retrospective secondary analysis using the 2012-2017 Healthcare Cost and Utilization Project State Emergency Department Databases for children and young adults aged 0-19 who visited any ED in Florida, Massachusetts, and New York. We estimated the association between persistent frequent ED use and individuals' characteristics using multivariable logistic regression models. RESULTS Among 1.3 million patients with 1.8 million ED visits in 2012, 2.9% (37,558) exhibited frequent ED use (≥4 visits in 2012) and accounted for 10.2% (181,138) of all ED visits. Longitudinal follow-up of frequent ED users indicated that 15.4% (5770) remained frequent users periodically over the next 1 or 2 years, while 2.2% (831) exhibited persistent frequent use over the next 3-5 years. Over the 6-year study period, persistent frequent users had 31,551 ED visits at an average of 38.0 (standard deviation = 16.2) visits. Persistent frequent ED use was associated with higher intensity of ED use in 2012, public health insurance coverage, inconsistent health insurance coverage over time, residence in non-metropolitan and lower-income areas, multimorbidity, and more ED visits for less medically urgent conditions. CONCLUSIONS Clinicians and policymakers should consider the diverse characteristics and needs of pediatric persistent frequent ED users compared to broader definitions of frequent users when designing and implementing interventions to improve health outcomes and contain ED visit costs.
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Affiliation(s)
- Theodoros V Giannouchos
- Department of Health Policy & Organization (TV Giannouchos), School of Public Health, The University of Alabama at Birmingham, Birmingham, Ala.
| | - Benjamin Ukert
- Department of Health Policy and Management (B Ukert, H-C Kum), School of Public Health, Texas A and M University, College Station, Tex
| | - Ronald G Pirrallo
- University of South Carolina School of Medicine (RG Pirrallo, J Smith, and A Dietrich), Greenville, SC; Department of Emergency Medicine (RG Pirrallo, J Smith, and A Dietrich), Prisma Health, Greenville, SC
| | - Jeremiah Smith
- University of South Carolina School of Medicine (RG Pirrallo, J Smith, and A Dietrich), Greenville, SC; Department of Emergency Medicine (RG Pirrallo, J Smith, and A Dietrich), Prisma Health, Greenville, SC
| | - Hye-Chung Kum
- Department of Health Policy and Management (B Ukert, H-C Kum), School of Public Health, Texas A and M University, College Station, Tex
| | - Brad Wright
- Department of Health Services Policy and Management (B Wright), Arnold School of Public Health, University of South Carolina, Columbia, SC
| | - Ann Dietrich
- University of South Carolina School of Medicine (RG Pirrallo, J Smith, and A Dietrich), Greenville, SC; Department of Emergency Medicine (RG Pirrallo, J Smith, and A Dietrich), Prisma Health, Greenville, SC
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Tan CD, Vermont CL, Zachariasse JM, von Both U, Carrol ED, Eleftheriou I, Emonts M, van der Flier M, Herberg J, Kohlmaier B, Levin M, Lim E, Maconochie IK, Martinon-Torres F, Nijman RG, Pokorn M, Rivero-Calle I, Rudzāte A, Tsolia M, Zenz W, Zavadska D, Moll HA. Which low urgent triaged febrile children are suitable for a fast track? An observational European study. Emerg Med J 2024; 41:236-241. [PMID: 38238066 PMCID: PMC10982627 DOI: 10.1136/emermed-2023-213375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 01/07/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND The number of paediatric patients visiting the ED with non-urgent problems is increasing, leading to poor patient flow and ED crowding. Fast track aims to improve the efficiency of evaluation and discharge of low acuity patients. We aimed to identify which febrile children are suitable for a fast track based on presenting symptoms and management. METHODS This study is part of the Management and Outcome of Fever in children in Europe study, which is an observational study including routine data of febrile children <18 years attending 12 European EDs. We included febrile, low urgent children (those assigned a triage acuity of either 'standard' or 'non-urgent' using the Manchester Triage System) and defined children as suitable for fast track when they have minimal resource use and are discharged home. Presenting symptoms consisted of neurological (n=237), respiratory (n=8476), gastrointestinal (n=1953) and others (n=3473, reference group). Multivariable logistic regression analyses regarding presenting symptoms and management (laboratory blood testing, imaging and admission) were performed with adjustment for covariates: patient characteristics, referral status, previous medical care, previous antibiotic use, visiting hours and ED setting. RESULTS We included 14 139 children with a median age of 2.7 years (IQR 1.3-5.2). The majority had respiratory symptoms (60%), viral infections (50%) and consisted of self-referrals (69%). The neurological group received imaging more often (adjusted OR (aOR) 1.8, 95% CI 1.1 to 2.9) and were admitted more frequently (aOR 1.9, 95% CI 1.4 to 2.7). The respiratory group had fewer laboratory blood tests performed (aOR 0.6, 95% CI 0.5 to 0.7), were less frequently admitted (aOR 0.6, 95% CI 0.5 to 0.7), but received imaging more often (aOR 1.8, 95% CI 1.6 to 2.0). Lastly, the gastrointestinal group had more laboratory blood tests performed (aOR 1.2. 95% CI 1.1 to 1.4) and were admitted more frequently (aOR 1.4, 95% CI 1.2 to 1.6). CONCLUSION We determined that febrile children triaged as low urgent with respiratory symptoms were most suitable for a fast track. This study provides evidence for which children could be triaged to a fast track, potentially improving overall patient flow at the ED.
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Affiliation(s)
- Chantal D Tan
- General Paediatrics, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Clementien L Vermont
- Section of Paediatric Infectious Diseases and Immunology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Joany M Zachariasse
- General Paediatrics, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Ulrich von Both
- Paediatric Infectious Diseases, University Children's Hospital at Dr. von Haunersches Kinderspital, LMU Munich, Munich, Germany
| | - Enitan D Carrol
- Section of Paediatric Infectious Diseases and Immunology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
- Department of Clinical Infection, Microbiology and Immunology, University of Liverpool Institute of Infection Veterinary and Ecological Sciences, Liverpool, UK
| | | | - Marieke Emonts
- Paediatric Immunology, Infectious Diseases & Allergy, Great North Children's Hospital, Newcastle upon Tyne, UK
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
| | - Michiel van der Flier
- Paediatric Infectious Diseases and Immunology, Wilhelmina Children's Hospital University Medical Centre, Utrecht, The Netherlands
- Paediatric Infectious Diseases and Immunology, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Jethro Herberg
- Section of Paediatric Infectious Diseases, Imperial College London, London, UK
| | - Benno Kohlmaier
- Department of General Paediatrics, Medical University of Graz, Graz, Austria
| | | | - Emma Lim
- Paediatric Immunology, Infectious Diseases & Allergy, Great North Children's Hospital, Newcastle upon Tyne, UK
| | - Ian K Maconochie
- Paediatric Emergency Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - Federico Martinon-Torres
- Genetics, Vaccines, Infections and Paediatrics Research group, Hospital de Clinico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Ruud G Nijman
- Section of Paediatric Infectious Diseases, Imperial College London, London, UK
- Paediatric Emergency Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - Marko Pokorn
- Department of Infectious Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Irene Rivero-Calle
- Genetics, Vaccines, Infections and Paediatrics Research group, Hospital de Clinico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | | | - Maria Tsolia
- Paediatrics, P and A Kyriakou Children's Hospital, Athens, Greece
| | - Werner Zenz
- Department of General Paediatrics, Medical University of Graz, Graz, Austria
| | - Dace Zavadska
- Paediatrics, Children's Clinical University Hospital, Riga, Latvia
| | - Henriette A Moll
- Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
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Rogachev S, Hashavya S, Rekhtman D, Schiesel G, Benenson-Weinberg T, Weiser G, Gordon O, Gross I. Return Visits in Infants Younger Than 90 Days Presenting to the Pediatric Emergency Department for Fever. Clin Pediatr (Phila) 2024:99228241234963. [PMID: 38415681 DOI: 10.1177/00099228241234963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
Fever in infants presenting to pediatric emergency departments (PEDs) often results in significant return visits (RVs). This retrospective study aimed to identify factors associated with RVs in febrile infants aged 0 to 90 days. Data from infants presenting to PED between 2018 and 2021 and returning within 7 days (RV group) were compared to age-matched febrile infants without RVs (control group). Each group had 95 infants with similar demographics and medical history. RVs were primarily due to positive cultures and persistent fever. The control group had higher initial hospitalization rates, longer PED stays, and increased antibiotic treatment. Prevalence of serious bacterial infections (SBIs) did not significantly differ. Higher hospitalization, prolonged PED stays, and initial antibiotic treatment were associated with reduced RV incidence despite similar SBI rates. Return visits in infants <90 days were primarily driven by persistent fever and positive cultures. Addressing these factors through targeted parental education and improved care protocols may reduce RVs.
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Affiliation(s)
- Sonia Rogachev
- Department of Pediatric Emergency Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - Saar Hashavya
- Department of Pediatric Emergency Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - David Rekhtman
- Department of Pediatric Emergency Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - Gali Schiesel
- Department of Pediatric Emergency Medicine, Hadassah Medical Center, Jerusalem, Israel
| | | | - Giora Weiser
- Department of Pediatric Emergency Medicine, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Oren Gordon
- Infectious Disease Unit, Department of Pediatrics, Faculty of Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Itai Gross
- Department of Pediatric Emergency Medicine, Hadassah Medical Center, Jerusalem, Israel
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Seers T, Reynard C, Martin GP, Body R. Development and Internal Validation of a Multivariable Prediction Model to Predict Repeat Attendances in the Pediatric Emergency Department: A Retrospective Cohort Study. Pediatr Emerg Care 2024; 40:16-21. [PMID: 37195679 DOI: 10.1097/pec.0000000000002975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
OBJECTIVE Unplanned reattendances to the pediatric emergency department (PED) occur commonly in clinical practice. Multiple factors influence the decision to return to care, and understanding risk factors may allow for better design of clinical services. We developed a clinical prediction model to predict return to the PED within 72 hours from the index visit. METHODS We retrospectively reviewed all attendances to the PED of Royal Manchester Children's Hospital between 2009 and 2019. Attendances were excluded if they were admitted to hospital, aged older than 16 years or died in the PED. Variables were collected from Electronic Health Records reflecting triage codes. Data were split temporally into a training (80%) set for model development and a test (20%) set for internal validation. We developed the prediction model using LASSO penalized logistic regression. RESULTS A total of 308,573 attendances were included in the study. There were 14,276 (4.63%) returns within 72 hours of index visit. The final model had an area under the receiver operating characteristic curve of 0.64 (95% confidence interval, 0.63-0.65) on temporal validation. The calibration of the model was good, although with some evidence of miscalibration at the high extremes of the risk distribution. After-visit diagnoses codes reflecting a nonspecific problem ("unwell child") were more common in children who went on to reattend. CONCLUSIONS We developed and internally validated a clinical prediction model for unplanned reattendance to the PED using routinely collected clinical data, including markers of socioeconomic deprivation. This model allows for easy identification of children at the greatest risk of return to PED.
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Affiliation(s)
- Tim Seers
- From the Emergency Department, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, United Kingdom
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Cavallaro SC, Michelson KA, D'Ambrosi G, Monuteaux MC, Li J. Critical Revisits Among Children After Emergency Department Discharge. Ann Emerg Med 2023; 82:575-582. [PMID: 37462598 PMCID: PMC10889433 DOI: 10.1016/j.annemergmed.2023.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 06/02/2023] [Accepted: 06/05/2023] [Indexed: 08/11/2023]
Abstract
STUDY OBJECTIVE Identifying higher risk groups could reveal ways to prevent critical emergency department (ED) revisits. The study objectives were to determine the rate of critical ED revisits among children discharged from the ED and to identify factors associated with critical revisits. METHODS We performed a retrospective study using the Healthcare Cost and Utilization Project State ED Databases (SEDD) and the State Inpatient Databases (SID). We included data from 6 states from 2014 through 2017. Critical ED revisit was defined as either ICU admission or death within 3 days of the initial ED discharge. We included all patients younger than 21 years. The main outcome was the rate of critical ED revisit. We also determined the relative risk (RR) of a critical ED revisit for the most common index ED visit diagnoses. We used negative binomial regression to calculate incidence rate ratios (IRR) of a critical ED visit by pediatric volume and complex chronic conditions. RESULTS A total of 16.3 million children were discharged from an ED over the 4-year study period. There were 18,704 (0.1%) critical ED revisits, 180 (0.00001%) of whom died. Asthma (RR 2.24, 95% confidence interval [CI] [2.11 to 2.38) had the highest relative risk of a critical revisit among all ED diagnoses. Adjusting for hospital volume and patient age, patients with complex chronic conditions were also more likely to have a critical ED revisit (IRR 11.03, 95% CI, 7.76 to 15.67). CONCLUSIONS Critical revisits after ED discharge were uncommon among children in our study sample, with revisits resulting in patient death within 3 days of an ED discharge being rare. Given the short time interval between ED discharges, however, future research should focus on understanding higher risk patients among those with asthma and a history of complex chronic conditions.
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Affiliation(s)
- Sarah C Cavallaro
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA.
| | | | | | | | - Joyce Li
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
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Namgung M, Lee DH, Bae SJ, Chung HS, Park JY, Kim K, Lee CA, Kim DH, Kim EC, Lim JY, Han SS, Choi YH. A Comparison of Emergency Department Revisit Rates of Pediatric Patients between Pre-COVID-19 and COVID-19 Periods. CHILDREN 2022; 9:children9071003. [PMID: 35883987 PMCID: PMC9322694 DOI: 10.3390/children9071003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/16/2022] [Accepted: 06/29/2022] [Indexed: 11/24/2022]
Abstract
Unscheduled revisits to emergency departments (EDs) are important because they indicate the quality of emergency care. However, the characteristics of pediatric patients visiting EDs changed during the coronavirus disease (COVID-19) pandemic, and these changes may have affected their revisit patterns. Therefore, we aimed to compare the ED revisit patterns of pediatric patients between the pre-COVID-19 and COVID-19 periods. This retrospective multicenter study included patients aged below 18 years who visited the ED in the pre-COVID-19 and COVID-19 periods. ED revisit rates were analyzed using five age groups and three visit-revisit intervals. In the pre-COVID-19 period, the revisit rates decreased with increasing age. In the COVID-19 period, the revisit rates were the lowest for the group aged 4–6 years, and the rates increased for those aged ≥7 years. In conclusion, there were changes in the patterns of revisit rates of pediatric patients according to age between the pre-COVID-19 and COVID-19 periods. Therefore, it is necessary to identify the reasons for revisits according to age and establish strategies to reduce the revisit rates of pediatric patients.
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Affiliation(s)
- Myeong Namgung
- Department of Emergency Medicine, College of Medicine, Chung-Ang University, Seoul 06973, Korea;
| | - Dong Hoon Lee
- Department of Emergency Medicine, College of Medicine, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University, Gwangmyeong-si 14353, Korea; (S.J.B.); (H.S.C.)
- Correspondence: ; Tel.: +82-2-2610-6751
| | - Sung Jin Bae
- Department of Emergency Medicine, College of Medicine, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University, Gwangmyeong-si 14353, Korea; (S.J.B.); (H.S.C.)
| | - Ho Sub Chung
- Department of Emergency Medicine, College of Medicine, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University, Gwangmyeong-si 14353, Korea; (S.J.B.); (H.S.C.)
| | - Ji Young Park
- Department of Pediatrics, College of Medicine, Chung-Ang University, Seoul 06973, Korea;
| | - Keon Kim
- Department of Emergency Medicine, College of Medicine, Ewha Womans University, Seoul 07804, Korea;
| | - Choung Ah Lee
- Department of Emergency Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong-si 18450, Korea;
| | - Duk Ho Kim
- Department of Emergency Medicine, Eulji University, Seoul 01830, Korea;
| | - Eui Chung Kim
- CHA Bundang Medical Center, Department of Emergency Medicine, Seongnam-si 13496, Korea;
| | - Jee Yong Lim
- Department of Emergency Medicine, Seoul St. Mary’s Hospital, Seoul 06591, Korea;
| | - Sang Soo Han
- Department of Emergency Medicine, Soonchunhyang University Bucheon Hospital, Bucheon-si 14584, Korea;
| | - Yoon Hee Choi
- Department of Emergency Medicine, College of Medicine, Ewha Womans University Mokdong Hospital, Seoul 07985, Korea;
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Leeb F, Sharma U, Yeghiazaryan L, Moll HA, Greber-Platzer S. Improving the safety of the Manchester triage system for children with congenital heart disease. Eur J Pediatr 2022; 181:3831-3838. [PMID: 36029332 PMCID: PMC9546792 DOI: 10.1007/s00431-022-04594-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 05/16/2022] [Accepted: 08/15/2022] [Indexed: 11/07/2022]
Abstract
UNLABELLED This study is a prospective evaluation of the validity of a Manchester triage system (MTS) modification for detecting under-triaged pediatric patients with congenital heart disease (CHD). Children with CHD visiting the emergency unit of the Department of Pediatrics and Adolescent Medicine, University Hospital Vienna in 2014 were included. The MTS modification updated the prioritization of patients with complex syndromic diseases, specific symptoms related to chronic diseases, decreased general condition (DGC), profound language impairment, unknown medical history, or special needs. A four-level outcome severity index based on diagnostic and therapeutic interventions, admission to hospital, and follow-up strategies was defined as a reference standard for the correct clinical classification of the MTS urgency level. Of the 19,264 included children, 940 had CHD. Of this group, 266 fulfilled the inclusion criteria for the modified triage method. The MTS modification was significantly more often applied in under-triaged (65.9%) than correctly or over-triaged (25%) children with CHD (p-value χ2 test < 0.0001, OR 5.848, 95% CI: 3.636-9.6). CONCLUSION The MTS urgency level upgrade modification could reduce under-triage in children with CHD. Applying a safety strategy concept to the MTS could mitigate under-triage in such a high-risk patient group. WHAT IS KNOWN • The Manchester triage system is considered to be valid and reliable but tends to over-triage. • A study by Seiger et al. showed poor performance in children with chronic illnesses, especially in children with cardiovascular diseases. WHAT IS NEW • The MTS modification with one urgency level upgrade could decrease under-triage in children with congenital heart disease. • As reference standard a four level outcome severity index (OSI) was established to include diagnostic investigations, medical interventions, hospital admission or follow up visits in the assessment.
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Affiliation(s)
- Franziska Leeb
- grid.22937.3d0000 0000 9259 8492Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine, Medical University Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Ursula Sharma
- grid.22937.3d0000 0000 9259 8492Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine, Medical University Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Lusine Yeghiazaryan
- grid.22937.3d0000 0000 9259 8492Center for Medical Statistics, Informatics and Intelligent Systems, Institute of Medical Statistics, Medical University Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Henriëtte A. Moll
- grid.416135.40000 0004 0649 0805Department of General Paediatrics, Erasmus MC-Sophia Children’s Hospital, Wytemaweg 80, 3015 Rotterdam, CN Netherlands
| | - Susanne Greber-Platzer
- Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine, Medical University Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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