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McCahill C, Laycock HC, Guris RJD, Chigaru L. State-of-the-art management of the acutely unwell child. Anaesthesia 2022; 77:1288-1298. [PMID: 36089884 PMCID: PMC9826095 DOI: 10.1111/anae.15816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2022] [Indexed: 01/11/2023]
Abstract
Children make up around one-fifth of all emergency department visits in the USA and UK, with an increasing trend of emergency admissions requiring intensive care. Anaesthetists play a vital role in the management of paediatric emergencies contributing to stabilisation, emergency anaesthesia, transfers and non-technical skills that optimise team performance. From neonates to adolescents, paediatric patients have diverse physiology and present with a range of congenital and acquired pathologies that often differ from the adult population. With increasing centralisation of paediatric services, staff outside these centres have less exposure to caring for children, yet are often the first responders in managing these high stakes situations. Staying abreast of the latest evidence for managing complex low frequency emergencies is a challenge. This review focuses on recent evidence and pertinent clinical updates within the field. The challenges of maintaining skills and training are explored as well as novel advancements in care.
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Affiliation(s)
- C. McCahill
- Department of AnaesthesiaGreat Ormond Street HospitalLondonUK
| | - H. C. Laycock
- Department of AnaesthesiaGreat Ormond Street HospitalLondonUK,Department of Surgery and CancerImperial CollegeLondonUK
| | - R. J. Daly Guris
- Department of Anesthesiology and Critical Care MedicineChildren's Hospital of PhiladelphiaPhiladelphiaPAUSA,Department of Anesthesiology and Critical CareUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPAUSA
| | - L. Chigaru
- Department of AnaesthesiaGreat Ormond Street HospitalLondonUK,Children's Acute Transport ServiceLondonUK
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Leung KKY, Ku SW, Hon KL, Chigaru L, Chiang AKS, Kan EYL, Oberender F. Recommendations on the Management of Interhospital Transport of Pediatric Patients With Mediastinal Mass. Pediatr Emerg Care 2022; 38:e1104-e1111. [PMID: 34417789 DOI: 10.1097/pec.0000000000002517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Children with mediastinal masses often present with insidious symptoms to nonspecialist centers and require interhospital transport to oncology centers for definitive care. We evaluated clinical characteristics and patient outcomes and proposed a management protocol. MATERIALS AND METHODS This is a retrospective review of all children with mediastinal mass at the pediatric intensive care unit of the Hong Kong Children's Hospital between April 2019 and March 2020. RESULTS Ten children with a median age of 14.5 years (interquartile range, 9.3-17.0 years) were included. Leukemia and lymphoma accounted for the majority of cases (n = 6, 60%). Nearly all patients (n = 9, 90%) required interhospital transport before definitive treatment could be instituted. There were no deaths, but 2 patients were transported with significant respiratory compromise. Among patients requiring more than 1 interhospital transport, there was a higher incidence of shortness of breath (100% vs 40%; odds ratio, 33; P = 0.048) and orthopnea (80% vs 0%; odds ratio, 33; P = 0.048), whereas none had a neck mass (0% vs 80%; odds ratio, 0.03; P = 0.048). CONCLUSIONS Children with mediastinal mass are at risk of life-threatening cardiorespiratory compromise. Pretransport assessment, planning, and stabilization along with clear management plans for deterioration during transport are crucial especially for patients who are symptomatic at time of presentation, to reduce risks associated with delays in arriving at the specialist point of care for definitive treatment.
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Affiliation(s)
- Karen Ka Yan Leung
- From the Paediatric Intensive Care Unit, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong
| | - Shu Wing Ku
- From the Paediatric Intensive Care Unit, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong
| | - Kam Lun Hon
- From the Paediatric Intensive Care Unit, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong
| | - Linda Chigaru
- Children's Acute Transport Service and Paediatric Anaesthesia, Great Ormond Street Hospital, London, United Kingdom
| | | | - Elaine Y L Kan
- Department of Radiology, Hong Kong Children's Hospital, Hong Kong
| | - Felix Oberender
- Paediatric Intensive Care Unit, Monash Children's Hospital Melbourne, Clayton, Australia
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Visram S, Potts L, Sebire NJ, Rogers Y, Broughton E, Chigaru L, Nambyiah P. Making the invisible visible: New perspectives on the intersection of human-environment interactions of clinical teams in intensive care. J Perinatol 2022; 42:503-504. [PMID: 34420042 PMCID: PMC9001169 DOI: 10.1038/s41372-021-01160-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 06/09/2021] [Accepted: 07/09/2021] [Indexed: 11/19/2022]
Abstract
Understanding human behaviour is essential to the successful adoption of new technologies, and for the promotion of safer care. This requires capturing the detail of clinical workflows to inform the design of new human-technology interactions. We are interested particularly in the possibilities for touchless technologies that can decipher human speech, gesture and motion and allow for interactions that are free of contact. Here, we employ a new approach by installing a single 360° camera into a clinical environment to analyse touch patterns and human-environment interactions across a clinical team to recommend design considerations for new technologies with the potential to reduce avoidable touch.
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Affiliation(s)
- Sheena Visram
- Department of Computer Science/UCL Interaction Centre, University College London, London, UK. .,Digital Research, Informatics and Virtual Environments (DRIVE) Centre, Great Ormond Street Hospital for Children, London, UK.
| | - Laura Potts
- grid.420468.cClinical Simulation Centre, Great Ormond Street Hospital for Children, London, UK
| | - Neil J. Sebire
- grid.420468.cDigital Research, Informatics and Virtual Environments (DRIVE) Centre, Great Ormond Street Hospital for Children, London, UK
| | - Yvonne Rogers
- grid.83440.3b0000000121901201Department of Computer Science/UCL Interaction Centre, University College London, London, UK
| | - Emma Broughton
- grid.420468.cClinical Simulation Centre, Great Ormond Street Hospital for Children, London, UK
| | - Linda Chigaru
- grid.420468.cClinical Simulation Centre, Great Ormond Street Hospital for Children, London, UK
| | - Pratheeban Nambyiah
- Clinical Simulation Centre, Great Ormond Street Hospital for Children, London, UK.
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Broughton E, Ross A, Chigaru L, Nambyiah P, Williams S, Ingram C. 175 Embracing a System-Based Approach to Simulation – The Experience of a Paediatric Hospital During a Global Pandemic. Simul Healthc 2021. [DOI: 10.54531/javb6206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The GOSH Clinical Simulation Centre (CSC) delivers an established paediatric The aim of the study was to expand the applications of our pan-trust Over the course of 18 months, simulation exercises were designed to focus on rehearsal and refinement of processes and systems, towards uncovering latent safety threats or gaps in practice. A reporting tool was developed; to capture risks and identify mitigating actions. In addition to this, an established reporting structure enabled faculty to share findings and escalate risks to the local patient safety team. The COVID-19 pandemic presented healthcare workers with many new or unfamiliar working practices. This context further shifted our focus towards systems safety simulations (SSS) with the aim of enabling teams to focus on rehearsing and preparing for new ways of working.Ten different exercises were delivered with clinical teams across the trust: successfully informing the development of five new clinical guidelines relating to COVID-19-specific practices. In one exercise alone, 11 latent safety threats (LSTs) were captured and managed with the appropriate teams (Themes from LSTs captured during COVID-19 CT transfer simulationSSS fire evacuation exercise in the IMRI suiteSSS fire evacuation exercise in the new sight and sound buildingThese exercises demonstrate the potential applications of simulation to support process and system improvement. Beyond the pandemic, we aim to continue to deliver SSS exercises to help make clinical systems and spaces safer for patients and teams. Following in the footsteps of successful simulation teams in the USA, we aim to advance this work to deliver SSS at the preconstruction level in future to inform the design of new clinical spaces.
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Peshimam N, Bruce-Hickman K, Chigaru L. Laryngeal mask airway for inter-hospital transfer: An 11-year retrospective study. Trends in Anaesthesia and Critical Care 2021. [DOI: 10.1016/j.tacc.2021.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Brown KL, Pagel C, Ridout D, Wray J, Tsang VT, Anderson D, Banks V, Barron DJ, Cassidy J, Chigaru L, Davis P, Franklin R, Grieco L, Hoskote A, Hudson E, Jones A, Kakat S, Lakhani R, Lakhanpaul M, McLean A, Morris S, Rajagopal V, Rodrigues W, Sheehan K, Stoica S, Tibby S, Utley M, Witter T. Early morbidities following paediatric cardiac surgery: a mixed-methods study. Health Serv Deliv Res 2020. [DOI: 10.3310/hsdr08300] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Background
Over 5000 paediatric cardiac surgeries are performed in the UK each year and early survival has improved to > 98%.
Objectives
We aimed to identify the surgical morbidities that present the greatest burden for patients and health services and to develop and pilot routine monitoring and feedback.
Design and setting
Our multidisciplinary mixed-methods study took place over 52 months across five UK paediatric cardiac surgery centres.
Participants
The participants were children aged < 17 years.
Methods
We reviewed existing literature, ran three focus groups and undertook a family online discussion forum moderated by the Children’s Heart Federation. A multidisciplinary group, with patient and carer involvement, then ranked and selected nine key morbidities informed by clinical views on definitions and feasibility of routine monitoring. We validated a new, nurse-administered early warning tool for assessing preoperative and postoperative child development, called the brief developmental assessment, by testing this among 1200 children. We measured morbidity incidence in 3090 consecutive surgical admissions over 21 months and explored risk factors for morbidity. We measured the impact of morbidities on quality of life, clinical burden and costs to the NHS and families over 6 months in 666 children, 340 (51%) of whom had at least one morbidity. We developed and piloted methods suitable for routine monitoring of morbidity by centres and co-developed new patient information about morbidities with parents and user groups.
Results
Families and clinicians prioritised overlapping but also different morbidities, leading to a final list of acute neurological event, unplanned reoperation, feeding problems, renal replacement therapy, major adverse events, extracorporeal life support, necrotising enterocolitis, surgical infection and prolonged pleural effusion. The brief developmental assessment was valid in children aged between 4 months and 5 years, but not in the youngest babies or 5- to 17-year-olds. A total of 2415 (78.2%) procedures had no measured morbidity. There was a higher risk of morbidity in neonates, complex congenital heart disease, increased preoperative severity of illness and with prolonged bypass. Patients with any morbidity had a 6-month survival of 81.5% compared with 99.1% with no morbidity. Patients with any morbidity scored 5.2 points lower on their total quality of life score at 6 weeks, but this difference had narrowed by 6 months. Morbidity led to fewer days at home by 6 months and higher costs. Extracorporeal life support patients had the lowest days at home (median: 43 days out of 183 days) and highest costs (£71,051 higher than no morbidity).
Limitations
Monitoring of morbidity is more complex than mortality, and hence this requires resources and clinician buy-in.
Conclusions
Evaluation of postoperative morbidity provides important information over and above 30-day survival and should become the focus of audit and quality improvement.
Future work
National audit of morbidities has been initiated. Further research is needed to understand the implications of feeding problems and renal failure and to evaluate the brief developmental assessment.
Funding
This project was funded by the NIHR Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 30. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Katherine L Brown
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Christina Pagel
- Clinical Operational Research Unit, University College London, London, UK
| | - Deborah Ridout
- Population, Policy and Practice Programme, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Jo Wray
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Victor T Tsang
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - David Anderson
- Departments of Paediatric Intensive Care, Cardiology and Cardiac Surgery, Evelina London Children’s Hospital, London, UK
| | - Victoria Banks
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - David J Barron
- Departments of Intensive Care and Paediatric Cardiac Surgery, Birmingham Children’s Hospital, Birmingham, UK
| | - Jane Cassidy
- Departments of Intensive Care and Paediatric Cardiac Surgery, Birmingham Children’s Hospital, Birmingham, UK
| | - Linda Chigaru
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Peter Davis
- Departments of Intensive Care and Paediatric Cardiac Surgery, Bristol Royal Hospital for Children, Bristol, UK
| | - Rodney Franklin
- Paediatric Cardiology Department, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Luca Grieco
- Clinical Operational Research Unit, University College London, London, UK
| | - Aparna Hoskote
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Emma Hudson
- Department of Applied Health Research, University College London, London, UK
| | - Alison Jones
- Departments of Intensive Care and Paediatric Cardiac Surgery, Birmingham Children’s Hospital, Birmingham, UK
| | - Suzan Kakat
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Rhian Lakhani
- Departments of Paediatric Intensive Care, Cardiology and Cardiac Surgery, Evelina London Children’s Hospital, London, UK
| | - Monica Lakhanpaul
- Population, Policy and Practice Programme, UCL Great Ormond Street Institute of Child Health, London, UK
- Community Child Health, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Andrew McLean
- Department of Intensive care, Royal Hospital for Children, Glasgow, UK
| | - Steve Morris
- Department of Applied Health Research, University College London, London, UK
| | - Veena Rajagopal
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Warren Rodrigues
- Department of Intensive care, Royal Hospital for Children, Glasgow, UK
| | - Karen Sheehan
- Departments of Intensive Care and Paediatric Cardiac Surgery, Bristol Royal Hospital for Children, Bristol, UK
| | - Serban Stoica
- Departments of Intensive Care and Paediatric Cardiac Surgery, Bristol Royal Hospital for Children, Bristol, UK
| | - Shane Tibby
- Departments of Paediatric Intensive Care, Cardiology and Cardiac Surgery, Evelina London Children’s Hospital, London, UK
| | - Martin Utley
- Clinical Operational Research Unit, University College London, London, UK
| | - Thomas Witter
- Departments of Paediatric Intensive Care, Cardiology and Cardiac Surgery, Evelina London Children’s Hospital, London, UK
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Desai N, Johnson M, Priddis K, Ray S, Chigaru L. Comparative evaluation of Airtraq™ and GlideScope® videolaryngoscopes for difficult pediatric intubation in a Pierre Robin manikin. Eur J Pediatr 2019; 178:1105-1111. [PMID: 31119438 DOI: 10.1007/s00431-019-03396-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 04/27/2019] [Accepted: 04/30/2019] [Indexed: 11/25/2022]
Abstract
Airway management in children is associated with anatomical and physiological challenges compared with adults. Pierre Robin sequence (PRS) is a condition characterized by micrognathia, glossoptosis, and cleft palate and related to a difficult airway. Both the Airtraq™ and GlideScope® have never been previously directly compared in PRS. Our aim was to evaluate the performance of these two airway devices in a PRS manikin for ethical and practical reasons. Between April and July 2017, 26, pediatric intensive care clinical fellows or trainees from a tertiary pediatric center were recruited to participate. In this prospective and randomized crossover trial, all participants first set up the Airtraq™ and the GlideScope® and then used these videolaryngoscopes to intubate an AirSim® PRS manikin. Our primary outcome measure was the duration of the successful intubation attempt. Duration of the successful intubation attempt was 18.1 (14.2-34.9 [10.2-51.3]) s for the Airtraq™ compared to 31.1 (18.7-55.6 [6.2-119]) s for the GlideScope® (p = 0.045). Setup time was 50.0 ± 6.9 s for the Airtraq™ and 27.8 ± 8.6 s for the GlideScope® (p < 0.001).Conclusion: Even though setup time was longer, the characteristics of intubation performance were superior with the Airtraq™ relative to the GlideScope® in an AirSim® PRS manikin. What is Known: • Several case reports have described the successful use of Airtraq™ to intubate children with Pierre Robin sequence. • The GlideScope® has demonstrated similar rates of first-attempt successful intubation to flexible fiberoptic bronchoscopy in a Pierre Robin sequence manikin. What is New: • In the hands of pediatric non-airway specialists, the characteristics of intubation performance, including the duration of the successful intubation attempt, are superior with the Airtraq™ compared with the GlideScope® in a Pierre Robin sequence manikin. • Setup time for the Airtraq™ is, however, longer relative to that for the GlideScope®.
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Affiliation(s)
- Neel Desai
- Department of Anaesthetics, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, UK.
| | - Mae Johnson
- Children's Acute Transport Service, Ormond House, 26-27 Boswell Street, London, UK
- Department of Anaesthetics, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, UK
| | - Kat Priddis
- Children's Acute Transport Service, Ormond House, 26-27 Boswell Street, London, UK
| | - Samiran Ray
- Children's Acute Transport Service, Ormond House, 26-27 Boswell Street, London, UK
- Respiratory, Critical Care and Anaesthesia Section, University College London Great Ormond Street Institute of Child Health, 30 Guildford Street, London, UK
| | - Linda Chigaru
- Children's Acute Transport Service, Ormond House, 26-27 Boswell Street, London, UK
- Department of Anaesthetics, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, UK
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Desai N, Jerrom T, Chigaru L. S-shaped tracheal tubes for videolaryngoscopy. Anaesthesia 2017; 72:1277. [PMID: 28891050 DOI: 10.1111/anae.14052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- N Desai
- Children's Acute Transport Service, London, UK
| | - T Jerrom
- Children's Acute Transport Service, London, UK
| | - L Chigaru
- Children's Acute Transport Service, London, UK
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Pagel C, Brown KL, McLeod I, Jepps H, Wray J, Chigaru L, McLean A, Treasure T, Tsang V, Utley M. Selection by a panel of clinicians and family representatives of important early morbidities associated with paediatric cardiac surgery suitable for routine monitoring using the nominal group technique and a robust voting process. BMJ Open 2017; 7:e014743. [PMID: 28554921 PMCID: PMC5729972 DOI: 10.1136/bmjopen-2016-014743] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 02/27/2017] [Accepted: 03/22/2017] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE With survival following paediatric cardiac surgery improving, the attention of quality assurance and improvement initiatives is shifting to long-term outcomes and early surgical morbidities. We wanted to involve family representatives and a range of clinicians in selecting the morbidities to be measured in a major UK study. SETTING Paediatric cardiac surgery services in the UK. PARTICIPANTS We convened a panel comprising family representatives, paediatricians from referring centres, and surgeons and other clinicians from surgical centres. PRIMARY AND SECONDARY OUTCOME MEASURES Using the nominal group technique augmented by a robust voting process to identify group preferences, suggestions for candidate morbidities were elicited, discussed, ranked and then shortlisted. The shortlist was passed to a clinical group that provided a view on the feasibility of monitoring each shortlisted morbidity in routine practice. The panel then met again to select a prioritised list of morbidities for further study, with the list finalised by the clinical group and chief investigators. RESULTS At the first panel meeting, 66 initial suggestions were made, with this reduced to a shortlist of 24 after two rounds of discussion, consolidation and voting. At the second meeting, this shortlist was reduced to 10 candidate morbidities. Two were dropped on grounds of feasibility and replaced by another the panel considered important. The final list of nine morbidities included indicators of organ damage, acute events and feeding problems. Family representatives and clinicians from outside tertiary centres brought some issues to greater prominence than if the panel had consisted solely of tertiary clinicians or study investigators. CONCLUSION The inclusion of patient and family perspectives in identifying metrics for use in monitoring a specialised clinical service is challenging but feasible and can broaden notions of quality and how to measure it.
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Affiliation(s)
| | - Katherine L Brown
- Department of Cardiorespiratory, Great Ormond Street Hospital for Children, London, UK
| | | | - Helen Jepps
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Jo Wray
- Department of Cardiorespiratory, Great Ormond Street Hospital for Children, London, UK
| | - Linda Chigaru
- Department of Cardiorespiratory, Great Ormond Street Hospital for Children, London, UK
| | | | - Tom Treasure
- Clinical Operational Research Unit, UCL, London, UK
| | - Victor Tsang
- Department of Cardiorespiratory, Great Ormond Street Hospital for Children, London, UK
| | - Martin Utley
- Clinical Operational Research Unit, UCL, London, UK
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