1
|
De Zen L, Divisic A, Molinaro G, Solidoro S, Barbi E. Dexmedetomidine at Home for Intractable Dystonia and Insomnia in Children With Special Needs: A Case Series. J Pain Symptom Manage 2023; 66:e653-e657. [PMID: 37544550 DOI: 10.1016/j.jpainsymman.2023.07.018] [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: 04/11/2023] [Revised: 07/28/2023] [Accepted: 07/30/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND We know that syndromic conditions and severe chronic diseases can be associated with symptoms that may interfere with sleep, significantly impacting the life quality of children and caregivers. Drugs commonly used in treating insomnia, such as melatonin, benzodiazepines, niaprazine, and antihistamines, are often either ineffective or associated with adverse effects, requiring new therapeutic perspectives. Dexmedetomidine is a selective alpha-2 agonist with hypnotic and anxiolytic effects, which, by stimulating alpha-2 adrenergic receptors in the locus coeruleus, induces sleep comparable to stages 2-3 of the non-REM phase without substantially affecting the respiratory drive during sedation. Its use has already been extensively described in pediatric intensive care or procedural sedation literature. In 2018, the Italian Medicines Agency (Agenzia Italiana Del Farmaco AIFA) authorized the off-label use of dexmedetomidine outside of intensive care in Children undergoing palliative treatment to control distressing symptoms related to pathology and refractory sleep disorders, and the literature reported cases of children who received dexmedetomidine at home. OBJECTIVE Our study aims to describe the home use of dexmedetomidine in children with insomnia or intractable dystonic states. MEASURES We conducted a retrospective analysis through a questionnaire addressed to 12 Italian pediatric palliative care centers regarding the home use of dexmedetomidine in sleep disorders and intractable dystonic states. INTERVENTION We collected a case series of 9 children treated with dexmedetomidine at home, 8 via intranasal and 1 via intravenous route. All children received the first drug administration in the hospital or hospice during a dedicated admission, under close monitoring of vital signs parameters for 72 hours (3 days, range 2-7 days). After discharge, the potential side effects of the drug were explained to the patient's families, and, once informed consent was obtained, the home administration of dexmedetomidine continued, with follow-up by the palliative care team. At home, dexmedetomidine was administered for 3000 days (minimum 1 month, maximum 36 months). The first patient was treated for 1095 days, from 2019 to 2021 (discontinued due to underlying condition-related death). OUTCOMES All patients observed a persistent benefit from the treatment on symptoms, and none of them discontinued dexmedetomidine administration due to drug-related adverse effects or perceived lack of therapeutic efficacy. CONCLUSIONS Therefore, its use at home may represent a promising therapeutic approach for intractable sleep disorders or dystonic states in pediatric palliative care children. Further studies are needed to confirm our results.
Collapse
Affiliation(s)
- Lucia De Zen
- Pediatric Palliative Care and Pain Service (L.D.Z., E.B.), Institute for Maternal and Child Health-IRCCS Burlo Garofolo, Trieste, Italy
| | - Antuan Divisic
- Department of Women's and Children's Health (A.D.), Pediatric Pain and Palliative Care Service, University Hospital, Padova, Italy
| | - Grazia Molinaro
- Department of Pediatrics (G.M.), Hospital of Bolzano, Bolzano, Italy
| | - Sara Solidoro
- Department of Medical, Surgical and Health Sciences (S.S., E.B.), University of Trieste, Trieste, Italy.
| | - Egidio Barbi
- Pediatric Palliative Care and Pain Service (L.D.Z., E.B.), Institute for Maternal and Child Health-IRCCS Burlo Garofolo, Trieste, Italy; Department of Medical, Surgical and Health Sciences (S.S., E.B.), University of Trieste, Trieste, Italy
| |
Collapse
|
2
|
Kubek LA, Angenendt N, Hasan C, Zernikow B, Wager J. Relevance of Potential Contributing Factors for the Development and Maintenance of Irritability of Unknown Origin in Pediatric Palliative Care. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1726. [PMID: 38002817 PMCID: PMC10670487 DOI: 10.3390/children10111726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/19/2023] [Accepted: 10/23/2023] [Indexed: 11/26/2023]
Abstract
Potential contributing factors (PCFs) for irritability of an unknown origin (IUO) in children with neurological conditions are identifiable through structured diagnostics. Uncertainty exists regarding the actual relevance of identified PCFs to IUO. Assessments from parents as well as nursing, psycho-social, and medical professionals were used to determine the contribution of different PCFs in the development and maintenance of IUO. For this, individual PCFs of N = 22 inpatient children with IUO were presented to four raters. Descriptive statistics, Kruskal-Wallis tests, and Krippendorff's alpha were used to determine which PCFs were most relevant to explain IUO and rater agreement. Psycho-social aspects (44.7%), hyperarousal (47.2%), pain (24.6%), and dystonia (18.1%) were identified as the most relevant PCFs for IUO. Descriptively, physicians' relevance rating regarding psycho-social aspects, hyperarousal, and dystonia deviated the most from the overall group rating. All professional raters considered psycho-social aspects to be more relevant than did parents. Parents rated pain as more relevant than the other raters. Kruskal-Wallis tests showed no significant differences between relevance ratings (H = 7.42, p = 0.059) or the four parties' deviations (H = 3.32, p = 0.344). A direct comparison of the six two-party constellations showed that across all factors, agreement was weak to moderate. The highest agreement was between physicians and nurses (α = 0.70), and the lowest was between nurses and psycho-social experts (α = 0.61). Understanding which psycho-social and various biological PCFs are significant for IUO can facilitate more targeted and individualized pediatric palliative care for affected patients.
Collapse
Affiliation(s)
- Larissa Alice Kubek
- PedScience Research Institute, 45711 Datteln, Germany; (B.Z.); (J.W.)
- Department of Children’s Pain Therapy and Paediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, 58448 Witten, Germany; (N.A.); (C.H.)
| | - Nina Angenendt
- Department of Children’s Pain Therapy and Paediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, 58448 Witten, Germany; (N.A.); (C.H.)
- Paediatric Palliative Care Centre, Children’s and Adolescents’ Hospital, 45711 Datteln, Germany
| | - Carola Hasan
- Department of Children’s Pain Therapy and Paediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, 58448 Witten, Germany; (N.A.); (C.H.)
- Paediatric Palliative Care Centre, Children’s and Adolescents’ Hospital, 45711 Datteln, Germany
| | - Boris Zernikow
- PedScience Research Institute, 45711 Datteln, Germany; (B.Z.); (J.W.)
- Department of Children’s Pain Therapy and Paediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, 58448 Witten, Germany; (N.A.); (C.H.)
- Paediatric Palliative Care Centre, Children’s and Adolescents’ Hospital, 45711 Datteln, Germany
| | - Julia Wager
- PedScience Research Institute, 45711 Datteln, Germany; (B.Z.); (J.W.)
- Department of Children’s Pain Therapy and Paediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, 58448 Witten, Germany; (N.A.); (C.H.)
- Paediatric Palliative Care Centre, Children’s and Adolescents’ Hospital, 45711 Datteln, Germany
| |
Collapse
|
3
|
Alotaibi Q, Dighe M, Aldaihani S. The clinical features of OSTM1-associated malignant infantile osteopetrosis: A retrospective, single-center experience over one decade. Am J Med Genet A 2023; 191:459-468. [PMID: 36369659 DOI: 10.1002/ajmg.a.63042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/24/2022] [Accepted: 10/25/2022] [Indexed: 11/15/2022]
Abstract
Mutation in OSTM1 give rise to the rarest and most lethal subtype of malignant infantile osteopetrosis (MIOP), and an improved understanding of OSTM1-associated MIOP would help with informed decision-making regarding symptom management and early palliative care referral. This retrospective study describes the clinical and laboratory features of patients with a genetic diagnosis of OSTM1 MIOP made between January 2011 and December 2021 in the Department of Pediatrics, Al-Adan Hospital, Kuwait. Twenty-two children had confirmed homozygous deletion in OSTM1 (13 females, nine males). Consanguinity was reported in almost all parents. 72.7% were diagnosed before the age of two months, most commonly incidentally with a high clinical suspicion. All 22 patients developed upper respiratory symptoms, hepatosplenomegaly, poor feeding, and had severe developmental delay. 80% of patients developed pain and/or irritability, and 40.9% were diagnosed with primary seizures. Bone fractures developed in 27% of patients, most likely iatrogenic, and some patients had hernia and gum abnormalities. The mean survival was 10.9 months. The clinical presentation, symptomatology, and mortality of our cohort were compared with other cases of OSTM1 MIOP identified through a comperhensive search of the PubMed database. The findings conclude that OSTM1 MIOP is a multi-systemic disease with distinct clinical features, of which neurological complications are the most severe and include nociplastic pain and irritability. Although orthopedic complications influence the trajectory of most patients with other forms of osteopetrosis, OSTM1 MIOP is driven by its neurological complications. Hence, OSTM1 should be regarded as a neurodegenerative disease with osteopetrosis as a comorbidity that warrants early palliative care referral.
Collapse
Affiliation(s)
| | - Manjiri Dighe
- Pediatric Department, Aladan Hospital, Al-Masayel, Kuwait
| | - Saad Aldaihani
- Pediatric Department, Aladan Hospital, Al-Masayel, Kuwait
| |
Collapse
|
4
|
HarnEnz Z, Vermilion P, Foster-Barber A, Treat L. Pediatric neuropalliative care. HANDBOOK OF CLINICAL NEUROLOGY 2023; 191:157-184. [PMID: 36599507 DOI: 10.1016/b978-0-12-824535-4.00015-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Pediatric palliative care seeks to support quality of life for children and families affected by serious illness. Children with neurological disease are among the most frequent recipients of pediatric palliative care. Several important elements distinguish pediatric palliative care from adult practice, including a longer illness duration, longitudinal relationships over the span of years, diseases characterized by chronic fragility rather than progressive pathology, and the reliance on parents as proxy decision makers. This chapter will provide an overview of pediatric neuropalliative care, with emphasis on the types of disease trajectories, symptom management, and communication principles for supporting shared decision making with families. The role of neurology expertise is highlighted throughout, with special attention toward incorporating palliative care into pediatric neurology practice.
Collapse
Affiliation(s)
- Zoe HarnEnz
- Department of Neurology, University of California San Francisco, San Francisco, CA, United States
| | - Paul Vermilion
- Department of Medicine, University of Rochester, Rochester, NY, United States
| | - Audrey Foster-Barber
- Department of Neurology, University of California San Francisco, San Francisco, CA, United States
| | - Lauren Treat
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States.
| |
Collapse
|
5
|
Kubek LA, Kutz P, Roll C, Zernikow B, Wager J. Applicability of Actigraphy for Assessing Sleep Behaviour in Children with Palliative Care Needs Benchmarked against the Gold Standard Polysomnography. J Clin Med 2022; 11:jcm11237107. [PMID: 36498681 PMCID: PMC9739292 DOI: 10.3390/jcm11237107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 11/18/2022] [Accepted: 11/29/2022] [Indexed: 12/02/2022] Open
Abstract
In children with life-limiting conditions and severe neurological impairment receiving pediatric palliative care (PPC), the degree to which actigraphy generates meaningful sleep data is uncertain. Benchmarked against the gold standard polysomnography (PSG), the applicability of actigraphy in this complex population was to be assessed. An actigraph was placed on N = 8 PPC patients during one-night polysomnography measurement in a pediatric tertiary care hospital's sleep laboratory. Patient characteristics, sleep phase data, and respiratory abnormalities are presented descriptively. Bland-Altman plots evaluated actigraphy's validity regarding sleep onset, sleep offset, wake after sleep onset (WASO), number of wake phases, total sleep time (TST) and sleep efficiency compared to PSG. PSG revealed that children spent most of their time in sleep stage 2 (46.6%) and most frequently showed central apnea (28.7%) and irregular hypopnea (14.5%). Bland-Altman plots showed that actigraphy and PSG gave similar findings for sleep onset, sleep offset, wake after sleep onset (WASO), total sleep time (TST) and sleep efficiency. Actigraphy slightly overestimated TST and sleep efficiency while underestimating all other parameters. Generally, the Actiwatch 2 low and medium sensitivity levels showed the best approximation to the PSG values. Actigraphy seems to be a promising method for detecting sleep problems in severely ill children.
Collapse
Affiliation(s)
- Larissa Alice Kubek
- PedScience Research Institute, 45711 Datteln, Germany
- Department of Children's Pain Therapy and Paediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, 58455 Witten, Germany
| | - Patrizia Kutz
- Department of Neonatology, Pediatric Intensive Care and Sleep Medicine, Children's and Adolescents' Hospital, Witten/Herdecke University, 45711 Datteln, Germany
| | - Claudia Roll
- Department of Neonatology, Pediatric Intensive Care and Sleep Medicine, Children's and Adolescents' Hospital, Witten/Herdecke University, 45711 Datteln, Germany
| | - Boris Zernikow
- PedScience Research Institute, 45711 Datteln, Germany
- Department of Children's Pain Therapy and Paediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, 58455 Witten, Germany
- Palliative Care Centre, Children's and Adolescents' Hospital, 45711 Datteln, Germany
| | - Julia Wager
- PedScience Research Institute, 45711 Datteln, Germany
- Department of Children's Pain Therapy and Paediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, 58455 Witten, Germany
- Palliative Care Centre, Children's and Adolescents' Hospital, 45711 Datteln, Germany
| |
Collapse
|
6
|
Piette V, Smets T, Deliens L, van Berlaer G, Beernaert K, Cohen J. Population-Level Analysis of Appropriateness of End-of-Life Care for Children with Neurologic Conditions. J Pediatr 2022; 255:128-136.e8. [PMID: 36372096 DOI: 10.1016/j.jpeds.2022.10.037] [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] [Received: 06/29/2022] [Revised: 09/14/2022] [Accepted: 10/09/2022] [Indexed: 11/12/2022]
Abstract
OBJECTIVE The objective of this study was to measure the appropriateness of end-of-life care for children who died with neurologic conditions. STUDY DESIGN Based on linked routinely collected databases, we conducted a population-level decedent retrospective cohort study of children with neurologic conditions who died in Belgium between 2010 and 2017. We measured a set of 22 face-validated quality indicators. The set concerns 12 indicators of potentially appropriate end-of-life care (eg, specialized comfort medication, physician contact, continuous care) and 10 indicators of potentially inappropriate end-of-life care (eg, diagnostic tests, phlebotomy). We performed ANOVA for predictors (age, sex, disease category, nationality, having siblings, year of death) for scales of appropriate and inappropriate care. RESULTS Between 2010 and 2017, 139 children with neurologic conditions died in Belgium. For potentially appropriate care, in the last 30 days, 76% of children received clinical care, 55% had continuous care relationships, 17% had contact with a general physician, 8% of children received specialized comfort medication, and 14% received care from a palliative care team. For potentially inappropriate care, in the last 14 days, 45% had blood drawn and 27% were admitted to intensive care unit. CONCLUSIONS Our study found indications of appropriate as well as inappropriate end-of-life care for children who died with neurologic conditions. These findings reveal a substantial margin for potential quality improvement, in regard to palliative care provision, multidisciplinary care, financial support, specialized comfort medication, clinical follow-up, general physician contact, diagnostics, and blood drawing.
Collapse
Affiliation(s)
- Veerle Piette
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Brussels, Belgium.
| | - Tinne Smets
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Gerlant van Berlaer
- Department of Pediatrics and Emergency Department, University Hospital Brussels, Brussels, Belgium
| | - Kim Beernaert
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Joachim Cohen
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Brussels, Belgium
| |
Collapse
|
7
|
Dreier LA, Angenendt N, Hasan C, Zernikow B, Wager J. Potential Contributing Factors for Irritability of Unknown Origin in Pediatric Palliative Care. J Pain Symptom Manage 2022; 64:156-167. [PMID: 35430284 DOI: 10.1016/j.jpainsymman.2022.04.168] [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: 12/13/2021] [Revised: 03/11/2022] [Accepted: 04/04/2022] [Indexed: 11/29/2022]
Abstract
CONTEXT In pediatric palliative care, irritability of unknown origin (IUO) in children with severe neurological impairment is a peculiarly complex and challenging symptom, yet its etiology remains poorly understood. OBJECTIVES Presenting a structured IUO diagnostic and therapeutic approach developed in a specialized inpatient pediatric palliative care facility for identifying IUO's potential contributing factors (PCFs). METHODS Prospective observational study with N = 22 children showing IUO at admission to the inpatient pediatric palliative care facility. Analysis of patient records and participation in ward routine to identify and treat PCFs. Treatment outcome was assessed using a standardized protocol for tracking IUO at 24-hour intervals. RESULTS Altogether, 136 PCFs were identified (average 6.18 per child) with pain and psycho-social problems being the most common. Two hundred and twenty-two diagnostic measures were initiated of which 159 (71.6%) helped identify a PCF. The majority of PCFs were identified by basic diagnostics (93.7%). Inpatient length of stay and duration of IUO phases correlated significantly. Between baseline (days 3-5; timing at which inpatients experientially show regular behavior) and discharge, patients showed a significant reduction in average 24-hours IUO duration by 1 hour and 26 minutes (Wilcoxon test: Z = -3.29, P < 0.01). CONCLUSION Results lead to a more thorough understanding of PCFs to IUO. Following a systematic approach such as the one presented, PCFs can be detected even by simple diagnostics. In addition to biological aspects, diagnostics and therapy should address psycho-social aspects of IUO.
Collapse
Affiliation(s)
- Larissa Alice Dreier
- PedScience Research Institute (L.A.D., B.Z., J.W.), Datteln, North Rhine-Westphalia, Germany; Department of Children's Pain Therapy and Paediatric Palliative Care (L.A.D., N.A., C.H., B.Z., J.W.), Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, North Rhine-Westphalia, Germany.
| | - Nina Angenendt
- Department of Children's Pain Therapy and Paediatric Palliative Care (L.A.D., N.A., C.H., B.Z., J.W.), Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, North Rhine-Westphalia, Germany; Paediatric Palliative Care Centre (N.A., C.H., B.Z., J.W.), Children's and Adolescents' Hospital, Datteln, North Rhine-Westphalia, Germany
| | - Carola Hasan
- Department of Children's Pain Therapy and Paediatric Palliative Care (L.A.D., N.A., C.H., B.Z., J.W.), Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, North Rhine-Westphalia, Germany; Paediatric Palliative Care Centre (N.A., C.H., B.Z., J.W.), Children's and Adolescents' Hospital, Datteln, North Rhine-Westphalia, Germany
| | - Boris Zernikow
- PedScience Research Institute (L.A.D., B.Z., J.W.), Datteln, North Rhine-Westphalia, Germany; Department of Children's Pain Therapy and Paediatric Palliative Care (L.A.D., N.A., C.H., B.Z., J.W.), Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, North Rhine-Westphalia, Germany; Paediatric Palliative Care Centre (N.A., C.H., B.Z., J.W.), Children's and Adolescents' Hospital, Datteln, North Rhine-Westphalia, Germany
| | - Julia Wager
- PedScience Research Institute (L.A.D., B.Z., J.W.), Datteln, North Rhine-Westphalia, Germany; Department of Children's Pain Therapy and Paediatric Palliative Care (L.A.D., N.A., C.H., B.Z., J.W.), Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, North Rhine-Westphalia, Germany; Paediatric Palliative Care Centre (N.A., C.H., B.Z., J.W.), Children's and Adolescents' Hospital, Datteln, North Rhine-Westphalia, Germany
| |
Collapse
|
8
|
Diskin C, Malik K, Gill PJ, Rashid N, Chan CY, Nelson KE, Thomson J, Berry J, Agrawal R, Orkin J, Cohen E. Research priorities for children with neurological impairment and medical complexity in high-income countries. Dev Med Child Neurol 2022; 64:200-208. [PMID: 34462917 PMCID: PMC9291325 DOI: 10.1111/dmcn.15037] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 07/16/2021] [Accepted: 08/03/2021] [Indexed: 02/05/2023]
Abstract
AIM To identify the highest-priority clinical research areas related to children with neurological impairment and medical complexity among clinicians and caregivers. METHOD A modified, three-stage Delphi study using online surveys and guided by a steering committee was completed. In round 1, clinicians and family caregivers suggested clinical topics and related questions that require research to support this subgroup of children. After refinement of the suggestions by the steering committee, participants contributed to 1 (family caregivers) or 2 (clinicians) subsequent rounds to develop a prioritized list. RESULTS A diverse international expert panel consisting of 49 clinicians and 12 family caregivers provided 601 responses. Responses were distilled into 26 clinical topics comprising 126 related questions. The top clinical topics prioritized for research were irritability and pain, child mental health, disorders of tone, polypharmacy, sleep, aspiration, behavior, dysautonomia, and feeding intolerance. The clinician expert panel also prioritized 10 specific research questions. INTERPRETATION Study findings support a research agenda for children with neurological impairment and medical complexity focused on addressing clinical questions, prioritized by an international group of clinicians and caregivers.
Collapse
Affiliation(s)
- Catherine Diskin
- Division of Paediatric MedicineDepartment of PaediatricsThe Hospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada
| | - Kristina Malik
- Department of PediatricsUniversity of Colorado School of MedicineAuroraCOUSA,Special Care ClinicChildren’s Hospital ColoradoAuroraCOUSA
| | - Peter J Gill
- Division of Paediatric MedicineDepartment of PaediatricsThe Hospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada,Child Health Evaluative SciencesSickKids Research InstituteTorontoOntarioCanada,Institute for Health Policy, Management and EvaluationUniversity of TorontoTorontoOntarioCanada,Centre for Evidence‐Based MedicineUniversity of OxfordOxfordUK
| | - Nada Rashid
- The Hospital for Sick ChildrenTorontoOntarioCanada
| | - Carol Y Chan
- Child Health Evaluative SciencesSickKids Research InstituteTorontoOntarioCanada
| | - Katherine E Nelson
- Division of Paediatric MedicineDepartment of PaediatricsThe Hospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada,Child Health Evaluative SciencesSickKids Research InstituteTorontoOntarioCanada,Institute for Health Policy, Management and EvaluationUniversity of TorontoTorontoOntarioCanada
| | - Joanna Thomson
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOHUSA,Division of Hospital MedicineCincinnati Children’s Hospital Medical CenterCincinnatiOHUSA
| | - Jay Berry
- Division of General PediatricsChildren’s Hospital BostonBostonMAUSA,Department of PediatricsHarvard Medical SchoolBostonMAUSA
| | - Rishi Agrawal
- Department of PediatricsHarvard Medical SchoolBostonMAUSA,Division of Hospital‐Based MedicineDepartment of PediatricsAnn & Robert H. Lurie Children’s Hospital of ChicagoNorthwestern University Feinberg School of MedicineChicagoILUSA,Section of Chronic DiseaseLa Rabida Children’s HospitalChicagoILUSA
| | - Julia Orkin
- Division of Paediatric MedicineDepartment of PaediatricsThe Hospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada,Child Health Evaluative SciencesSickKids Research InstituteTorontoOntarioCanada
| | - Eyal Cohen
- Division of Paediatric MedicineDepartment of PaediatricsThe Hospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada,Child Health Evaluative SciencesSickKids Research InstituteTorontoOntarioCanada,Institute for Health Policy, Management and EvaluationUniversity of TorontoTorontoOntarioCanada,Edwin S.H. Leong Centre for Healthy ChildrenUniversity of TorontoTorontoOntarioCanada,CanChild Centre for Childhood Disability ResearchMcMaster UniversityHamiltonOntarioCanada
| |
Collapse
|
9
|
Kernebeck S, Jux C, Busse TS, Meyer D, Dreier LA, Zenz D, Zernikow B, Ehlers JP. Participatory Design of a Medication Module in an Electronic Medical Record for Paediatric Palliative Care: A Think-Aloud Approach with Nurses and Physicians. CHILDREN (BASEL, SWITZERLAND) 2022; 9:82. [PMID: 35053707 PMCID: PMC8774744 DOI: 10.3390/children9010082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 12/19/2021] [Accepted: 01/02/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Electronic medical records (EMRs) play a key role in improving documentation and quality of care in paediatric palliative care (PPC). Inadequate EMR design can cause incorrect prescription and administration of medications. Due to the fact of complex diseases and the resulting high level of medical complexity, patients in PPC are vulnerable to medication errors. Consequently, involving users in the development process is important. Therefore, the aim of this study was to evaluate the acceptance of a medication module from the perspective of potential users in PPC and to involve them in the development process. METHODS A qualitative observational study was conducted with 10 nurses and four physicians using a concurrent think-aloud protocol and semi-structured qualitative interviews. A qualitative content analysis was applied based on a unified theory of acceptance and use of technology. RESULTS Requirements from the user's perspective could be identified as possible influences on acceptance and actual use. Requirements were grouped into the categories "performance expectancies" and "effort expectancies". CONCLUSIONS The results serve as a basis for further development. Attention should be given to the reduction of display fragmentation, as it decreases cognitive load. Further approaches to evaluation should be taken.
Collapse
Affiliation(s)
- Sven Kernebeck
- Faculty of Health, Witten/Herdecke University, 58448 Witten, Germany; (C.J.); (T.S.B.); (J.P.E.)
| | - Chantal Jux
- Faculty of Health, Witten/Herdecke University, 58448 Witten, Germany; (C.J.); (T.S.B.); (J.P.E.)
| | - Theresa Sophie Busse
- Faculty of Health, Witten/Herdecke University, 58448 Witten, Germany; (C.J.); (T.S.B.); (J.P.E.)
| | - Dorothee Meyer
- PedScience Research Institute, 45711 Datteln, Germany; (D.M.); (L.A.D.); (B.Z.)
- Department of Children’s Pain Therapy and Pediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, 58448 Witten, Germany
| | - Larissa Alice Dreier
- PedScience Research Institute, 45711 Datteln, Germany; (D.M.); (L.A.D.); (B.Z.)
- Department of Children’s Pain Therapy and Pediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, 58448 Witten, Germany
| | - Daniel Zenz
- Smart-Q Software Systems GmbH, Lise-Meitner-Allee 4, 44801 Bochum, Germany;
| | - Boris Zernikow
- PedScience Research Institute, 45711 Datteln, Germany; (D.M.); (L.A.D.); (B.Z.)
- Department of Children’s Pain Therapy and Pediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, 58448 Witten, Germany
- Paediatric Palliative Care Centre, Children’s and Adolescents’ Hospital, 45711 Datteln, Germany
| | - Jan Peter Ehlers
- Faculty of Health, Witten/Herdecke University, 58448 Witten, Germany; (C.J.); (T.S.B.); (J.P.E.)
| |
Collapse
|
10
|
Flyckt N, Wong C, Michelsen JS. Non-pharmacological and non-surgical treatment of pain in children and adolescents with cerebral palsy: A scoping review. J Pediatr Rehabil Med 2022; 15:49-67. [PMID: 35275574 DOI: 10.3233/prm-210046] [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: 11/15/2022] Open
Abstract
PURPOSE To explore the existing literature on non-pharmacological and non-surgical pain management in children and adolescents with cerebral palsy (CP). METHODS Databases (Cochrane Library, PubMed MEDLINE, Ovid Embase, and PsycINFO) were systematically searched to identify literature on non-pharmacological and non-surgical interventions for relieving pain in children with CP or similar conditions. RESULTS Thirteen publications met the inclusion criteria. Based on study designs, the overall level of evidence of the included studies was low, justifying the use of a scoping review. Only three were randomized controlled trials. Pain reduction was reported in 8 of the 13 studies from following interventions: physiotherapy/rehabilitation, massage, cranial osteopathy, swimming and aquatics, and assistive devices. These complementary strategies should not omit conventional treatment, and a multidisciplinary approach using multifaceted treatment of pharmacological and non-pharmacological therapy is recommended to increase the pain-relieving effect. CONCLUSION The results indicate that physiotherapy, massage, swimming exercise, and various assistive devices can have pain-relieving effects. We found limited evidence on the topic of non-pharmacological and non-surgical treatment of pain in children with CP. Due to the lack of power in the included studies, no true evidence-based recommendations can be made from the collected articles; thus, further studies with larger cohorts and more power are needed to substantiate evidence-based treatment of pain in children and adolescents with CP.
Collapse
Affiliation(s)
- Natasja Flyckt
- Department of Orthopedic Surgery, Hvidovre Hospital, Hvidovre, Denmark
| | - Christian Wong
- Department of Orthopedic Surgery, Hvidovre Hospital, Hvidovre, Denmark
| | | |
Collapse
|
11
|
Meyer D, Kernebeck S, Busse TS, Ehlers J, Wager J, Zernikow B, Dreier LA. Electronic Health Records in Specialized Pediatric Palliative Care: A Qualitative Needs Assessment among Professionals Experienced and Inexperienced in Electronic Documentation. CHILDREN (BASEL, SWITZERLAND) 2021; 8:249. [PMID: 33806842 PMCID: PMC8004830 DOI: 10.3390/children8030249] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 03/15/2021] [Accepted: 03/19/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Currently, to the best of our knowledge, no findings exist concerning the needs of professionals in specialized pediatric palliative care (PPC) regarding electronic health records (EHRs). Several studies have highlighted benefits concerning the use of EHRs in pediatrics. However, usability is strongly affected by the degree of adaptivity to the context of application. The aim of this study is to examine the needs of professionals concerning an EHR in the specialized PPC inpatient and outpatient settings. METHODS A qualitative research design was chosen to address the complex aspects of user demands. Focus group interviews and semi-structured one-on-one interviews were conducted with PPC professionals. N = 23 participants from inpatient and N = 11 participants from outpatient settings of specialized PPC representing various professions took part in the study. RESULTS The findings could be grouped into four categories: (1) attitude towards the current methods of documentation, (2) attitude towards electronic documentation in general, (3) general requirements for an EHR, and (4) content requirements for an EHR. CONCLUSIONS Professionals in specialized PPC expect and experience many benefits of using electronic documentation. Their requirements for an EHR for inpatient and outpatient settings of PPC are largely consistent with EHRs for pediatrics. However, individual specifications and adaptations are necessary for this particular setting.
Collapse
Affiliation(s)
- Dorothee Meyer
- PedScience Research Institute, 45711 Datteln, Germany; (J.W.); (B.Z.); (L.A.D.)
- Department of Children’s Pain Therapy and Pediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, 58448 Witten, Germany
| | - Sven Kernebeck
- Chair of Didactics and Educational Research in Health Science, Faculty of Health, Witten/Herdecke University, 58448 Witten, Germany; (S.K.); (T.S.B.); (J.E.)
| | - Theresa Sophie Busse
- Chair of Didactics and Educational Research in Health Science, Faculty of Health, Witten/Herdecke University, 58448 Witten, Germany; (S.K.); (T.S.B.); (J.E.)
| | - Jan Ehlers
- Chair of Didactics and Educational Research in Health Science, Faculty of Health, Witten/Herdecke University, 58448 Witten, Germany; (S.K.); (T.S.B.); (J.E.)
| | - Julia Wager
- PedScience Research Institute, 45711 Datteln, Germany; (J.W.); (B.Z.); (L.A.D.)
- Department of Children’s Pain Therapy and Pediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, 58448 Witten, Germany
- Pediatric Palliative Care Centre, Children’s and Adolescents’ Hospital, 45711 Datteln, Germany
| | - Boris Zernikow
- PedScience Research Institute, 45711 Datteln, Germany; (J.W.); (B.Z.); (L.A.D.)
- Department of Children’s Pain Therapy and Pediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, 58448 Witten, Germany
- Pediatric Palliative Care Centre, Children’s and Adolescents’ Hospital, 45711 Datteln, Germany
| | - Larissa Alice Dreier
- PedScience Research Institute, 45711 Datteln, Germany; (J.W.); (B.Z.); (L.A.D.)
- Department of Children’s Pain Therapy and Pediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, 58448 Witten, Germany
| |
Collapse
|
12
|
De Zen L, Della Paolera S, Del Rizzo I, Taucar V, Skabar A, Barbi E. Home Intranasal Dexmedetomidine for Refractory Dystonia in Pediatric Palliative Care. J Pain Symptom Manage 2020; 59:e3-e5. [PMID: 32145338 DOI: 10.1016/j.jpainsymman.2020.02.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 02/21/2020] [Indexed: 01/27/2023]
Affiliation(s)
- Lucia De Zen
- Pediatric Palliative Care and Pain Service, Institute for Maternal and Child Health Burlo Garofolo, Trieste, Italy
| | | | | | - Valentina Taucar
- Pediatric Palliative Care and Pain Service, Institute for Maternal and Child Health Burlo Garofolo, Trieste, Italy
| | - Aldo Skabar
- Child Neurology and Psychiatry Unit, Institute for Maternal and Child Health Burlo Garofolo, Trieste, Italy
| | - Egidio Barbi
- University of Trieste, Trieste, Italy; Pediatric Department, Institute for Maternal and Child Health Burlo Garofolo, Trieste, Italy
| |
Collapse
|
13
|
Craig F, Savino R, Scoditti S, Lucarelli E, Fanizza I, De Rinaldis M, Gennaro L, Simone M, Russo L, Trabacca A. Coping, stress and negative psychological outcomes in parents of children admitted to a pediatric neurorehabilitation care unit. Eur J Phys Rehabil Med 2019; 55:772-782. [PMID: 31290304 DOI: 10.23736/s1973-9087.19.05695-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Parents' attitudes and psychological adjustment during their child's hospitalization in a pediatric neurorehabilitation care unit are key aspects for the child's adherence to care and the impact of the disease. AIM The aim of this study was to examine the relationship between parenting stress, coping style, and negative psychological outcomes in families of children admitted for the first time to a pediatric neurorehabilitation care unit. DESIGN This is an observational study. SETTING Pediatric neurorehabilitation care unit. POPULATION One hundred twenty-four parents of children diagnosed with neurodevelopmental or neurological conditions. METHODS Parents completed standardized questionnaires assessing parenting stress, coping style, anxiety and depressive symptoms. RESULTS We found that parents of children with neurodevelopmental conditions showed more emotion-focused coping strategies (P=0.016) and depressive symptoms (P=0.01) compared with parents of children with neurological conditions. Hierarchical regression analyses showed that emotion- and avoidance-oriented coping style and socioeconomic status are crucial factors in the adjustment process of parents of children with neurodevelopmental conditions. By contrast, parenting stress and child difficulties were the most significant predictors of negative psychological outcomes in parents with neurological conditions. CONCLUSIONS This study sought to develop more understanding of the relationship among parenting stress, coping, and anxiety or depressive symptoms in parent of children hospitalized in a pediatric neurorehabilitation care unit. We suggest that examining parents may increase our understanding of the interplay between child and parent functioning in families with children admitted for the first time to a pediatric neurorehabilitation care unit. CLINICAL REHABILITATION IMPACT Identify these predictors might help professionals to develop screening procedures to identify parent at high risk for anxiety or depression, and to conduct early interventions to reduce uncertainty and maladaptive coping strategies that may influences rehabilitation process.
Collapse
Affiliation(s)
- Francesco Craig
- Unit for Severe Disabilities in Developmental Age and Young Adults, Scientific Institute, IRCCS E. Medea, Brindisi, Italy
| | - Rosa Savino
- Unit for Severe Disabilities in Developmental Age and Young Adults, Scientific Institute, IRCCS E. Medea, Brindisi, Italy
| | - Sara Scoditti
- Unit for Severe Disabilities in Developmental Age and Young Adults, Scientific Institute, IRCCS E. Medea, Brindisi, Italy
| | - Elisabetta Lucarelli
- Unit for Severe Disabilities in Developmental Age and Young Adults, Scientific Institute, IRCCS E. Medea, Brindisi, Italy
| | - Isabella Fanizza
- Unit for Severe Disabilities in Developmental Age and Young Adults, Scientific Institute, IRCCS E. Medea, Brindisi, Italy
| | - Marta De Rinaldis
- Unit for Severe Disabilities in Developmental Age and Young Adults, Scientific Institute, IRCCS E. Medea, Brindisi, Italy
| | - Leonarda Gennaro
- Unit for Severe Disabilities in Developmental Age and Young Adults, Scientific Institute, IRCCS E. Medea, Brindisi, Italy
| | - Marta Simone
- Unit for Severe Disabilities in Developmental Age and Young Adults, Scientific Institute, IRCCS E. Medea, Brindisi, Italy
| | - Luigi Russo
- Unit for Severe Disabilities in Developmental Age and Young Adults, Scientific Institute, IRCCS E. Medea, Brindisi, Italy
| | - Antonio Trabacca
- Unit for Severe Disabilities in Developmental Age and Young Adults, Scientific Institute, IRCCS E. Medea, Brindisi, Italy -
| |
Collapse
|
14
|
Slater T, Hughes G, Lumsden DE, Laddie J. Management of dystonia in paediatric palliative care. Arch Dis Child 2019; 104:102-103. [PMID: 29769175 DOI: 10.1136/archdischild-2018-315002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/01/2018] [Indexed: 11/04/2022]
Affiliation(s)
- Thomas Slater
- Department of Paediatric Neurosciences, Evelina London Children's Hospital, London, UK
| | - Gillian Hughes
- Department of Paediatric Palliative Care, Evelina London Children's Hospital, London, UK
| | - Daniel E Lumsden
- Department of Paediatric Neurosciences, Evelina London Children's Hospital, London, UK
| | - Joanna Laddie
- Department of Paediatric Palliative Care, Evelina London Children's Hospital, London, UK
| |
Collapse
|
15
|
Siden H. Pediatric Palliative Care for Children with Progressive Non-Malignant Diseases. CHILDREN-BASEL 2018; 5:children5020028. [PMID: 29461497 PMCID: PMC5835997 DOI: 10.3390/children5020028] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 02/04/2018] [Accepted: 02/12/2018] [Indexed: 11/16/2022]
Abstract
A substantial number of children cared for by pediatric palliative care physicians have progressive non-malignant conditions. Some elements of their care overlap with care for children with cancer while other elements, especially prognosis and trajectory, have nuanced differences. This article reviews the population, physical-emotional and social concerns, and trajectory.
Collapse
Affiliation(s)
- Harold Siden
- Canuck Place Children's Hospice, BC Children's Hospital, University of British Columbia, Vancouver, BC V6H 3N1, Canada.
| |
Collapse
|
16
|
Duc JK, Herbert AR, Heussler HS. Paediatric palliative care and intellectual disability—A unique context. JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2017; 30:1111-1124. [DOI: 10.1111/jar.12389] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2017] [Indexed: 01/21/2023]
Affiliation(s)
- Jacqueline K Duc
- Paediatric Palliative Care ServiceChildren's Health Queensland Australia
- Centre for Children's Health Ethics and LawQueensland Health Australia
- Faculty of MedicineUniversity of Queensland Brisbane Australia
| | - Anthony Robert Herbert
- Paediatric Palliative Care ServiceChildren's Health Queensland Australia
- Centre for Children's Health Ethics and LawQueensland Health Australia
- Faculty of MedicineUniversity of Queensland Brisbane Australia
| | - Helen S Heussler
- Paediatric Palliative Care ServiceChildren's Health Queensland Australia
- Faculty of MedicineUniversity of Queensland Brisbane Australia
- Mater Research InstituteUniversity of Queensland Brisbane Australia
| |
Collapse
|
17
|
Kuhlen M, Hoell JI, Gagnon G, Balzer S, Oommen PT, Borkhardt A, Janßen G. Effective treatment of spasticity using dronabinol in pediatric palliative care. Eur J Paediatr Neurol 2016; 20:898-903. [PMID: 27506815 DOI: 10.1016/j.ejpn.2016.07.021] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 06/15/2016] [Accepted: 07/22/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cannabis extracts have a wide therapeutic potential but in many countries they have not been approved for treatment in children so far. OBJECTIVE We conducted an open, uncontrolled, retrospective study on the administration of dronabinol to determine the value, efficacy, and safety of cannabis-based medicines in the treatment of refractory spasticity in pediatric palliative care. DESIGN AND PARTICIPANTS Sixteen children, adolescents and young adults having complex neurological conditions with spasticity (aged 1.3-26.6 years, median 12.7 years) were treated with dronabinol by our specialized pediatric palliative care team between 01.12.2010 and 30.04.2015 in a home-care setting. Therapeutic efficacy and side effects were closely monitored. RESULTS Drops of the 2.5% oily tetrahydrocannabinol solution (dronabinol) were administered. A promising therapeutic effect was seen, mostly due to abolishment or marked improvement of severe, treatment resistant spasticity (n = 12). In two cases the effect could not be determined, two patients did not benefit. The median duration of treatment was 181 days (range 23-1429 days). Dosages to obtain a therapeutic effect varied from 0.08 to 1.0 mg/kg/d with a median of 0.33 mg/kg/d in patients with a documented therapeutic effect. When administered as an escalating dosage scheme, side effects were rare and only consisted in vomiting and restlessness (one patient each). No serious and enduring side effects occurred even in young children and/or over a longer period of time. CONCLUSIONS In the majority of pediatric palliative patients the treatment with dronabinol showed promising effects in treatment resistant spasticity.
Collapse
Affiliation(s)
- Michaela Kuhlen
- University of Dusseldorf, Medical Faculty, Department of Pediatric Oncology, Hematology and Clinical Immunology, Center for Child and Adolescent Health, Moorenstr. 5, 40225 Dusseldorf, Germany.
| | - Jessica I Hoell
- University of Dusseldorf, Medical Faculty, Department of Pediatric Oncology, Hematology and Clinical Immunology, Center for Child and Adolescent Health, Moorenstr. 5, 40225 Dusseldorf, Germany
| | - Gabriele Gagnon
- University of Dusseldorf, Medical Faculty, Department of Pediatric Oncology, Hematology and Clinical Immunology, Center for Child and Adolescent Health, Moorenstr. 5, 40225 Dusseldorf, Germany
| | - Stefan Balzer
- University of Dusseldorf, Medical Faculty, Department of Pediatric Oncology, Hematology and Clinical Immunology, Center for Child and Adolescent Health, Moorenstr. 5, 40225 Dusseldorf, Germany
| | - Prasad T Oommen
- University of Dusseldorf, Medical Faculty, Department of Pediatric Oncology, Hematology and Clinical Immunology, Center for Child and Adolescent Health, Moorenstr. 5, 40225 Dusseldorf, Germany
| | - Arndt Borkhardt
- University of Dusseldorf, Medical Faculty, Department of Pediatric Oncology, Hematology and Clinical Immunology, Center for Child and Adolescent Health, Moorenstr. 5, 40225 Dusseldorf, Germany
| | - Gisela Janßen
- University of Dusseldorf, Medical Faculty, Department of Pediatric Oncology, Hematology and Clinical Immunology, Center for Child and Adolescent Health, Moorenstr. 5, 40225 Dusseldorf, Germany
| |
Collapse
|