1
|
Bacha T, Obremskey A, Buxton J, Fink EL, von Saint Andre-von Arnim A, Raees M. Practice patterns in pediatric infectious encephalopathy in four centers in Africa. Front Pediatr 2024; 12:1304245. [PMID: 38464900 PMCID: PMC10920287 DOI: 10.3389/fped.2024.1304245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 02/02/2024] [Indexed: 03/12/2024] Open
Abstract
Introduction Infectious encephalopathy (IE), including meningitis, infectious encephalitis, and cerebral abscess, remains prevalent and carries high mortality and morbidity in children, especially in low and middle income countries (LMIC). This study aims to describe the usual care and outcomes of pediatric IE in four LMIC hospitals in sub-Saharan Africa to support evidence-based care guideline development. Methods This is a secondary analysis of the Prevalence of Acute Critical Neurological disease in children: A Global Epidemiological Assessment-Developing Countries study, a 4-week, prospective, observational study in children (1 week to 17 years) with IE presenting to referral hospitals in Ethiopia, Kenya, Rwanda, and Ghana. Data collection included diagnostic testing, interventions, and patient outcomes [e.g., mortality, Pediatric Cerebral and Overall Performance Category Scores (PCPC and POPC)]. Results Seventy-two children with IE were enrolled. Most patients were diagnosed with undifferentiated IE (78%, n = 56). Specific etiologies included cerebral malaria (10%, n = 7), viral encephalitis (4%, n = 3), tuberculosis (4%, n = 3), bacterial meningitis (3%, n = 2), and cerebral abscess (1%, n = 1). Fourteen patients (20%) had a head computed tomography performed. Thirty two (44%) children had a lumbar puncture but only 9 samples (28%) were sent for culture. Median time from diagnosis to antimicrobial therapy was 3 h (IQR 1-12 h). Half (51%, n = 33) of inpatients received intracranial pressure (ICP)-directed treatment but none underwent ICP monitoring. Mortality was 13% (n = 9). The percentage of children with a favorable cognitive score decreased from 95% (n = 62) prior to admission to 80% (n = 52) and 77% (n = 50) at discharge for PCPC and POPC respectively. Discussion IE led to considerable morbidity and mortality in this cohort, and evaluation and management varied across the care continuum. Resource limitations and diagnostic constraints may have affected diagnosis-directed therapy and other aspects of management. Further studies are needed to describe the epidemiology and management of IE in LMICs to inform future treatment protocols, the role of technological and human capacity building to support both basic monitoring and interventions, as well as creative new solutions to emergency and critical care in these settings.
Collapse
Affiliation(s)
- Tigist Bacha
- Department of Pediatrics and Child Health, St. Paul Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Alexandra Obremskey
- Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - Jessica Buxton
- Department of Molecular and Cell Biology, University of California, Berkeley, CA, United States
| | - Ericka L. Fink
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Amelie von Saint Andre-von Arnim
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle Children’s, Seattle, WA, United States
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Madiha Raees
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| |
Collapse
|
2
|
Carter B, Roland D, Bray L, Harris J, Pandey P, Fox J, Carrol ED, Neill S. A systematic review of the organizational, environmental, professional and child and family factors influencing the timing of admission to hospital for children with serious infectious illness. PLoS One 2020; 15:e0236013. [PMID: 32702034 PMCID: PMC7377491 DOI: 10.1371/journal.pone.0236013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/26/2020] [Indexed: 11/26/2022] Open
Abstract
Background Infection, particularly in the first 5 years of life, is a major cause of childhood deaths globally, many deaths from infections such as pneumonia and meningococcal disease are avoidable, if treated in time. Some factors that contribute to morbidity and mortality can be modified. These include organisational and environmental factors as well as those related to the child, family or professional. Objective Examine what organizational and environmental factors and individual child, family and professional factors affect timing of admission to hospital for children with a serious infectious illness. Design Systematic review. Data sources Key search terms were identified and used to search CINAHL Plus, Medline, ASSIA, Web of Science, The Cochrane Library, Joanna Briggs Institute Database of Systematic Review. Study appraisal methods Primary research (e.g. quantitative, qualitative and mixed methods studies) and literature reviews (e.g., systematic, scoping and narrative) were included if participants included or were restricted to children under 5 years of age with serious infectious illnesses, included parents and/or first contact health care professionals in primary care, urgent and emergency care and where the research had been conducted in OECD high income countries. The Mixed Methods Appraisal Tool was used to review the methodological quality of the studies. Main findings Thirty-six papers were selected for full text review; 12 studies fitted the inclusion criteria. Factors influencing the timing of admission to hospital included the variability in children’s illness trajectories and pathways to hospital, parental recognition of symptoms and clinicians non-recognition of illness severity, parental help-seeking behaviour and clinician responses, access to services, use and non-use of ‘gut feeling’ by clinicians, and sub-optimal management within primary, secondary and tertiary services. Conclusions The pathways taken by children with a serious infectious illness to hospital are complex and influenced by a variety of potentially modifiable individual, organisational, environmental and contextual factors. Supportive, accessible, respectful services that provide continuity, clear communication, advice and safety-netting are important as is improved training for clinicians and a mandate to attend to ‘gut feeling’. Implications Relatively simple interventions such as improved communication have the potential to improve the quality of care and reduce morbidity and mortality in children with a serious infectious illness.
Collapse
Affiliation(s)
- Bernie Carter
- Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, United Kingdom
- * E-mail:
| | - Damian Roland
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Lucy Bray
- Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, United Kingdom
| | - Jane Harris
- Faculty of Health, Public Health Institute, Liverpool John Moores University, Liverpool, United Kingdom
| | - Poornima Pandey
- Children’s and Adolescent Services, Kettering General Hospital NHS Foundation Trust, Kettering, United Kingdom
| | - Jo Fox
- Faculty of Health & Social Care, University of Chester, Chester, United Kingdom
| | - Enitan D. Carrol
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Sarah Neill
- School of Nursing and Midwifery, University of Plymouth, Plymouth, United Kingdom
| |
Collapse
|
3
|
Maturana Martínez D, Aguilera-Alonso D, García Mancebo J, Navarro ML, Hernández Sampelayo T, Rincón López EM, Santiago-García B, Saavedra-Lozano J, Santos M, Cercenado E. Enfermedad meningocócica invasiva en niños y adultos en un hospital terciario: epidemiología reciente y factores pronósticos. An Pediatr (Barc) 2019; 91:296-306. [DOI: 10.1016/j.anpedi.2018.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 11/25/2018] [Accepted: 12/15/2018] [Indexed: 11/25/2022] Open
|
4
|
Maturana Martínez D, Aguilera-Alonso D, García Mancebo J, Navarro ML, Hernández Sampelayo T, Rincón López EM, Santiago-García B, Saavedra-Lozano J, Santos M, Cercenado E. Invasive meningococcal disease in children and adults in a tertiary level hospital. Recent epidemiology and prognostic factors. An Pediatr (Barc) 2019. [DOI: 10.1016/j.anpede.2019.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
|
5
|
A Validation Argument for a Simulation-Based Training Course Centered on Assessment, Recognition, and Early Management of Pediatric Sepsis. Simul Healthc 2018; 13:16-26. [PMID: 29346221 DOI: 10.1097/sih.0000000000000271] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Early recognition of sepsis remains one of the greatest challenges in medicine. Novice clinicians are often responsible for the recognition of sepsis and the initiation of urgent management. The aim of this study was to create a validity argument for the use of a simulation-based training course centered on assessment, recognition, and early management of sepsis in a laboratory-based setting. METHODS Five unique simulation scenarios were developed integrating critical sepsis cues identified through qualitative interviewing. Scenarios were piloted with groups of novice, intermediate, and expert pediatric physicians. The primary outcome was physician recognition of sepsis, measured with an adapted situation awareness global assessment tool. Secondary outcomes were physician compliance with pediatric advanced life support (PALS) guidelines and early sepsis management (ESM) recommendations, measured by two internally derived tools. Analysis compared recognition of sepsis by levels of expertise and measured association of sepsis recognition with the secondary outcomes. RESULTS Eighteen physicians were recruited, six per study group. Each physician completed three sepsis simulations. Sepsis was recognized in 19 (35%) of 54 simulations. The odds that experts recognized sepsis was 2.6 [95% confidence interval (CI) = 0.5-13.8] times greater than novices. Adjusted for severity, for every point increase in the PALS global performance score, the odds that sepsis was recognized increased by 11.3 (95% CI = 3.1-41.4). Similarly, the odds ratio for the PALS checklist score was 1.5 (95% CI = 0.8-2.6). Adjusted for severity and level of expertise, the odds of recognizing sepsis was associated with an increase in the ESM checklist score of 1.8 (95% CI = 0.9-3.6) and an increase in ESM global performance score of 4.1 (95% CI = 1.7-10.0). CONCLUSIONS Although incomplete, evidence from initial testing suggests that the simulations of pediatric sepsis were sufficiently valid to justify their use in training novice pediatric physicians in the assessment, recognition, and management of pediatric sepsis.
Collapse
|
6
|
Pollard AJ. Meningococcal Disease. THE ULSTER MEDICAL JOURNAL 2018; 87:81-82. [PMID: 29867258 PMCID: PMC5974659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Andrew J Pollard
- Department of Paediatrics, University of Oxford, Oxford, UK,E-mail:
| |
Collapse
|
7
|
Abstract
Infection with the meningococcus is one of the main causes of meningitis and septicaemia worldwide. Humans are the only natural reservoir for the meningococcus which is found primarily as a commensal inhabitant in the nasopharynx in ~10% of adults, and may be found in over 25% of individuals during adolescence. Prompt recognition of meningococcal infection and early aggressive treatment are essential in order to reduce mortality, which occurs in up to 10% of those with invasive meningococcal disease (IMD). This figure may be significantly higher in those with inadequate or delayed treatment. Early administration of effective parenteral antimicrobial therapy and prompt recognition and appropriate management of the complications of IMD, including circulatory shock and raised intracranial pressure (ICP), are critical to help improve patient outcome. This review summarizes clinical features of IMD and current treatment recommendations. We will discuss the evidence for immunization and effects of vaccine strategies, particularly following implementation of effective vaccines against Group B meningococcus.
Collapse
Affiliation(s)
- Simon Nadel
- Paediatric Intensive Care Unit, St. Mary's Hospital and Imperial College London, London, United Kingdom
| | - Nelly Ninis
- Paediatrics, St Mary's Hospital, London, United Kingdom
| |
Collapse
|
8
|
A Quality Improvement Collaborative for Pediatric Sepsis: Lessons Learned. Pediatr Qual Saf 2017; 3:e051. [PMID: 30229187 PMCID: PMC6132697 DOI: 10.1097/pq9.0000000000000051] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Accepted: 11/16/2017] [Indexed: 01/20/2023] Open
Abstract
Background: Sepsis is a leading cause of morbidity and mortality in children worldwide. Barriers exist for timely recognition and management in emergency care settings. This 1-year quality improvement collaborative sought to reduce mortality from sepsis. Methods: Fifteen hospitals participated initially. We included children with a spectrum of illness from sepsis to septic shock. The intervention bundle focused on recognition, escalation of care, and the first hour of resuscitation. We conducted monthly learning sessions and disseminated data reports of site-specific and aggregated metrics to drive rapid cycle improvement. Results: Seven sites contributed enough data to be analyzed. Of the 1,173 pediatric patients in the total cohort, 506 presented with severe sepsis/septic shock. Quarterly data demonstrated a mean improvement in initial clinical assessment from 46% to 60% (P < 0.001) and in adherence to the administration of first fluid bolus within 15 minutes from 38% to 46% (P < 0.015). There was no statistically significant improvement in other process metrics. There was no statistically significant improvement in mortality for the total cohort (sepsis to septic shock) or either of the subgroups in either 3- or 30-day mortality. Conclusions: A quality improvement collaborative focused on improving timely recognition and management of pediatric sepsis to septic shock led to some process improvements but did not show improvement in mortality. Future national efforts should standardize definitions and processes of care for sepsis to septic shock, including the identification of a “time zero” for measuring the timeliness of treatment.
Collapse
|
9
|
Ponte AGD, Jácomo RH. Capillary refill time in febrile neutropenia. Rev Assoc Med Bras (1992) 2016; 62:320-3. [PMID: 27437676 DOI: 10.1590/1806-9282.62.04.320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 05/16/2015] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Febrile neutropenia is a major cause of morbidity and mortality in patients presenting this condition following chemotherapy against several malignancies. OBJECTIVE To evaluate if capillary refill time (CRT) allows the prediction of poor clinical outcome with or without antibiotic dose escalation. METHOD Capillary refill time was assessed in 50 patients with febrile neutropenia at its nadir after chemotherapy admitted to the emergency department at Hospital Universitário de Brasília. All patients included had a minimum average arterial blood pressure of 75 mmHg, O2/FiO2 saturation rate > 300, and 15 points in the Glasgow coma scale. Inclusion depended on at least three of the systemic inflammatory response syndrome (SIRS) criteria, suspected infection, and neutropenia after chemotherapy. Capillary refill time was calculated by pressing the index finger for 15 seconds, and then timing the return to the initial color. We studied whether there is a relationship between CRT and antibiotic escalation. The gold standard used to gravity was the level of lactate. RESULTS 31 patients had CRT ≥ 3 seconds, which it is associated with increased serum concentration of lactate (> 2 mmol/L; p<0.05). 32 patients underwent antibiotic escalation, which it is associated with CRT ≥ 3 seconds (p<0.01). CONCLUSION CRT higher than three seconds was effective to predict antibiotic escalation.
Collapse
Affiliation(s)
| | - Rafael Henrique Jácomo
- PhD in Hematology from Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil
| |
Collapse
|
10
|
Invasive meningococcal disease in England: assessing disease burden through linkage of multiple national data sources. BMC Infect Dis 2015; 15:551. [PMID: 26626321 PMCID: PMC4667514 DOI: 10.1186/s12879-015-1247-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 10/28/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In England, Public Health England conducts enhanced surveillance of invasive meningococcal disease (IMD). The continuing decline in reported IMD cases has raised concerns that the MRU may be underestimating true IMD incidence. METHODS We linked five national datasets to estimate disease burden over five years, including PHE Meningococcal Reference Unit (MRU) confirmations, hospital episode statistics (HES), electronic reports of significant infections by National Health Service (NHS) Hospitals, death registrations and private laboratory reports. RESULTS During 2007-11, MRU confirmed 5115 IMD cases and 4275 (84%) matched to HES, including 3935 (92%) with A39* (meningococcal disease) and 340 (8%) with G00* (bacterial meningo-encephalitis) ICD-10 codes. An additional 2792 hospitalised cases with an A39* code were identified in HES. Of these, 1465 (52%) matched to one of 53,806 samples tested PCR-negative for IMD by MRU and only 73 of the remaining 1327 hospitalised A39* cases were confirmed locally or by a private laboratory. The characteristics of hospitalised cases without laboratory confirmation were similar to PCR-negative than PCR-positive IMD cases. CONCLUSIONS Interrogation of multiple national data sources identified very few laboratory confirmations in addition to the MRU-confirmed cases. The large number of unconfirmed and PCR-negative cases in HES suggests increased awareness among clinicians with low thresholds for hospitalising patients with suspected IMD.
Collapse
|
11
|
Tirani M, Meregaglia M, Melegaro A. Health and economic outcomes of introducing the new MenB vaccine (Bexsero) into the Italian routine infant immunisation programme. PLoS One 2015; 10:e0123383. [PMID: 25874805 PMCID: PMC4395261 DOI: 10.1371/journal.pone.0123383] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 02/20/2015] [Indexed: 01/04/2023] Open
Abstract
Introduction In January 2013 a novel type of multicomponent protein-based vaccine against group B meningococcal disease was licensed by the European Medicines Agency. With the widespread use of the meningococcal serogroup C conjugate vaccines, serogroup B remains now the major cause of bacterial meningitis and septicaemia in young children in Europe. The aim of this study is to investigate the health and the economic outcomes of MenB vaccine introduction into the Italian routine mass vaccination programme. Methods The present work is structured in two main parts. Firstly, we assess the epidemiological burden of group B meningococcal disease using official hospitalisation and notification data from two of the most populated Italian regions (Lombardia and Piemonte) during a 6-year study period (2007-2012). Secondly, we evaluate the cost-effectiveness of the immunisation programme in Italy from the public health payer perspective under base case parameters assumptions and performing a comprehensive sensitivity analysis to assess the robustness and the uncertainty of our model results. Results MenB serotype is responsible for 59% of the 341 cases of Invasive Meningococcal Disease in Lombardia and Piemonte. Incidence rate for MenB infection is estimated to be 0.21/100,000/y resulting at the highest level in children ≤4 years of age. Although the new MenB vaccine can potentially prevent about one third of the disease cases in the Italian population, model results show this strategy is unlikely to be cost-effective (ICER value over €350,000/QALY) with a vaccine that prevents disease only. These results are robust under most of the sensitivity scenarios except when allowing for lower discount rates. Discussion The introduction of the novel vaccine into the routine immunisation schedule needs to be carefully evaluated. The new MenB vaccine has the potential to reduce the disease burden at the population level. However, from the Italian Health Service perspective, the immunisation programme is unlikely to be cost-effective at the current incidence levels and vaccine price.
Collapse
Affiliation(s)
- Marcello Tirani
- Postgraduate School of Public Health, Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy
- * E-mail:
| | - Michela Meregaglia
- CeRGAS—Centre for Research on Health and Social Care Management, Bocconi University, Milan, Italy
| | - Alessia Melegaro
- Department of Policy Analysis and Public Management & Dondena Centre for Research on Social Dynamics and Public Policy, Bocconi University, Milan, Italy
| |
Collapse
|
12
|
Pollard AJ. Meningococcal disease prevention in India. Indian Pediatr 2014; 51:445-6. [PMID: 24986276 DOI: 10.1007/s13312-014-0423-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Andrew J Pollard
- Department of Paediatric Infection and Immunity, University of Oxford, and the NIHR Oxford Biomedical Research Centre, UK.
| |
Collapse
|
13
|
Bourke TW, Fairley DJ, Shields MD. Rapid diagnosis of meningococcal disease. Expert Rev Anti Infect Ther 2014; 8:1321-3. [DOI: 10.1586/eri.10.132] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
14
|
Memish Z, Al Hakeem R, Al Neel O, Danis K, Jasir A, Eibach D. Laboratory-confirmed invasive meningococcal disease: effect of the Hajj vaccination policy, Saudi Arabia, 1995 to 2011. ACTA ACUST UNITED AC 2013; 18. [PMID: 24079399 DOI: 10.2807/1560-7917.es2013.18.37.20581] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Saudi Arabia (SA) experienced two large invasive meningococcal disease (IMD) outbreaks during the 2000 and 2001 Hajj pilgrimages. In 2002, polysaccharide quadrivalent ACWY vaccines became mandatory for Mecca and Medina pilgrims/residents older than two years. This study aimed to analyse IMD surveillance data among citizens, residents and pilgrims in SA from 1995 to 2011, focusing on changes before and after the new vaccination policy. For all laboratory-confirmed IMD cases in the national surveillance database from 1995 to 2011, serogroup and age were retrieved. The cases' seasonal distribution as well as the case fatality ratios (CFR) were obtained. For Saudi citizens/residents and Hajj pilgrims, annual rates were calculated using mid-year population estimates. The Student's t-test was used to compare means between the pre-epidemic (1995-1999) and post-epidemic (2002-2011) periods, excluding outbreak years. From 1995 to 2011, laboratories notified 1,103 cases. Between the pre- and post-epidemic periods, mean annual IMD rates decreased from 0.20 (standard deviation (SD): 0.1) to 0.06 cases/100,000 (SD: 0.06; p=0.02), mean numbers of Hajj-related cases from 13 (SD: 9.3) to 2 cases/year (SD: 2.3; p=0.02) and the mean age from 31 (SD: 1.3) to 18 years (SD: 1.4; p<0.01). The CFR in Saudi citizens (10.4) was lower than among foreign pilgrims (28.9) and decreased from 19.3% (SD: 1.8) in the pre-epidemic to 11.4% (SD: 7.0; p=0.04) in the post-epidemic phase. The decrease of annual IMD rates, CFR and Hajj-related cases between the pre- and post- vaccine era suggests a possible positive effect of the mandatory ACWY vaccination for pilgrims/residents in Mecca and Medina. Regular surveillance with an annual data analysis is necessary to monitor trends and circulating serotypes and to implement appropriate public health measures to avoid new IMD epidemics during upcoming Hajj seasons.
Collapse
Affiliation(s)
- Z Memish
- Public Health Directorate, WHO Collaborating Center for Mass Gathering Medicine, Ministry of Health, Riyadh, Kingdom of Saudi Arabia
| | | | | | | | | | | |
Collapse
|
15
|
Pediatric sepsis-light at the end of the tunnel?*. Pediatr Crit Care Med 2013; 14:721-2. [PMID: 24162959 DOI: 10.1097/pcc.0b013e31829b1c05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
16
|
Wolzak NK, Cooke ML, Orth H, van Toorn R. The changing profile of pediatric meningitis at a referral centre in Cape Town, South Africa. J Trop Pediatr 2012; 58:491-5. [PMID: 22791086 DOI: 10.1093/tropej/fms031] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Pediatric meningitis remains a common cause of childhood morbidity and mortality in developing countries. Knowledge of the causative organisms in a region is of importance in guiding empiric antibiotic regimes and immunization schedules assisting decisions on primary health-care interventions. METHODS This retrospective review of 557 meningitis cases represents a third pediatric survey conducted over a 3-year period (January 2007 to December 2009) at the same institution and after an interval of 14 years. Cases were identified using cerebrospinal fluid results. Demographic and laboratory variables were collected and meningitis was classified as aseptic/viral, bacterial, septic, tuberculous meningitis (TBM) or fungal. RESULTS The commonest form of bacterial meningitis was TBM diagnosed in 22% (n = 126) of children. Streptococcus pneumoniae 4% (n = 23) and Klebsiella pneumoniae 3% (n = 17) were the next commonest causes of bacterial meningitis diagnosed. Haemophilus influenzae meningitis occurred in <1% (n = 3) of cases with a median age of 3 months. Aseptic meningitis remains the commonest category. Human immunodeficiency virus (HIV) testing was requested in 43% (n = 241) of cases; 8% (n = 46) were positive. CONCLUSION TBM remains the commonest cause of pediatric bacterial meningitis in the Western Cape. It is concerning that the percentage of TBM cases out of the total study population has more than doubled compared with that in previous surveys. The low prevalence and young age of H. influenzae meningitis cases confirm the benefits derived from H. influenzae type b (Hib) vaccination.
Collapse
Affiliation(s)
- Nena Katrina Wolzak
- Emma Children's Hospital, Academic Medical Centre, Amsterdam, The Netherlands.
| | | | | | | |
Collapse
|
17
|
Riley C, Basu RK, Kissoon N, Wheeler DS. Pediatric sepsis: preparing for the future against a global scourge. Curr Infect Dis Rep 2012; 14:503-11. [PMID: 22864953 DOI: 10.1007/s11908-012-0281-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Sepsis is a leading cause of morbidity and mortality among children worldwide. As consensus statements emerge regarding early recognition and goal-directed management of sepsis, scrutiny should be given to the unique characteristics of sepsis in children. Pediatric patients are not small adults! Sepsis epidemiology, pathophysiology, and management strategy can vary significantly from those for adults. Herein, we describe the epidemiology of pediatric sepsis, in both resource-rich and resource-poor worlds, and discuss how the pathophysiology of pediatric sepsis differs from that for adults. We discuss the timeline of management of pediatric sepsis, studying how discoveries over the past 50 years have changed the way sepsis is treated. Finally, we discuss the future of pediatric sepsis. We focus on approaches that carry the most substantive impact on the global burden of disease.
Collapse
Affiliation(s)
- Carley Riley
- Division of Critical Care Medicine, Cincinnati Children's Hospital and Medical Center, 3333 Burnet Avenue, Division of Critical Care, ML 2005, Cincinnati, OH, 45229, USA
| | | | | | | |
Collapse
|
18
|
Maiden MCJ, Frosch M. Can we, should we, eradicate the meningococcus? Vaccine 2012; 30 Suppl 2:B52-6. [PMID: 22607899 PMCID: PMC3366072 DOI: 10.1016/j.vaccine.2011.12.068] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Revised: 12/13/2011] [Accepted: 12/13/2011] [Indexed: 12/28/2022]
Abstract
The eradication of infectious agents is an attractive means of disease control that, to date, has been achieved for only one human pathogen, the smallpox virus. The introduction of vaccines against Neisseria meningitidis into immunisation schedules, and particularly the conjugate polysaccharide vaccines which can interrupt transmission, raises the question of whether disease caused by this obligate human bacterium can be controlled, eliminated, or even eradicated. The limited number of meningococcal serogroups, lack of an animal reservoir, and importance of meningococcal disease are considerations in favour of eradication; however, the commensal nature of most infections, the high diversity of meningococcal populations, and the lack of comprehensive vaccines are all factors that suggest that this is not feasible. Indeed, any such attempt might be harmful by perturbing the human microbiome and its interaction with the immune system. On balance, the control and possible elimination of disease caused by particular disease-associated meningococcal genotypes is a more achievable and worthwhile goal.
Collapse
Affiliation(s)
- Martin C J Maiden
- Department of Zoology, University of Oxford, South Parks Road, Oxford OX1 3PS, United Kingdom.
| | | |
Collapse
|
19
|
Kelly C, Sohal A, Michael BD, Riordan A, Solomon T, Kneen R. Suboptimal management of central nervous system infections in children: a multi-centre retrospective study. BMC Pediatr 2012; 12:145. [PMID: 22958329 PMCID: PMC3443041 DOI: 10.1186/1471-2431-12-145] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2012] [Accepted: 08/02/2012] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE We aimed to audit the regional management of central nervous system (CNS) infection in children. METHODS The study was undertaken in five district general hospitals and one tertiary paediatric hospital in the Mersey region of the UK. Children admitted to hospital with a suspected CNS infection over a three month period were identified. Children were aged between 4 weeks and 16 years old. Details were recorded from the case notes and electronic records. We measured the appropriateness of management pathways as outlined by national and local guidelines. RESULTS Sixty-five children were identified with a median age of 6 months (range 1 month to 15 years). Ten had a CNS infection: 4 aseptic meningitis, 3 purulent meningitis, 3 encephalitis [2 with herpes simplex virus (HSV) type 1]. A lumbar puncture (LP) was attempted in 50 (77%) cases but only 43 had cerebrospinal fluid (CSF) available for analysis. Of these 24 (57%) had a complete standard set of tests performed. Fifty eight (89%) received a third generation cephalosporin. Seventeen (26%) also received aciclovir with no obvious indication in 9 (53%). Only 11 (65%) of those receiving aciclovir had CSF herpes virus PCR. Seventeen had cranial imaging and it was the first management step in 14. Treatment lengths of both antibiotics and aciclovir were highly variable: one child with HSV encephalitis was only treated with aciclovir for 7 days. CONCLUSIONS The clinical management of children with suspected CNS infections across the Mersey region is heterogeneous and often sub-optimal, particularly for the investigation and treatment of viral encephalitis. National guidelines for the management of viral encephalitis are needed.
Collapse
Affiliation(s)
- Christine Kelly
- Neurological Infectious Disease, Brain Infections Group, Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Aman Sohal
- Paediatric Neurology Registrar, Littlewood Neurosciences Unit, Alder Hey Children’s Hospital NHS Foundation Trust, Liverpool, UK
| | - Benedict D Michael
- NIHR Doctoral Research Registrar Brain Infections Group, Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
- Division of Neurological Science, Walton Neuro-Centre NHS Foundation Trust, Liverpool, UK
| | - Andrew Riordan
- Paediatric Infectious Diseases Department of Infectious Diseases, Alder Hey Children’s Hospital NHS Foundation Trust, Liverpool, UK
| | - Tom Solomon
- Division of Neurological Science, Walton Neuro-Centre NHS Foundation Trust, Liverpool, UK
- Director, Institute for Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Rachel Kneen
- Paediatric Neurologist and Honorary Clinical Lecturer Littlewoods Neuroscience Unit, Alder Hey Children’s Hospital NHS Foundation Trust, Liverpool, L12 2AP, UK
- Brain Infections Group, Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| |
Collapse
|
20
|
Ladhani SN, Flood JS, Ramsay ME, Campbell H, Gray SJ, Kaczmarski EB, Mallard RH, Guiver M, Newbold LS, Borrow R. Invasive meningococcal disease in England and Wales: Implications for the introduction of new vaccines. Vaccine 2012; 30:3710-6. [DOI: 10.1016/j.vaccine.2012.03.011] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2011] [Revised: 02/13/2012] [Accepted: 03/05/2012] [Indexed: 01/06/2023]
|
21
|
Meningococcal disease in children in Merseyside, England: a 31 year descriptive study. PLoS One 2011; 6:e25957. [PMID: 22016791 PMCID: PMC3189236 DOI: 10.1371/journal.pone.0025957] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Accepted: 09/14/2011] [Indexed: 11/19/2022] Open
Abstract
Meningococcal disease (MCD) is the leading infectious cause of death in early childhood in the United Kingdom, making it a public health priority. MCD most commonly presents as meningococcal meningitis (MM), septicaemia (MS), or as a combination of the two syndromes (MM/MS). We describe the changing epidemiology and clinical presentation of MCD, and explore associations with socioeconomic status and other risk factors. A hospital-based study of children admitted to a tertiary children's centre, Alder Hey Children's Foundation Trust, with MCD, was undertaken between 1977 to 2007 (n = 1157). Demographics, clinical presentations, microbiological confirmation and measures of deprivation were described. The majority of cases occurred in the 1–4 year age group and there was a dramatic fall in serogroup C cases observed with the introduction of the meningococcal C conjugate (MCC) vaccine. The proportion of MS cases increased over the study period, from 11% in the first quarter to 35% in the final quarter. Presentation with MS (compared to MM) and serogroup C disease (compared to serogroup B) were demonstrated to be independent risk factors for mortality, with odds ratios of 3.5 (95% CI 1.18 to 10.08) and 2.18 (95% CI 1.26 to 3.80) respectively. Cases admitted to Alder Hey were from a relatively more deprived population (mean Townsend score 1.25, 95% CI 1.09 to 1.41) than the Merseyside reference population. Our findings represent one of the largest single-centre studies of MCD. The presentation of MS is confirmed to be a risk factor of mortality from MCD. Our study supports the association between social deprivation and MCD.
Collapse
|
22
|
Khilnani P, Singhi S, Lodha R, Santhanam I, Sachdev A, Chugh K, Jaishree M, Ranjit S, Ramachandran B, Ali U, Udani S, Uttam R, Deopujari S. Pediatric Sepsis Guidelines: Summary for resource-limited countries. Indian J Crit Care Med 2011; 14:41-52. [PMID: 20606908 PMCID: PMC2888329 DOI: 10.4103/0972-5229.63029] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Justification: Pediatric sepsis is a commonly encountered global issue. Existing guidelines for sepsis seem to be applicable to the developed countries, and only few articles are published regarding application of these guidelines in the developing countries, especially in resource-limited countries such as India and Africa. Process: An expert representative panel drawn from all over India, under aegis of Intensive Care Chapter of Indian Academy of Pediatrics (IAP) met to discuss and draw guidelines for clinical practice and feasibility of delivery of care in the early hours in pediatric patient with sepsis, keeping in view unique patient population and limited availability of equipment and resources. Discussion included issues such as sepsis definitions, rapid cardiopulmonary assessment, feasibility of early aggressive fluid therapy, inotropic support, corticosteriod therapy, early endotracheal intubation and use of positive end expiratory pressure/mechanical ventilation, initial empirical antibiotic therapy, glycemic control, and role of immunoglobulin, blood, and blood products. Objective: To achieve a reasonable evidence-based consensus on the basis of published literature and expert opinion to formulating clinical practice guidelines applicable to resource-limited countries such as India. Recommendations: Pediatric sepsis guidelines are presented in text and flow chart format keeping resource limitations in mind for countries such as India and Africa. Levels of evidence are indicated wherever applicable. It is anticipated that once the guidelines are used and outcomes data evaluated, further modifications will be necessary. It is planned to periodically review and revise these guidelines every 3–5 years as new body of evidence accumulates.
Collapse
Affiliation(s)
- Praveen Khilnani
- IAP (Intensive Care Chapter), B42 Panchsheel enclave New Delhi 110017, India
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Severe malaria and sepsis: will one fluid strategy suit both? Crit Care Med 2010; 38:1744-5. [PMID: 20647801 DOI: 10.1097/ccm.0b013e3181e876c2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
24
|
Dasgupta S, Playfor SD. Intraosseous fluid resuscitation in meningococcal disease and lower limb injury. Pediatr Rep 2010; 2:e5. [PMID: 21589841 PMCID: PMC3094012 DOI: 10.4081/pr.2010.e5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2009] [Revised: 09/24/2009] [Accepted: 10/13/2009] [Indexed: 11/23/2022] Open
Abstract
We set out to review the recent incidence of extravasation and compartment syndrome in children with meningococcal disease admitted to our Paediatric Intensive Care Unit (PICU) who had been resuscitated with intraosseous (IO) needles. Over a 12-month period, 18 children were admitted to PICU with meningococcal sepsis. Four of these children were resuscitated with IO needles and 2 developed serious complications as a result of extravasation and compartment syndrome. Clinical practice guidelines for children with severe sepsis advocate aggressive early fluid resuscitation therapy. We have identified extravasation and lower limb injury as a potential issue of increasing concern with appropriate aggressive IO fluid resuscitation in severe septic shock in children. Powered IO access systems such as the EZ-IO system offer advantages in terms of placement speed, accuracy and bone entry site profile at minimal extra financial cost.
Collapse
Affiliation(s)
- Suparna Dasgupta
- Royal Manchester Children's Hospital, Oxford Road, Manchester, UK
| | | |
Collapse
|
25
|
Mercier JC. Signes évocateurs de méningite chez le nourrisson. Med Mal Infect 2009; 39:452-61. [DOI: 10.1016/j.medmal.2009.02.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2009] [Accepted: 02/20/2009] [Indexed: 10/20/2022]
|
26
|
Caugant DA, Maiden MCJ. Meningococcal carriage and disease--population biology and evolution. Vaccine 2009; 27 Suppl 2:B64-70. [PMID: 19464092 PMCID: PMC2719693 DOI: 10.1016/j.vaccine.2009.04.061] [Citation(s) in RCA: 265] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Meningococcal disease occurs worldwide with incidence rates varying from 1 to 1000 cases per 100,000. The causative organism, Neisseria meningitidis, is an obligate commensal of humans, which normally colonizes the mucosa of the upper respiratory tract without causing invasive disease, a phenomenon known as carriage. Studies using molecular methods have demonstrated the extensive genetic diversity of meningocococci isolated from carriers, in contrast to a limited number of genetic types, known as the hyperinvasive lineages, associated with invasive disease. Population and evolutionary models that invoke positive selection can be used to resolve the apparent paradox of virulent lineages persisting during the global spread of a non-clonal and normally commensal bacterium. The application of insights gained from studies of meningococcal population biology and evolution is important in understanding the spread of disease, as well as in vaccine development and implementation, especially with regard to the challenge of producing comprehensive vaccines based on sub-capsular antigens and measuring their effectiveness.
Collapse
Affiliation(s)
- Dominique A Caugant
- WHO Collaborating Centre for Reference and Research on Meningococci, Norwegian Institute of Public Health, Oslo, Norway.
| | | |
Collapse
|
27
|
Abstract
PURPOSE OF REVIEW Paediatric sepsis continues to be a disease with unacceptably high morbidity and mortality, despite huge advances in paediatric intensive care organization and technology. This review examines the epidemiology, pathophysiology and advances in the treatment of paediatric sepsis. RECENT FINDINGS Many studies initially reporting encouraging or positive results on adult patients with sepsis have subsequently been disproved either in further studies on adults or in proof-of-principle studies on children. Publication of treatment guidelines for paediatric sepsis has led to better organization and implementation of care; however, this has yet to translate into demonstrable improvement in outcome. We will examine the major therapeutic advances of recent years and put them into the context of paediatric sepsis, examining why they often have not translated into survival benefit. SUMMARY This review aims to evaluate the recent therapeutic advances and potential for further developments in the management of paediatric sepsis in the ICU.
Collapse
|
28
|
Grimprel E. [Corticosteroids in children with bacterial meningitis: indications and administration]. Med Mal Infect 2009; 39:539-46. [PMID: 19394773 DOI: 10.1016/j.medmal.2009.02.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2009] [Accepted: 02/20/2009] [Indexed: 11/19/2022]
Abstract
The use of dexamethasone (DXM) as adjunctive therapy for bacterial meningitis (BM) in infants and children has remained controversial for 20 years. In spite of solid pathophysiological arguments, the limited number of patients, methodological flaws in clinical studies taken individually and pooled into meta-analyses, and the emergence of pneumococcal cephalosporin-resistance did not allow to reach a consensus on the effectiveness of DXM in the prevention of neurological sequelae, in the course of non Haemophilus influenzae b (Hib) BM. A recent meta-analysis conducted with an adequate number of patients (2,750 patients including 2,074 infants and children below 15 years of age) demonstrated that DXM prevented mortality and sequelae in adults with pneumococcal meningitis and suggested that this efficacy could also apply to infants and children. Data from the active surveillance networks of pediatric BM and pneumococcal resistance in France suggested that DXM anti-inflammatory effect on antibiotic CSF penetration would not have a significant impact on the bactericidal efficacy if recommended dosages of cefotaxime (300 mg/kg per day) and vancomycin (60 mg/kg per day) were used. DXM could be considered in the early treatment of pneumococcal BM in infants and children in industrialized countries. But there is no proven efficacy of DXM in meningococcal meningitis in infants and children.
Collapse
Affiliation(s)
- E Grimprel
- Groupe de pathologie infectieuse pédiatrique de la Société française de pédiatrie, France.
| |
Collapse
|
29
|
[Use of mechanical ventilation in pediatric patients]. VOJNOSANIT PREGL 2009; 65:876-81. [PMID: 19160980 DOI: 10.2298/vsp0812876m] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIM Major aims of mechanical ventilation (MV) in pediatrics mean the contribution to complete recovery of acute disorder or to establishing stability of previously long-term changed health condition. MV is used today in 16-46% of patients treated in pediatric intensive care units. The aim of this paper was to get insight into the presence of the disease and pathologic conditions and outcome of MV regarding previous health condition of pediatric patients. METHODS This retrospective study included 476 pediatric patients (beyond neonatal age) who underwent mechanical ventilation (MV). On the basis of previous health status the patients were classified in two groups: the group A consisted of 157 children with no previous chronic disease leading to MV and the group H comprised of 319 children who received MV due to worsening ofprevious chronic disease. RESULTS In both groups of pediatric patients there was significant predominance of younger age patients. Acute and chronic neurological disorders were the most frequent conditions requiring use of MV. Out of a total number (476) of the patients, 178 patients (37.40%) died. In the group A 17 patients (10.9%) died, while in the group H mortality rate was significantly higher (161 or 50.5% patients died; p < 0.01; RR 4.85; CI 3.1-7.6). Total duration time of MV in all the patients was 7 525 days, with 1 345 days (15%) accounted for the group A and 4 567 days (85%) for the group H. Mean MV duration was 7.48 (+/- 9.23) days for the patients in the group A which is significantly shorter in comparison to mean 21.8 (+/- 57.96) days for the group H patients (p < 0.001). CONCLUSION These results point out significant contribution of MV to better outcome in pediatric patients with different acute disorders. Clear dominance of chronically ill children requiring mechanical ventilation due to acute worsening of their condition implies new complexity of problems regarding organization of pediatric intensive care and treatment.
Collapse
|
30
|
Paize F, Playfor SD. Improvements in the outcome of children with meningococcal disease. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 11:172. [PMID: 18001494 PMCID: PMC2556760 DOI: 10.1186/cc6140] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Recent years have seen a marked reduction in the mortality of children with meningococcal disease in paediatric intensive care units (PICU); the reasons for this improvement are multifactorial. The mortality rates for critically ill children overall have improved and reasons for this are probably increased centralisation of PICU services and that fewer critically ill children are now looked after on adult units. Specific treatment pathways for sepsis have improved with the publication of clinical guidelines for children and initiatives such as the Surviving Sepsis Campaign. There is a continuing need to focus on the care delivered to children before reaching PICU and to minimise the morbidity suffered by survivors of this disease.
Collapse
|
31
|
Gray MP, Gour A, Davison C, Round J, Murdoch L. Indication for tracheal intubation in meningococcal disease and septic shock. Arch Dis Child 2007; 92:827. [PMID: 17715452 PMCID: PMC2084022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
|