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Ricci Conesa H, Skröder H, Norton N, Bencina G, Tsoumani E. Clinical and economic burden of acute otitis media caused by Streptococcus pneumoniae in European children, after widespread use of PCVs-A systematic literature review of published evidence. PLoS One 2024; 19:e0297098. [PMID: 38564583 PMCID: PMC10986968 DOI: 10.1371/journal.pone.0297098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 12/21/2023] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Acute otitis media (AOM) is a common childhood disease frequently caused by Streptococcus pneumoniae. Pneumococcal conjugate vaccines (PCV7, PCV10, PCV13) can reduce the risk of AOM but may also shift AOM etiology and serotype distribution. The aim of this study was to review estimates from published literature of the burden of AOM in Europe after widespread use of PCVs over the past 10 years, focusing on incidence, etiology, serotype distribution and antibiotic resistance of Streptococcus pneumoniae, and economic burden. METHODS This systematic review included published literature from 31 European countries, for children aged ≤5 years, published after 2011. Searches were conducted using PubMed, Embase, Google, and three disease conference websites. Risk of bias was assessed with ISPOR-AMCP-NPC, ECOBIAS or ROBIS, depending on the type of study. RESULTS In total, 107 relevant records were identified, which revealed wide variation in study methodology and reporting, thus limiting comparisons across outcomes. No homogenous trends were identified in incidence rates across countries, or in detection of S. pneumoniae as a cause of AOM over time. There were indications of a reduction in hospitalization rates (decreases between 24.5-38.8% points, depending on country, PCV type and time since PCV introduction) and antibiotic resistance (decreases between 14-24%, depending on country), following the widespread use of PCVs over time. The last two trends imply a potential decrease in economic burden, though this was not possible to confirm with the identified cost data. There was also evidence of an increase in serotype distributions towards non-vaccine serotypes in all of the countries where non-PCV serotype data were available, as well as limited data of increased antibiotic resistance within non-vaccine serotypes. CONCLUSIONS Though some factors point to a reduction in AOM burden in Europe, the burden still remains high, residual burden from uncovered serotypes is present and it is difficult to provide comprehensive, accurate and up-to-date estimates of said burden from the published literature. This could be improved by standardised methodology, reporting and wider use of surveillance systems.
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Affiliation(s)
| | | | | | - Goran Bencina
- Center for Observational and Real-World Evidence, MSD, Madrid, Spain
| | - Eleana Tsoumani
- Center for Observational and Real-World Evidence, MSD, Athens, Greece
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Guertin JR, Gilbert-Ouimet M, Dugas M, Carnovale V, Jalbert L, Svyntozelska O, Demers J, Matteau L, Bergeron F, LeBlanc A. Methods used to account for caregivers' sex and gender within studies examining the financial burden of caregivers of children and adolescents : Results from a scoping review. CLINICOECONOMICS AND OUTCOMES RESEARCH 2024; 16:35-53. [PMID: 38298908 PMCID: PMC10829241 DOI: 10.2147/ceor.s443077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 01/11/2024] [Indexed: 02/02/2024] Open
Abstract
Background Interest in the financial burden of informal caregivers has been growing. Unfortunately, it remains unclear which method(s) should be used when quantifying this burden. Purpose We conducted a scoping review aimed at identifying which methods have been used to conduct such work and quantified their performance. We were also interested in examining how sex and gender considerations were considered within selected studies. Data Sources Using a standardized approach, we identified studies published between 2012 and 2022 that aimed to document the financial burden of caregivers to child and adolescent patients. Our search strategy was applied to the MEDLINE, Embase, CINHAL, and Academic Search Premier databases. Study Selection Manuscript selection was performed by pairs of reviewers. Data Extraction Data extraction was performed by one reviewer with a second reviewer performing quality control. Results were reported using a narrative approach. Data Synthesis We identified 9801 unique citations, of which 200 were included in our review. Selected studies covered various disease area (eg, infection/parasitic diseases [n = 31, 16%]) and included quantitative (n = 180, 90%), qualitative (n = 4, 2%) and mixed study designs (n = 16, 8%). Most studies (n = 182, 91%) used questionnaires/surveys, either alone or in combination with other methods, to assess caregivers' financial burden. Less than half (n = 93, 47%) of studies reported on caregivers' sex and none reported on their gender. Conclusion We conducted an unrestricted review of published studies examining caregiver's financial burden which allowed us to identify general methodological trends observed in this literature. We believe this work may help improve future studies focusing on this important issue.
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Affiliation(s)
- Jason Robert Guertin
- Centre de recherche du Centre de recherche du CHU de Québec-Université Laval, Quebec City, Quebec, Canada
- Faculty of Medicine, Université Laval, Quebec City, Quebec, Canada
- Centre de recherche en organogénèse expérimentale de l’Université Laval/LOEX, Quebec City, Quebec, Canada
| | - Mahée Gilbert-Ouimet
- Centre de recherche du Centre de recherche du CHU de Québec-Université Laval, Quebec City, Quebec, Canada
- Department of Health Sciences, Université du Québec À Rimouski, Levis, Quebec, Canada
| | - Michèle Dugas
- VITAM Research Center on Sustainable Health, Quebec Integrated University Health and Social Services Center, Quebec City, Quebec, Canada
| | - Valérie Carnovale
- VITAM Research Center on Sustainable Health, Quebec Integrated University Health and Social Services Center, Quebec City, Quebec, Canada
| | - Laura Jalbert
- VITAM Research Center on Sustainable Health, Quebec Integrated University Health and Social Services Center, Quebec City, Quebec, Canada
| | - Olha Svyntozelska
- Faculty of Medicine, Université Laval, Quebec City, Quebec, Canada
- VITAM Research Center on Sustainable Health, Quebec Integrated University Health and Social Services Center, Quebec City, Quebec, Canada
| | - Juliette Demers
- VITAM Research Center on Sustainable Health, Quebec Integrated University Health and Social Services Center, Quebec City, Quebec, Canada
| | - Léonie Matteau
- Faculty of Medicine, Université Laval, Quebec City, Quebec, Canada
- Department of Health Sciences, Université du Québec À Rimouski, Levis, Quebec, Canada
| | - Frédéric Bergeron
- Bibliothèque-Direction des services-conseils, Université Laval, Quebec City, Quebec, Canada
| | - Annie LeBlanc
- Faculty of Medicine, Université Laval, Quebec City, Quebec, Canada
- VITAM Research Center on Sustainable Health, Quebec Integrated University Health and Social Services Center, Quebec City, Quebec, Canada
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Wai Wa Chan E, Liang L, Huinan Liu N, Hou WK. The moderated associations of self-compassion with physiological and psychological stress responses: Comparisons between cancer caregivers and non-caregivers. J Health Psychol 2021; 27:2318-2329. [PMID: 34281426 DOI: 10.1177/13591053211030994] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Self-compassion has been shown to be protective against stress. Whether its stress buffering effect differs between cancer caregivers and non-caregivers is unknown. This study examined the moderating effect of self-compassion among cancer caregivers relative to non-caregivers by recruiting cancer caregivers from the hospital and a community sample matching on sex and age. Participants completed a questionnaire which comprised the self-reported anxiety (STAI-6) and self-compassion (SCS-SF) measures, and administered cortisol sample collections with Salivette tubes at home. Whereas caregivers experienced higher diurnal cortisol level, the differential protective effects of self-compassion were only present against anxiety symptoms but not physiological stress.
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Affiliation(s)
- Edward Wai Wa Chan
- Centre for Psychosocial Health, The Education University of Hong Kong, China
| | - Li Liang
- Centre for Psychosocial Health, The Education University of Hong Kong, China
| | - Nancy Huinan Liu
- Centre for Psychosocial Health, The Education University of Hong Kong, China.,Department of Psychology, The Education University of Hong Kong, China
| | - Wai-Kai Hou
- Centre for Psychosocial Health, The Education University of Hong Kong, China.,Department of Psychology, The Education University of Hong Kong, China
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Quality of life in Swedish children receiving grommets - An analysis of pre- and postoperative results based on a national quality register. Int J Pediatr Otorhinolaryngol 2019; 120:44-50. [PMID: 30771552 DOI: 10.1016/j.ijporl.2019.02.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 02/03/2019] [Accepted: 02/03/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Otitis media with effusion (OME) and recurrent otitis media (rAOM) are two common diagnoses in childhood, both of which are treated with grommets, or ventilation tubes. It is known that affected children have a worse quality of life (QoL), and various questionnaires have been used to evaluate this. The national Swedish quality register for grommet insertions contains some QoL questions that have hitherto never been analysed. METHODS Data from 2010 to 2016 was extracted from the register and analysed with regards to QoL questions, reasons for surgery, hearing levels and number of AOM episodes. RESULTS Preoperative QoL data was available for 3835 children. Before surgery, most parents felt that the QoL of their children was negatively affected by the ear disease. Parents of children with OME were more likely to suspect that their child had a hearing loss (ORs 10.1 and 28.2 for suspecting a mild and severe hearing loss, respectively), but less likely to find that the ear disease affected the child's general wellbeing than did parents of children with rAOM (ORs 0.54 and 0.33 for somewhat and much affected, respectively). Many children underwent surgery despite not fulfilling the criteria for surgery as stipulated in the national guidelines. Those who did fulfil criteria, however, had a more severely affected QoL. A significant improvement was seen in individual QoL scores after surgery (p < 0.001). The degree of postoperative improvement in pure tone average correlated with the improvement in QoL (p < 0.001). CONCLUSION This is the first time that the QoL aspect has been analysed in the Swedish grommet register. Though the validity of the questions has not been proven, they provide valuable information. The relevance of the surgical criteria in national guidelines is illustrated by their correlation with the QoL questions, particularly for OME, and the postoperative improvement in QoL suggests parents find that their children benefit from surgery.
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A nationwide study on the impact of pneumococcal conjugate vaccination on antibiotic use and ventilation tube insertion in Denmark 2000-2014. Vaccine 2017; 35:5858-5863. [PMID: 28928078 DOI: 10.1016/j.vaccine.2017.09.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Revised: 08/31/2017] [Accepted: 09/01/2017] [Indexed: 11/20/2022]
Abstract
Introduction of Pneumococcal Conjugated Vaccines (PCV) in national immunization programs have been successful in reducing the number of invasive and lower respiratory pneumococcal infections. The impact of the vaccines on upper respiratory infections caused by pneumococci is less clear although these account for most pneumococcal infections. In this study, we used likely proxies for respiratory infections in children, such as antibiotic use and ventilation tube insertions (VTI), to estimate the impact of the vaccine on a national level. The study was designed as a population-based retrospective observational study, comparing trends in the incidence rate of antibiotic prescriptions and VTIs in the period 2000-2014, where PCV7 was introduced in 2007 and PCV13 in 2010. The introduction of PCV7 and PCV13 correlated with changes in the incidence rate from an almost steady increase in prescription of antibiotics in the pre-PCV period to a decreasing incidence for all children age 0-15years. The 2.4 DDD per person year in 2014 was at almost the same level of antibiotic use as in 2000 at 2.3 DDD per person year. Similar patterns were observed in the mostly vaccinated age groups below 5years of age. For VTI we observed a decreasing incidence rate in the years following introduction of PCV13 ending with a slightly higher incidence at 35 per 1000 person years in 2014 compared to 31 in year 2000. We conclude that the steady increase in antibiotic use and VTI in the pre-PCV period have been partially reversed to near year 2000 levels after the introduction of PCV. This indicates that implementation of pneumococcal vaccines in the Childhood Vaccination Programme has likely reduced the incidence of upper respiratory diseases due to pneumococci in Denmark.
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The Effect of Ventilating Tubes in Young Children with Recurrent Acute Otitis Media: an Update of the Literature. CURRENT OTORHINOLARYNGOLOGY REPORTS 2017. [DOI: 10.1007/s40136-017-0150-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Hospital clinical trial: Homeopathy (Agraphis nutans 5CH, Thuya occidentalis 5CH, Kalium muriaticum 9CH and Arsenicum iodatum 9CH) as adjuvant, in children with otitis media with effusion. Int J Pediatr Otorhinolaryngol 2016; 88:217-23. [PMID: 27497418 DOI: 10.1016/j.ijporl.2016.06.039] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 05/15/2016] [Accepted: 06/08/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Otitis media with effusion (OME) is the most common cause of paediatric hearing loss. No single treatment has proved its effectiveness. There is a lack of evidence-based medicine studies in the area of homeopathy. METHOD A prospective randomized, double blinded interventional placebo control study was conducted. Patients, from 2 months to 12 years, with OME diagnosed by pneumatic otoscopy (PNO) and tympanometry, were randomized into two groups. Both groups received aerosol therapy (mucolytics and corticosteroids). In addition, the experimental group (EG) received homeopathy (Agraphis nutans 5CH, Thuya Occidentalis 5CH, Kalium muriaticum 9CH and Arsenicum iodatum), and the placebo group (PG) placebo, both of them for 3 months. Patients were evaluated by PNO examination and tympanometry at baseline, at 45 and 90 days. RESULTS 97 patients were enrolled. In the EG, 61.9% of individuals were cured (PNO went from negative in the 1st visit to positive in the 3rd visit) compared with 56.8% of patients treated with placebo. 4.8% of patients in the EG suffered a recurrence (positive PNO in the 2nd visit changed to negative in the 3rd visit) while 11.4% did in the PG. No significant difference was found. Adverse events were distributed similarly, except in the case of upper respiratory tract infections, which were less frequent in EG (3 vs. 13, p: 0.009). CONCLUSION The homeopathic scheme used as adjuvant treatment cannot be claimed to be an effective treatment in children with OME. TRIAL REGISTRATION EUDRACT number: 2011-006086-17, PROTOCOL code: 55005646.
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Holl K, Rosenlund M, Giaquinto C, Silfverdal SA, Carmona A, Larcombe J, Garcia-Sicilia J, Fuat A, Muñoz ME, Arroba ML, Sloesen B, Vollmar J, Pirçon JY, Liese JG. The Impact of Childhood Acute Otitis Media on Parental Quality of Life in a Prospective Observational Cohort Study. Clin Drug Investig 2016; 35:613-24. [PMID: 26350522 PMCID: PMC4579255 DOI: 10.1007/s40261-015-0319-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background and Objectives Acute otitis media (AOM) not only affects childhood quality of life (QoL), but can also affect parental QoL. We adapted a previously published questionnaire on the effect of childhood recurrent ear, nose and throat infections on parental QoL for use with AOM and used it in an observational, multicentre, prospective study of children with AOM. Methods The AOM-specific parental QoL questionnaire grouped 15 items into emotional, daily disturbance, total and overall parental QoL impact scores. The questionnaire was assessed using item-convergent and item-discriminant validity criteria and internal consistency reliability; and then used with parents of children aged <6 years diagnosed with AOM at 73 practices in Germany, Italy, Spain, Sweden and the UK. Bivariate analyses explored the differences in mean parental QoL impact scores by various characteristics. Results The questionnaire demonstrated good to excellent internal consistency reliability for the various components (Cronbach’s α 0.82–0.97). There were 1419 AOM episodes among 5882 healthy children over 1 year, of which 1063 episodes (74.9 %) among 852 children had a questionnaire. Parents reported interrupted sleep (68.4 %), worry (51.0 %), altered daily schedule (44.6 %) and less leisure time (41.5 %) with a score ≥3 (1 = least to 5 = most impact). Factors that adversely affected parental QoL included: increased parental perception of AOM severity, younger child age and multiple AOM episodes. Conclusions The AOM-specific parental QoL questionnaire demonstrated good performance across five European countries. Parental QoL was affected by childhood AOM proportionally to severity, number of episodes and younger child age. Electronic supplementary material The online version of this article (doi:10.1007/s40261-015-0319-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Mats Rosenlund
- Center for Pharmacoepidemiology, Unit of Clinical Epidemiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,IMS Health, Stockholm, Sweden
| | - Carlo Giaquinto
- Department of Women's and Children's Health, University of Padova, Padua, Italy
| | - Sven-Arne Silfverdal
- Department of Clinical Sciences, Pediatrics, Umeå University, Förvaltningshuset, Umeå, Sweden
| | | | - James Larcombe
- Harbinson House Surgery, Sedgefield, Stockton-on-Tees, UK.,Centre for Integrated Health Care Research, University of Durham, Stockton-on-Tees, UK
| | | | - Ahmet Fuat
- Centre for Integrated Health Care Research, University of Durham, Stockton-on-Tees, UK.,Carmel Medical Practice, Darlington, UK
| | | | | | | | | | | | - Johannes G Liese
- Kinderklinik und Poliklinik, Universitätsklinikum Würzburg, Würzburg, Germany
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Djurhuus BD, Christensen K, Skytthe A, Faber CE. The impact of ventilation tubes in otitis media on the risk of cholesteatoma on a national level. Int J Pediatr Otorhinolaryngol 2015; 79:605-9. [PMID: 25724629 DOI: 10.1016/j.ijporl.2015.02.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Revised: 02/03/2015] [Accepted: 02/03/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To estimate the impact of treatment with middle ear ventilation tube insertion (VTI) in children with otitis media (OM) on the risk of cholesteatoma on a national level. METHODS Data were obtained from the Danish National Patient Register, the National Health Service Register and Statistics Denmark. Cumulative incidence proportions were estimated by the Kaplan-Meier method and hazard ratios with Cox regression analysis. The first surgically treated middle ear cholesteatoma in a child (STMEC1) was considered an event. RESULTS A total of 217,206 children, born after December 31, 1996, who had VTI from January 1, 1997 to August 31, 2011 were identified. Of these, 374 subsequently had a STMEC1. A corresponding 36,981 children without any VTI were identified for comparison using a random 5% sample of the Danish population. Of these, 5 had a STMEC1. The cumulative incidence proportion with STMEC1 at 12 years of age for children with 0, 1, 2, 3, and ≥4 VTI's was 0.04% (95% confidence interval 0.02-0.12%), 0.21% (0.18-0.26%), 0.35% (0.28-0.43%), 0.40% (0.30-0.54%), and 0.55% (0.44-0.70%), respectively. In the regression model each additional year of age before the first VTI increased the risk of STMEC1 by 54% (47-63%), while each additional year between two successive tube insertions increased the risk by 28% (15-43%). CONCLUSION We found that prolonged OM requiring multiple VTIs was associated with an increased risk of STMEC1. Early age at first VTI and short time between two VTIs was associated with a lower risk of STMEC1. This may be the result of reduced time with negative middle ear pressure and OM. However, these findings may be susceptible to selection bias, as age at first VTI and time between VTIs, as well as the outcome variable, STMEC1, may all depend on the underlying indication for VTI. In short the present study suggests that treatment with VTI in children with OM reduces the risk of STMEC1 on a population level. However, for the individual child the absolute risk reduction is very small, and the decision of treatment with VTI must always rely on the symptoms and clinical findings in the individual child.
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Affiliation(s)
| | - Kaare Christensen
- Epidemiology, Biostatistics and Biodemography, Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Axel Skytthe
- Epidemiology, Biostatistics and Biodemography, Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Christian Emil Faber
- Department of ENT Head & Neck Surgery, Odense University Hospital, Odense, Denmark
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Heidemann CH, Lauridsen HH, Kjeldsen AD, Faber CE, Johansen ECJ, Godballe C. Quality-of-Life Differences among Diagnostic Subgroups of Children Receiving Ventilating Tubes for Otitis Media. Otolaryngol Head Neck Surg 2015; 153:636-43. [PMID: 25676152 DOI: 10.1177/0194599815569491] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 01/06/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The pathological picture may differ considerably between diagnostic subgroups of children with otitis media receiving ventilating tubes. The aims of this study are to investigate differences in quality of life among diagnostic subgroups of children treated with ventilating tubes and to investigate possible predictors for clinical success. STUDY DESIGN Longitudinal observational study. SETTING Secondary care units. METHODS Four hundred ninety-one families were enrolled in the study. The Otitis Media-6 questionnaire was applied in the assessment of child quality of life. Caregivers completed questionnaires at 7 time points from before treatment to 18-month follow-up. Logistic regression analysis was used to investigate possible predictors for clinical success. RESULTS Response rates ranged from 96% to 81%; diagnostic distribution: 15% recurrent acute otitis media (rAOM), 47% otitis media with effusion (OME), and 38% mixed diagnosis of rAOM and OME (rAOM/OME). There were no significant differences between children diagnosed with rAOM and children diagnosed with rAOM/OME. However, these children had a significantly poorer quality of life at baseline compared with children diagnosed with only OME. Factors associated with clinical success included a diagnosis of rAOM, number of interrupted nights, physician visits, and canceled social activities due to OM. CONCLUSIONS Results highlight the importance of distinguishing between diagnostic subgroups of children having ventilating tube treatment. A diagnosis of rAOM was found to predict baseline quality of life. Children with rAOM with or without OME were found to suffer significantly more than children with only OME before treatment. Factors associated with disease severity were found to predict clinical success.
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Affiliation(s)
- Christian Hamilton Heidemann
- Department of ENT Head & Neck Surgery, Odense University Hospital, Odense C, Denmark Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense M, Denmark
| | - Henrik Hein Lauridsen
- Research Unit for Clinical Biomechanics, Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense M, Denmark
| | - Anette Drøhse Kjeldsen
- Department of ENT Head & Neck Surgery, Odense University Hospital, Odense C, Denmark Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense M, Denmark
| | - Christian Emil Faber
- Department of ENT Head & Neck Surgery, Odense University Hospital, Odense C, Denmark Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense M, Denmark
| | | | - Christian Godballe
- Department of ENT Head & Neck Surgery, Odense University Hospital, Odense C, Denmark Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense M, Denmark
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