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Santschi M, Ammann RA, Agyeman PKA, Ansari M, Bodmer N, Brack E, Koenig C. Outcome prediction in pediatric fever in neutropenia: Development of clinical decision rules and external validation of published rules based on data from the prospective multicenter SPOG 2015 FN definition study. PLoS One 2023; 18:e0287233. [PMID: 37531403 PMCID: PMC10395874 DOI: 10.1371/journal.pone.0287233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 05/21/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND Fever in neutropenia (FN) remains a serious complication of childhood cancer therapy. Clinical decision rules (CDRs) are recommended to help distinguish between children at high and low risk of severe infection. The aim of this analysis was to develop new CDRs for three different outcomes and to externally validate published CDRs. PROCEDURE Children undergoing chemotherapy for cancer were observed in a prospective multicenter study. CDRs predicting low from high risk infection regarding three outcomes (bacteremia, serious medical complications (SMC), safety relevant events (SRE)) were developed from multivariable regression models. Their predictive performance was assessed by internal cross-validation. Published CDRs suitable for validation were identified by literature search. Parameters of predictive performance were compared to assess reproducibility. RESULTS In 158 patients recruited between April 2016 and August 2018, 360 FN episodes were recorded, including 56 (16%) with bacteremia, 30 (8%) with SMC and 72 (20%) with SRE. The CDRs for bacteremia and SRE used four characteristics (type of malignancy, severely reduced general condition, leucocyte count <0.3 G/L, bone marrow involvement), the CDR for SMC two characteristics (severely reduced general condition and platelet count <50 G/L). Eleven published CDRs were analyzed. Six CDRs showed reproducibility, but only one in both sensitivity and specificity. CONCLUSIONS This analysis developed CDRs predicting bacteremia, SMC or SRE at presentation with FN. In addition, it identified six published CDRs that show some reproducibility. Validation of CDRs is fundamental to find the best balance between sensitivity and specificity, and will help to further improve management of FN.
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Affiliation(s)
- Marina Santschi
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Roland A Ammann
- Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Kinderaerzte KurWerk, Burgdorf, Switzerland
| | - Philipp K A Agyeman
- Pediatric Infectiology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marc Ansari
- Pediatric Hematology/Oncology, Department of Women, Child and Adolescent, University Hospital of Geneva, Geneva, Switzerland
- Department of Pediatrics, Gynecology, and Obstetrics, Cansearch Research Platform of Pediatric Oncology and Hematology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Nicole Bodmer
- Pediatric Oncology, University Children's Hospital of Zürich, University of Zürich, Zürich, Switzerland
| | - Eva Brack
- Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christa Koenig
- Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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2
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Tapia LI, Olivares M, Torres JP, De la Maza V, Valenzuela R, Contardo V, Tordecilla J, Álvarez AM, Varas M, Zubieta M, Salgado C, Venegas M, Gutiérrez V, Claverie X, Villarroel M, Santolaya ME. Cytokine and chemokine profiles in episodes of persistent high-risk febrile neutropenia in children with cancer. Cytokine 2021; 148:155619. [PMID: 34134910 DOI: 10.1016/j.cyto.2021.155619] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 05/31/2021] [Accepted: 06/01/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND In children with cancer and persistent high-risk febrile neutropenia (HRFN), cytokines/chemokines profiles can guide the differentiation of febrile neutropenia (FN) due to infections and episodes of unknown origin (FN-UO). METHODS A prospective, multicenter study in Santiago, Chile included patients ≤ 18 years with cancer and HRFN. Clinical and microbiological studies were performed according to validated protocols. Serum levels of 38 cytokines/chemokines were determined on day 4 of persistent HRFN. We performed comparisons between i) HRFN episodes with a detected etiological agent (FN-DEA) and FN-UO, and ii) bacterial versus viral infections. ROC curves were used to assess the discriminatory power of the analytes. RESULTS 110 HRFN episodes were enrolled (median age 8 years, 53% female). Eighty-four patients were FN-DEA: 44 bacterial, 32 viral, and 8 fungal infections. Twenty-six cases were categorized as FN-UO. Both groups presented similar clinical and laboratory characteristics. Nineteen out of 38 analytes had higher concentrations in the FN-DEA versus FN-UO group. G-CSF, IL-6, and Flt-3L showed the highest discriminatory power to detect infection (AUC 0.763, 0.741, 0.701). Serum levels of G-CSF differentiated bacterial infections and IP-10 viral agents. A combination of G-CSF, IL-6, Flt-3L, and IP-10 showed an AUC of 0.839, 75% sensitivity, and 81% specificity. CONCLUSION A specific immune response is present on day four of persistent HRFN in children with cancer. We propose a combined measure of serum concentrations of G-CSF, IL-6, IP-10, and Flt-3L, in order to predict the presence of an infectious agent as compared to an episode of FN with unknown origin.
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Affiliation(s)
- Lorena I Tapia
- Department of Pediatrics, Hospital Dr. Luis Calvo Mackenna, Faculty of Medicine, Universidad de Chile, Santiago, Chile; Department of Pediatrics, Hospital Roberto del Río, Faculty of Medicine, Universidad de Chile, Santiago, Chile.
| | - Mauricio Olivares
- Department of Pediatrics, Hospital Dr. Luis Calvo Mackenna, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Juan P Torres
- Department of Pediatrics, Hospital Dr. Luis Calvo Mackenna, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Verónica De la Maza
- Department of Pediatrics, Hospital Dr. Luis Calvo Mackenna, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Romina Valenzuela
- Department of Pediatrics, Hospital Dr. Luis Calvo Mackenna, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Verónica Contardo
- Department of Pediatrics, Hospital Roberto del Río, Faculty of Medicine, Universidad de Chile, Santiago, Chile; Committee of Infectious Diseases, National Child Programme of Antineoplastic Drugs (PINDA), Santiago, Chile
| | - Juan Tordecilla
- Department of Pediatrics, Hospital Roberto del Río, Faculty of Medicine, Universidad de Chile, Santiago, Chile; Committee of Infectious Diseases, National Child Programme of Antineoplastic Drugs (PINDA), Santiago, Chile
| | - Ana M Álvarez
- Department of Pediatrics, Hospital San Juan de Dios, Faculty of Medicine, Universidad de Chile, Santiago, Chile; Committee of Infectious Diseases, National Child Programme of Antineoplastic Drugs (PINDA), Santiago, Chile
| | - Mónica Varas
- Department of Pediatrics, Hospital San Juan de Dios, Faculty of Medicine, Universidad de Chile, Santiago, Chile; Committee of Infectious Diseases, National Child Programme of Antineoplastic Drugs (PINDA), Santiago, Chile
| | - Marcela Zubieta
- Department of Pediatrics, Hospital Exequiel González Cortés, Faculty of Medicine, Universidad de Chile, Santiago, Chile; Committee of Infectious Diseases, National Child Programme of Antineoplastic Drugs (PINDA), Santiago, Chile
| | - Carmen Salgado
- Department of Pediatrics, Hospital Exequiel González Cortés, Faculty of Medicine, Universidad de Chile, Santiago, Chile; Committee of Infectious Diseases, National Child Programme of Antineoplastic Drugs (PINDA), Santiago, Chile
| | - Marcela Venegas
- Department of Pediatrics, Hospital San Borja Arriarán, Faculty of Medicine, Universidad de Chile, Santiago, Chile; Committee of Infectious Diseases, National Child Programme of Antineoplastic Drugs (PINDA), Santiago, Chile
| | - Valentina Gutiérrez
- Department of Pediatrics, Hospital Dr. Sótero del Río, Santiago, Chile; Committee of Infectious Diseases, National Child Programme of Antineoplastic Drugs (PINDA), Santiago, Chile
| | - Ximena Claverie
- Department of Pediatrics, Hospital Dr. Sótero del Río, Santiago, Chile; Committee of Infectious Diseases, National Child Programme of Antineoplastic Drugs (PINDA), Santiago, Chile
| | - Milena Villarroel
- Department of Pediatrics, Hospital Dr. Luis Calvo Mackenna, Faculty of Medicine, Universidad de Chile, Santiago, Chile; Committee of Infectious Diseases, National Child Programme of Antineoplastic Drugs (PINDA), Santiago, Chile
| | - María E Santolaya
- Department of Pediatrics, Hospital Dr. Luis Calvo Mackenna, Faculty of Medicine, Universidad de Chile, Santiago, Chile; Committee of Infectious Diseases, National Child Programme of Antineoplastic Drugs (PINDA), Santiago, Chile.
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3
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Pérez-Heras Í, Raynero-Mellado RC, Díaz-Merchán R, Domínguez-Pinilla N. Post chemotherapy febrile neutropenia. Length of stay and experience in our population. An Pediatr (Barc) 2020. [DOI: 10.1016/j.anpede.2019.05.008] [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
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Neutropenia febril posquimioterapia. Estancia hospitalaria y experiencia en nuestro medio. An Pediatr (Barc) 2020; 92:141-146. [DOI: 10.1016/j.anpedi.2019.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 04/17/2019] [Accepted: 05/21/2019] [Indexed: 11/19/2022] Open
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Arif T, Phillips RS. Updated systematic review and meta-analysis of the predictive value of serum biomarkers in the assessment and management of fever during neutropenia in children with cancer. Pediatr Blood Cancer 2019; 66:e27887. [PMID: 31250539 DOI: 10.1002/pbc.27887] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 06/01/2019] [Accepted: 06/03/2019] [Indexed: 11/12/2022]
Abstract
Routinely measurable biomarkers as predictors for adverse outcomes in febrile neutropenia could improve management through risk stratification. This systematic review assesses the predictive role of biomarkers in identifying events such as bacteraemia, clinically documented infections, microbiologically documented infection, severe sepsis requiring intensive care or high dependency care and death. This review collates 8319 episodes from 4843 patients. C-reactive protein (CRP), interleukin (IL)-6, IL-8 and procalcitonin (PCT) consistently predict bacteraemia and severe sepsis; other outcomes have highly heterogeneous results. Performance of the biomarkers at admission using different thresholds demonstrates that PCT > 0.5 ng/mL offers the best compromise between sensitivity and specificity: sensitivity 0.67 (confidence interval [CI] 0.53-0.79) specificity 0.73 (CI 0.66-0.77). Seventeen studies describe the use of serial biomarkers, with PCT having the greatest discriminatory role. Biomarkers, potentially with serial measurements, may predict adverse outcomes in paediatric febrile neutropenia and their role in risk stratification is promising.
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Affiliation(s)
- Tasnim Arif
- Department of Paediatric Haematology and Oncology, Great North Children's Hospital, Royal Victoria Infirmary, Newcastle Upon Tyne, United Kingdom
| | - Robert S Phillips
- Centre for Reviews and Dissemination, University of York, York, United Kingdom.,Department of Paediatric Haematology and Oncology, Leeds Teaching Hospital NHS Trust, Leeds, United Kingdom
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Hatamabadi H, Arhami Dolatabadi A, Akhavan A, Safari S. Clinical Characteristics and Associated Factors of Mortality in Febrile Neutropenia Patients; a Cross Sectional Study. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2019; 7:39. [PMID: 31555769 PMCID: PMC6732199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION The duration and severity of neutropenia directly correlate with the incidence of life-threatening infections. This study aimed to evaluate the clinical characteristics and associated factors of mortality in febrile neutropenia patients. METHOD This retrospective cross sectional study was conducted on all febrile neutropenia patients who were admitted to oncology department of two educational hospitals, Tehran, Iran, from 2011 to 2016. Available patients' data regarding baseline characteristics, treatment, and outcome were collected and analyzed using SPSS 21. RESULTS 357 patients with the mean age of 50.9±17.7 years were studied (59.7% female). Mean white blood cell count of the studied patients was 715.1 ± 270.4 (100 - 1400) cells/mm3. The absolute neutrophil count (ANC) of all patients was <500 cells/mm3. The most frequent sources of malignancy in studied patients were gastrointestinal (35.9%), breast (22.4%), and sarcoma (15.7%), respectively. The mean time interval between initiation of treatment in ED and increase of ANC to > 500 cells/mm3 was 2.45 ± 2.1 (1 - 16) days. 186 (52.1%) subjects reached ANC>500 cells/ mm3 after 2-5 days of hospitalization. The rate of hospital mortality was 5.3% (338 (94.7%) survived). The correlation between gender (p = 0.11), temperature (p = 0.123), number of ED visits (p = 0.765), presenting clinical manifestation (p = 0.201), source of malignancy (p= 0.328), presence of metastasis (p = 0.69), positive urine culture (p = 0.45), positive blood culture (p = 0.62), time from last chemotherapy (p = 0.677), and time to reach ANC>500 cells/mm3 (p = 0.739) with mortality was not significant. CONCLUSION Based on the findings of the present study, the rate of hospital mortality in patients with febrile neutropenia was 5.3%. Older age and lower white blood cell count were among the significant associated factors of mortality in this series.
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Affiliation(s)
- Hamidreza Hatamabadi
- Safety Promotion and Injury Prevention Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Arhami Dolatabadi
- Emergency Department, Imam Hossein Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ayda Akhavan
- Emergency Department, Imam Hossein Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Corresponding Author: Ayda Akhavan; Emergency Department, Imam Hossein
Hospital, Madani Avenue, Imam Hossein Square, Tehran, Iran. aydaakhavan@
yahoo.com
| | - Saeed Safari
- Emergency Department, Shohadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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7
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Fenton AN, Kretschmar PK, Steele RW, Fletcher MB, Warrier R. Procalcitonin to Identify Neoplastic Inflammation. Clin Pediatr (Phila) 2019; 58:918-920. [PMID: 30991827 DOI: 10.1177/0009922819843630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Anne N Fenton
- 1 Tulane University, New Orleans, LA, USA.,2 Ochsner Children's Hospital, New Orleans, LA, USA
| | - Paige K Kretschmar
- 1 Tulane University, New Orleans, LA, USA.,2 Ochsner Children's Hospital, New Orleans, LA, USA
| | - Russel W Steele
- 1 Tulane University, New Orleans, LA, USA.,2 Ochsner Children's Hospital, New Orleans, LA, USA.,3 University of Queensland, Brisbane, Queensland, Australia
| | - Matthew B Fletcher
- 1 Tulane University, New Orleans, LA, USA.,2 Ochsner Children's Hospital, New Orleans, LA, USA.,3 University of Queensland, Brisbane, Queensland, Australia
| | - Rajasekharan Warrier
- 1 Tulane University, New Orleans, LA, USA.,2 Ochsner Children's Hospital, New Orleans, LA, USA.,3 University of Queensland, Brisbane, Queensland, Australia
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8
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Jacquet J, Catala G, Machiels JP, Penaloza A. Neutropénie fébrile aux urgences, stratification du risque et conditions du retour à domicile. ANNALES FRANCAISES DE MEDECINE D URGENCE 2019. [DOI: 10.3166/afmu-2019-0133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
La neutropénie fébrile (NF) est une situation fréquemment rencontrée aux urgences avec un taux de mortalité non négligeable variant de 5 à 40 %. Cette variabilité importante met en avant l’importance de stratifier le risque afin de permettre un traitement ambulatoire per os de certains patients à faible risque. En plus du MASCC (The Multinational Association for Supportive Care in Cancer) score, d’autres outils permettent d’évaluer ce risque ou sont à l’étude dans ce but, tels que le dosage de la CRP, la procalcitonine ou encore le score CISNE. Après une prise en charge rapide aux urgences incluant l’administration sans délai d’un traitement adéquat, la poursuite de l’antibiothérapie per os à domicile est envisageable chez les patients à faible risque. La combinaison amoxicilline–acide clavulanique et ciprofloxacine est le plus souvent recommandée, mais la moxifloxacine ou la lévofloxacine en monothérapie peuvent également être utilisées pour les patients traités à domicile. Le retour à domicile permet de réduire fortement les coûts engendrés par l’hospitalisation, de diminuer le risque d’infection nosocomiale et d’améliorer la qualité de vie des patients avec NF à faible risque. Dans cette optique, plusieurs critères doivent être remplis, et une discussion avec le patient reste primordiale à la prise de décision. Parmi ceux-ci, nous retiendrons notamment un score MASCC supérieur à 21, une durée attendue de neutropénie inférieure à sept jours, l’accord du patient et de son entourage ainsi que la proximité entre le domicile et un service de soin adapté.
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Bobillo-Perez S, Rodríguez-Fanjul J, Jordan Garcia I. Is Procalcitonin Useful in Pediatric Critical Care Patients? Biomark Insights 2018; 13:1177271918792244. [PMID: 30093797 PMCID: PMC6081751 DOI: 10.1177/1177271918792244] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 07/11/2018] [Indexed: 12/11/2022] Open
Abstract
This review examines the use of procalcitonin in different clinical situations in the pediatric patient, with special emphasis on those requiring intensive care. We review the latest articles on its potency as a biomarker in both infectious processes at diagnosis and on the response to treatment.
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Affiliation(s)
- Sara Bobillo-Perez
- Pediatric Intensive Care Unit Service, Research Group of the Pediatric Critical Patient, Institut de Recerca Sant Joan de Déu, Hospital Sant Joan de Déu Barcelona, Barcelona, Spain
| | - Javier Rodríguez-Fanjul
- Neonatal Intensive Care Unit Service, Hospital de Sant Joan de Déu Maternal, Fetal and Neonatology Center Barcelona (BCNatal), University of Barcelona, Barcelona, Spain
| | - Iolanda Jordan Garcia
- Pediatric Intensive Care Unit, Paediatric Infectious Diseases Research Group, Institut de Recerca Sant Joan de Déu, CIBERESP, Hospital Sant Joan de Déu Barcelona, Barcelona, Spain
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Baumann P, Baer G, Bonhoeffer J, Fuchs A, Gotta V, Heininger U, Ritz N, Szinnai G, Bonhoeffer J. Procalcitonin for Diagnostics and Treatment Decisions in Pediatric Lower Respiratory Tract Infections. Front Pediatr 2017; 5:183. [PMID: 28894729 PMCID: PMC5581362 DOI: 10.3389/fped.2017.00183] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 08/11/2017] [Indexed: 12/12/2022] Open
Abstract
Mortality and morbidity remain high in pediatric lower respiratory tract infections (LRTIs) despite progress in research and implementation of global diagnostic and treatment strategies in the last decade. Still, 120 million annual episodes of pneumonia affect children younger than 5 years each year leading to 1.3 million fatalities with the major burden of disease carried by low- and middle-income countries (95%). The definition of pneumonia is still challenging. Traditional diagnostic measures (i.e., chest radiographs, C-reactive protein) are unable to distinguish viral and from bacterial etiology. As a result, common antibiotic overuse contributes to growing antibiotic resistance. We present an overview of current evidence from observational and randomized controlled trials on a procalcitonin (PCT)-based diagnosis of pediatric LRTIs and discuss the need for an adequate PCT threshold for antibiotic treatment decision-making.
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Affiliation(s)
- Philipp Baumann
- Department of Pediatric Infectious Diseases and Vaccinology, University of Basel Children's Hospital, Basel, Switzerland
| | - Gurli Baer
- Department of Pediatric Infectious Diseases and Vaccinology, University of Basel Children's Hospital, Basel, Switzerland
| | | | - Aline Fuchs
- Department of Pediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
| | - Verena Gotta
- Department of Pediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
| | - Ulrich Heininger
- Department of Pediatric Infectious Diseases and Vaccinology, University of Basel Children's Hospital, Basel, Switzerland
| | - Nicole Ritz
- Department of Pediatric Infectious Diseases and Vaccinology, University of Basel Children's Hospital, Basel, Switzerland.,Department of Pediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
| | - Gabor Szinnai
- Department of Pediatric Endocrinology and Diabetology, University of Basel Children's Hospital, Basel, Switzerland
| | - Jan Bonhoeffer
- Department of Pediatric Infectious Diseases and Vaccinology, University of Basel Children's Hospital, Basel, Switzerland
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