1
|
Azeez SS, Alsakee HM. Cryptosporidium spp. and rotavirus gastroenteritis and change of incidence after rotavirus vaccination among children in Raparin Pediatrics Hospital, Erbil, Iraq. MEDICAL JOURNAL OF INDONESIA 2017. [DOI: 10.13181/mji.v26i3.1957] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Background: Watery diarrhea is the most common medical problem among infants and young children, caused by different microbial etiology including Cryptosporidium spp. and rotavirus, which are usually misdiagnosed in conventional stool test. This study aimed to investigate the incidence of Cryptosporidium and rotavirus gastroenteritis among children in Erbil as well as evaluate the efficacy of rotavirus vaccination procedure applied in Erbil.Methods: Fecal specimens were collected from 400 children (boys and girls), aged one month to five years old, who attended Raparin Pediatrics Hospital in Erbil complaining from diarrhea, between January to August 2014. Modified Ziehl Neelsen technique and nested PCR were used for detection of cryptosporidiosis while rotavirus infection was detected by rapid CerTest.Results: Rate of detection of cryptosporidiosis was remarkably higher using PCR than Ziehl-Neelsen stain (0% versus 6%), and the infection was slightly higher among boys (6.25% vs 5.55%) and children ≤2 years (11.7%). The peak of infection reached during spring season (March and April) (9.5%). The detection rate of rotavirus was 32.0%, which was slightly higher among males (34.4% vs 30.0%) and in children between one to three years old (39.3%). The highest detection rate (38.6%) was recorded during winter season (January and February). The infection was significantly higher among non-vaccinated children (65.9% vs 14.1%; p<0.05).Conclusion: The incidence of cryptosporidiosis is declining. However, rotavirus gastroenteritis was relatively high among young children in Erbil. Rotateq vaccine significantly reduced the incidence of rotavirus infection.
Collapse
|
2
|
Viral Agents of Diarrhea in Young Children in Two Primary Health Centers in Edo State, Nigeria. Int J Microbiol 2015; 2015:685821. [PMID: 26064123 PMCID: PMC4430648 DOI: 10.1155/2015/685821] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 04/13/2015] [Accepted: 04/20/2015] [Indexed: 11/23/2022] Open
Abstract
Enteric viruses have been shown to be responsible for diarrhea among children during their early childhood. This study was carried out to determine the prevalence of rotavirus, adenovirus, and norovirus infection in young children with diarrhea in two primary health centers in Edo State, Nigeria. A total of 223 stool specimens were collected from children aged 0–36 months with clinical signs of diarrhea and 59 apparently healthy age-matched children as control. These specimens were investigated for three viral agents using immunochromatographic technique (ICT). The overall results showed that at least one viral agent was detected in 95/223 (42.6%) of the children with diarrhea while the control had none. The prevalence of rotavirus was 28.3%, adenovirus 19.3%, and norovirus 3.6%. There was a significant association between age group and infection (P < 0.0001). Seasonal pattern of enteric viruses was not statistically significant (P = 0.17). The overall coinfection rate was 7.6% and rotavirus-adenovirus coinfection had the highest with 5.4%. Rotavirus was the most prevalent viral agent. Coinfections are not uncommon among the population studied. The most commonly associated clinical symptom of viral diarrhea in this study was vomiting. Viral diagnostic tests are advocated for primary health care facilities in this locality.
Collapse
|
3
|
Hoxha TF, Azemi M, Avdiu M, Ismaili-Jaha V, Grajqevci V, Petrela E. The usefulness of clinical and laboratory parameters for predicting severity of dehydration in children with acute gastroenteritis. Med Arch 2014; 68:304-7. [PMID: 25568559 PMCID: PMC4269529 DOI: 10.5455/medarh.2014.68.304-307] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 09/20/2014] [Indexed: 11/21/2022] Open
Abstract
Background: An accurate assessment of the degree of dehydration in infants and children is important for proper decision-making and treatment. This emphasizes the need for laboratory tests to improve the accuracy of clinical assessment of dehydration. The aim of this study was to assess the relationship between clinical and laboratory parameters in the assessment of dehydration. Methods: We evaluated prospectively 200 children aged 1 month to 5 years who presented with diarrhea, vomiting or both. Dehydration assessment was done following a known clinical scheme. Results: We enrolled in the study 200 children (57.5% were male). The mean age was 15.62±9.03 months, with more than half those studied being under 24 months old. Overall, 46.5% (93) had mild dehydration, 34% (68) had moderate dehydration, 5.5% (11) had severe dehydration whereas, 14% (28) had no dehydration. Patients historical clinical variables in all dehydration groups did not differ significantly regarding age, sex, fever, frequency of vomiting, duration of diarrhea and vomiting, while there was a trend toward severe dehydration in children with more frequent diarrhea (p=0.004). Serum urea and creatinine cannot discriminate between mild and moderate dehydration but they showed a good specificity for severe dehydration of 99% and 100% respectively. Serum bicarbonates and base excess decreased significantly with a degree of dehydration and can discriminate between all dehydration groups (P<0.001). Conclusion: Blood gases were useful to diagnose the degree of dehydration status among children presenting with acute gastroenteritis. Serum urea and creatinine were the most specific tests for severe dehydration diagnosis. Historical clinical patterns apart from frequency of diarrhea did not correlate with dehydration status. Further studies are needed to validate our results.
Collapse
Affiliation(s)
- Teuta Faik Hoxha
- Pediatric Clinic, University Clinical Center of Kosova, Prishtina, Kosovo ; Department of Statistics, Faculty of Medicine, University of Tirana, Tirana, Albania
| | - Mehmedali Azemi
- Pediatric Clinic, University Clinical Center of Kosova, Prishtina, Kosovo ; Department of Statistics, Faculty of Medicine, University of Tirana, Tirana, Albania
| | - Muharrem Avdiu
- Pediatric Clinic, University Clinical Center of Kosova, Prishtina, Kosovo ; Department of Statistics, Faculty of Medicine, University of Tirana, Tirana, Albania
| | - Vlora Ismaili-Jaha
- Pediatric Clinic, University Clinical Center of Kosova, Prishtina, Kosovo ; Department of Statistics, Faculty of Medicine, University of Tirana, Tirana, Albania
| | - Violeta Grajqevci
- Pediatric Clinic, University Clinical Center of Kosova, Prishtina, Kosovo ; Department of Statistics, Faculty of Medicine, University of Tirana, Tirana, Albania
| | - Ela Petrela
- Pediatric Clinic, University Clinical Center of Kosova, Prishtina, Kosovo ; Department of Statistics, Faculty of Medicine, University of Tirana, Tirana, Albania
| |
Collapse
|
4
|
The effect of a rapid rehydration guideline on Emergency Department management of gastroenteritis in children. Int Emerg Nurs 2013; 22:159-64. [PMID: 24210953 DOI: 10.1016/j.ienj.2013.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Revised: 09/16/2013] [Accepted: 09/26/2013] [Indexed: 11/20/2022]
Abstract
UNLABELLED This study evaluated the use and effect of a rapid rehydration guideline for the management of gastroenteritis in children 6months to 4years of age in an Emergency Department (ED). The guideline aims to facilitate rehydration within 4h of arrival to the ED, using oral or nasogastric fluids. Primary outcome measures were ED Length of Stay (LOS) and hospital admission rates. Documentation of physiological recovery and consistency of re-hydration regimes used were examined as secondary outcomes. METHODS A quasi-experimental design using the medical records of 235 children pre and post intervention was used. Descriptive statistics (frequencies, medians, interquartile ranges) were used to summarize the data. The pre and post-test groups were compared using Chi Square and the Mann Whitney U Test. RESULTS There was an increase in the ED LOS and in hospital admission rates post implementation of the rapid rehydration guideline in the ED. However, the time frame for initiation of rehydration therapy using oral or nasogastric routes improved post guideline implementation. CONCLUSION The need for improvements in the ED management of dehydration secondary to gastroenteritis has been highlighted providing potential benefits to patient care and outcomes.
Collapse
|
5
|
Diverging trends in gastroenteritis hospitalizations during 2 decades in western Australian Aboriginal and non-Aboriginal children. Pediatr Infect Dis J 2013; 32:1169-74. [PMID: 23958809 DOI: 10.1097/inf.0b013e31829dd34e] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Gastroenteritis is a major cause of pediatric morbidity. We describe temporal, spatial and seasonal trends in age-specific gastroenteritis hospitalizations among Aboriginal and non-Aboriginal Australian children during 2 decades, providing a baseline to evaluate the impact of a rotavirus vaccine program begun in 2007. METHODS We conducted a population-based, data linkage study of Aboriginal and non-Aboriginal births in Western Australia, 1983 to 2006, and analyzed gastroenteritis-coded hospitalizations before age 15 years in the cohort of 596,465 births. Hospitalization rates in Aboriginal and non-Aboriginal children and between geographical regions were compared between 1983 to 1994 and 1995 to 2006. RESULTS Gastroenteritis rates were highest in children 6-11 months of age (Aboriginal: 259.3/1000/annum; non-Aboriginal: 22.7/1000/annum). Rates declined in Aboriginal children between 1983 to 1994 and 1995 to 2006, particularly in those 12-17 months of age (309/1000 to 179/1000). Rates in non-Aboriginal children<5 years increased 10-40%. The disparity for gastroenteritis rates between Aboriginal and non-Aboriginal children<5 years declined from being 15.4 times higher to 7.6 times higher in those aged 12-17 months and from 8.4 to 4.4 in those aged 2-4 years. Rates were highest in rural and remote regions, and diverging temporal trends were seen in different geographical regions. Seasonality varied between Aboriginal and non-Aboriginal children and climatic zones. CONCLUSIONS This is the largest study of gastroenteritis hospitalization trends in children. We found diverging trends of gastroenteritis hospitalization rates in Aboriginal and non-Aboriginal children. Although rates have declined in Aboriginal children, disparity between Aboriginal and non-Aboriginal children continues. Our findings highlight the need to consider age, ethnicity, seasonality and climate when evaluating rotavirus vaccine programs.
Collapse
|
6
|
Gonzales L, Joffre E, Rivera R, Sjöling Å, Svennerholm AM, Iñiguez V. Prevalence, seasonality and severity of disease caused by pathogenic Escherichia coli in children with diarrhoea in Bolivia. J Med Microbiol 2013; 62:1697-1706. [PMID: 23851188 DOI: 10.1099/jmm.0.060798-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The prevalence of infection caused by different categories of diarrhoeagenic E. coli (DEC) strains, including enteroaggregative (EAEC), enteropathogenic (EPEC), enterotoxigenic (ETEC), enteroinvasive (EIEC) and enterohaemorrhagic (EHEC) E. coli, in children who suffered from diarrhoea (n = 3943) or did not have diarrhoea (n = 1026) were analysed in two areas in Bolivia over a period of 4 years. We also analysed the seasonality of DEC infections and severity of diarrhoea in children with DEC infection and compared antibiotic resistance in DEC strains isolated from children with and without diarrhoea. Stool samples were analysed for the presence of DEC by culturing followed by PCR. The most prevalent DEC categories in samples from the children were: EAEC (11.2 %); ETEC (6.6 %); EPEC (5.8 %); and EIEC and EHEC (<1 %). DEC strains were isolated significantly more often from diarrhoea cases (21.6 %) than from controls (17.6 %; P = 0.002). The number of children with diarrhoea associated with EAEC, EPEC and ETEC infections peaked in the Bolivian winter (April-September), although the proportion of DEC-positive stool samples was higher during the warm rainy season (October-March). High levels of antibiotic resistance were detected among the DEC strains. In particular, resistance to tetracycline and sulfamethoxazole-trimethoprim was significantly higher in strains isolated from individuals with diarrhoea than in samples from controls. The severity of disease in children infected with EAEC, EPEC and ETEC varied from mild to severe diarrhoea, although disease severity did not differ significantly between the different DEC categories. ETEC, EPEC and EAEC are commonly found in Bolivia and may cause severe disease in children.
Collapse
Affiliation(s)
- Lucia Gonzales
- Instituto de Biología Molecular y Biotecnología, Universidad Mayor de San Andrés, Facultad de Ciencias Puras y Naturales, Campus Universitario Cota-Cota, Calle 27 s/n La Paz, Bolivia.,Department of Microbiology and Immunology, Institute of Biomedicine, University of Gothenburg, Box 435, 405 30 Gothenburg, Sweden
| | - Enrique Joffre
- Instituto de Biología Molecular y Biotecnología, Universidad Mayor de San Andrés, Facultad de Ciencias Puras y Naturales, Campus Universitario Cota-Cota, Calle 27 s/n La Paz, Bolivia.,Department of Microbiology and Immunology, Institute of Biomedicine, University of Gothenburg, Box 435, 405 30 Gothenburg, Sweden
| | - Rosario Rivera
- Instituto de Biología Molecular y Biotecnología, Universidad Mayor de San Andrés, Facultad de Ciencias Puras y Naturales, Campus Universitario Cota-Cota, Calle 27 s/n La Paz, Bolivia
| | - Åsa Sjöling
- Department of Microbiology and Immunology, Institute of Biomedicine, University of Gothenburg, Box 435, 405 30 Gothenburg, Sweden
| | - Ann-Mari Svennerholm
- Department of Microbiology and Immunology, Institute of Biomedicine, University of Gothenburg, Box 435, 405 30 Gothenburg, Sweden
| | - Volga Iñiguez
- Instituto de Biología Molecular y Biotecnología, Universidad Mayor de San Andrés, Facultad de Ciencias Puras y Naturales, Campus Universitario Cota-Cota, Calle 27 s/n La Paz, Bolivia
| |
Collapse
|
7
|
Hayajneh WA, Jdaitawi H, Al Shurman A, Hayajneh YA. Comparison of clinical associations and laboratory abnormalities in children with moderate and severe dehydration. J Pediatr Gastroenterol Nutr 2010; 50:290-4. [PMID: 19644395 DOI: 10.1097/mpg.0b013e31819de85d] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To search for possible early clinical associations and laboratory abnormalities in children with severe dehydration in northern Jordan. PATIENTS AND METHODS We prospectively evaluated 251 children with acute gastroenteritis. Dehydration assessment was done following a known clinical scheme. Probable clinical associations and laboratory abnormalities were examined against the preassigned dehydration status. RESULTS Children with severe dehydration had significantly more hypernatremia and hyperkalemia, less isonatremia, and higher mean levels of urea, creatinine, and glucose (P < 0.005). Receiver operating characteristic curves showed statistically significant area under the curve values for laboratory variables. These area under the curve values were 0.991 (95% confidence interval [CI] 0.980-1.001) for serum urea, 0.862 (95% CI 0.746-0.978) for sodium, 0.850 (95% CI 0.751-0.949) for creatinine, 0.69 (95% CI 0.555-0.824) for potassium, and 0.684 (95% CI 0.574-0.795) for glucose (P < 0.05 for all). Certain independent serum cutoff levels of urea, creatinine, sodium, glucose, and potassium had high negative predictive value (100%), whereas other cutoff values for each, except potassium, had high positive predictive value (100%) for severe dehydration. Historic clinical characteristics of patients did not correlate to dehydration degree. CONCLUSIONS Serum urea, creatinine, sodium, potassium, and glucose were useful independently in augmenting clinical examination to diagnose the degree of dehydration status among children presenting with gastroenteritis. Serum urea performed the best among all. On the contrary, none of the examined historical clinical patterns could be correlated to the dehydration status. Larger and multicenter studies are needed to validate our results and to examine their impact on final outcomes.
Collapse
Affiliation(s)
- Wail A Hayajneh
- Department of Pediatrics, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan.
| | | | | | | |
Collapse
|
8
|
Orazzo F, Nespoli L, Ito K, Tassinari D, Giardina D, Funis M, Cecchi A, Trapani C, Forgeschi G, Vignini M, Nosetti L, Pigna S, Zanobetti A. Air pollution, aeroallergens, and emergency room visits for acute respiratory diseases and gastroenteric disorders among young children in six Italian cities. ENVIRONMENTAL HEALTH PERSPECTIVES 2009; 117:1780-5. [PMID: 20049132 PMCID: PMC2801171 DOI: 10.1289/ehp.0900599] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2009] [Accepted: 08/13/2009] [Indexed: 05/08/2023]
Abstract
BACKGROUND Past studies reported evidence of associations between air pollution and respiratory symptoms and morbidity for children. Few studies examined associations between air pollution and emergency room (ER) visits for wheezing, and even fewer for gastroenteric illness. We conducted a multicity analysis of the relationship between air pollution and ER visits for wheezing and gastroenteric disorder in children 0-2 years of age. METHODS We obtained ER visit records for wheezing and gastroenteric disorder from six Italian cities. A city-specific case-crossover analysis was applied to estimate effects of particulate matter (PM), nitrogen dioxide, sulfur dioxide, ozone, and carbon monoxide, adjusting for immediate and delayed effects of temperature. Lagged effects of air pollutants up to 6 prior days were examined. The city-specific results were combined using a random-effect meta-analysis. RESULTS CO and SO(2) were most strongly associated with wheezing, with a 2.7% increase [95% confidence interval (CI), 0.5-4.9] for a 1.04-microg/m(3) increase in 7-day average CO and a 3.4% (95% CI, 1.5-5.3) increase for an 8.0-microg/m(3) increase in SO(2). Positive associations were also found for PM with aerodynamic diameter < or = 10 microg and NO(2). We found a significant association between the 3-day moving average CO and gastroenteric disorders [3.8% increase (95% CI, 1.0-6.8)]. When data were stratified by season, the associations were stronger in summer for wheezing and in winter for gastroenteric disorders. CONCLUSION Air pollution is associated with triggering of wheezing and gastroenteric disorders in children 0-2 years of age; more work is needed to understand the mechanisms to help prevent wheezing in children.
Collapse
Affiliation(s)
- Flavia Orazzo
- Pediatric Emergency Room, Santobono’s Hospital, Naples, Italy
| | - Luigi Nespoli
- Pediatric Emergency Room, Pediatric Department, University of Varese, Varese, Italy
| | - Kazuhiko Ito
- Nelson Institute of Environmental Medicine, New York University School of Medicine, New York, New York, USA
| | - Davide Tassinari
- Pediatric Emergency Room, Pediatric Department, University of Bologna, Bologna, Italy
| | | | - Maurizio Funis
- Pediatric Emergency Room, Pediatric Department, Torre Galli, Florence, Italy
| | | | - Chiara Trapani
- Pediatric Emergency Room, Mayer Hospital, Florence, Italy
| | - Gisella Forgeschi
- Pediatric Emergency Room, Ponte a Niccheri Hospital, Florence, Italy
| | - Massimo Vignini
- Pediatric Emergency Room, Pediatric Department, Salesi Hospital, Ancona, Italy
| | - Luana Nosetti
- Pediatric Emergency Room, Pediatric Department, University of Varese, Varese, Italy
| | - Sabrina Pigna
- Pediatric Emergency Room, Gallarate Pediatric Hospital, Gallarate, Italy
| | - Antonella Zanobetti
- Department of Environmental Health, Harvard School of Public Health, Boston, Massachusetts, USA
- Address correspondence to A. Zanobetti, Department of Environmental Health, Exposure Epidemiology, and Risk Program, Harvard School of Public Health, 401 Park Drive, Landmark Center, Suite 415 West, P.O. Box 15698, Boston, MA 02215 USA. Telephone: (617) 384-8751. Fax: (617) 384-8745. E-mail:
| |
Collapse
|
9
|
The burden of rotavirus gastroenteritis in children presenting to a paediatric hospital. Epidemiol Infect 2008; 137:943-9. [DOI: 10.1017/s0950268808001520] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
SUMMARYThe aim of this study was to determine the burden, management and outcomes of rotavirus infection in young children presenting to a tertiary paediatric hospital in Sydney, Australia. All laboratory-confirmed cases of rotavirus in children aged <5 years were identified and medical records reviewed. In 2004, 80 children aged <5 years presented to the hospital with rotavirus gastroenteritis confirmed by stool testing. Infants aged <24 months comprised 75% of cases, with more males than females affected. Most children (86%) acquired rotavirus infection in the community, with a mean length of hospital admission of 2·3 days. There were eight cases of nosocomial infection at a rate of 3/10 000 admissions. The rates of intravenous fluid management (46%) and antibiotic use (28%) were high, reflecting the severity of disease presenting in a hospital setting. These data will help inform the assessment of the recently introduced rotavirus vaccination programme in Australia.
Collapse
|
10
|
Schutz J, Babl FE, Sheriff N, Borland M. Emergency department management of gastro-enteritis in Australia and New Zealand. J Paediatr Child Health 2008; 44:560-3. [PMID: 18564074 DOI: 10.1111/j.1440-1754.2008.01335.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Comparison of clinical practice guideline (CPG) recommendations and reported physician management of gastro-enteritis at Paediatric Research in Emergency Departments International Collaborative (PREDICT) network sites as a baseline for further randomised controlled trials. METHODS Two part survey comprising: (i) review of CPGs from PREDICT sites for gastro-enteritis; and (ii) survey of senior emergency department physicians regarding the management of gastro-enteritis. RESULTS All 11 PREDICT sites participated. Nine CPGs were available with three sites using a common CPG. For moderate dehydration, eight CPGs advocated nasogastric (NG) rehydration in preference to intravenous (IV) rehydration. The IV route was reserved for severe dehydration or failed NG rehydration. In the second component of the survey, 78 of 83 (94%) physicians responded. In moderate dehydration, 82% of respondents used NG rehydration. In severe dehydration, 86% used IV fluids; 12% used NG and 3% an initial IV bolus followed by NG fluid. Serum electrolytes were measured universally with IV fluid use and by 22% using NG rehydration. The IV fluid bolus was with normal saline (86%). Fifty-four per cent used anti-emetics 'rarely' or 'sometimes'. The commonest agents were ondansetron (60%) and metoclopramide (29%). CONCLUSIONS CPG recommendations and physician practice for the management of gastro-enteritis were similar across PREDICT sites with a focus on NG for moderate dehydration and IV for severe dehydration. A variety of fluids and administration rates were used. Anti-emetics were used infrequently. The efficacy and safety of newer anti-emetics should be explored in collaborative studies. Collaborative development of new CPGs should be considered to simplify fluid regimens.
Collapse
Affiliation(s)
- Jacquie Schutz
- Emergency Department, Womens and Childrens Hospital, Adelaide, South Australia, Australia.
| | | | | | | | | |
Collapse
|