196 results found
Osmanov IM, Spiridonova E, Bobkova P, et al., 2021, Risk factors for long covid in previoulsy hospitalsied children using the ISARIC Global Follow-Up Protocol: a prospective cohort study, European Respiratory Journal, ISSN: 0903-1936
Background The long-term sequelae of coronavirus disease 2019 (Covid-19) in children remain poorly characterised. This study aimed to assess long-term outcomes in children previously hospitalised with Covid-19 and associated risk factors.Methods This is a prospective cohort study of children (≤18 years old) admitted with confirmed Covid-19. Children admitted to the hospital between April 2, 2020 and August 26, 2020, were included. Telephone interview using the International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) Covid-19 Health and Wellbeing paediatric follow-up survey. Persistent symptoms (>5 months) were further categorised by system(s) involved.Findings 518 of 853 (61%) of eligible children were available for the follow-up assessment and included in the study. Median age was 10.4 years (IQR, 3–15.2) and 270 (52.1%) were girls; median follow-up since hospital discharge was 256 (223–271) days. At the time of the follow-up interview 126 (24.3%) participants reported persistent symptoms among which fatigue (53, 10.7%), sleep disturbance (36, 6.9%,) and sensory problems (29, 5.6%) were the most common. Multiple symptoms were experienced by 44 (8.4%) participants. Risk factors for persistent symptoms were: older age “6–11 years” (odds ratio 2.74 (95% confidence interval 1.37 to 5.75) and “12–18 years” (2.68, 1.41 to 5.4); and a history of allergic diseases (1.67, 1.04 to 2.67).Interpretation A quarter of children experienced persistent symptoms months after hospitalization with acute covid-19 infection, with almost one in ten experiencing multi-system involvement. Older age and allergic diseases were associated with higher risk of persistent symptoms at follow-up.
Ingeman K, Frostholm L, Frydendal DH, et al., 2021, A new measure of excessive parental worries about children's health: development of the Health Anxiety by Proxy Scale (HAPYS), Nordic Journal of Psychiatry, Pages: 1-9, ISSN: 0029-1455
OBJECTIVE: Health anxiety by proxy is a newly introduced term to describe parents' experience of excessive and unpleasant worries about their child's health. This article describes the development of a new measure, the Health Anxiety by Proxy Scale (HAPYS), for systematic assessment of health anxiety by proxy. METHOD: The development of the HAPYS was performed over three phases. (1) Patients clinically assessed to have health anxiety by proxy participated in semi-structured interviews to elaborate their experience of worries regarding their child's health and their related behaviours, and to examine the face validity of items in an existing questionnaire: 'Illness Worry Scale - parent version'. (2) Based on the findings from Phase 1 the project group and a panel of experts selected and formulated questionnaire items and scoring formats. (3) The HAPYS was pilot-tested twice using cognitive interviewing with healthy parents and parents with health anxiety by proxy followed by further adjustments. RESULTS: The final version of HAPYS consists of 26 items characteristic of health anxiety by proxy and of an impact section with five items. CONCLUSION: Based on the pilot testing the HAPYS showed good face and content validity. It holds the potential to be a valid questionnaire to help clinicians across health care settings assess parents suffering from health anxiety by proxy.
Pulham RA, Wray J, Feinstein Y, et al., 2019, Feasibility and Acceptability of Methods to Collect Follow-Up Information From Parents 12 Months After Their Child's Emergency Admission to Pediatric Intensive Care, PEDIATRIC CRITICAL CARE MEDICINE, Vol: 20, Pages: E199-E207, ISSN: 1529-7535
Reed GM, First MB, Kogan CS, et al., 2019, Innovations and changes in the ICD-11 classification of mental, behavioural and neurodevelopmental disorders., World Psychiatry, Vol: 18, Pages: 3-19, ISSN: 1723-8617
Following approval of the ICD-11 by the World Health Assembly in May 2019, World Health Organization (WHO) member states will transition from the ICD-10 to the ICD-11, with reporting of health statistics based on the new system to begin on January 1, 2022. The WHO Department of Mental Health and Substance Abuse will publish Clinical Descriptions and Diagnostic Guidelines (CDDG) for ICD-11 Mental, Behavioural and Neurodevelopmental Disorders following ICD-11's approval. The development of the ICD-11 CDDG over the past decade, based on the principles of clinical utility and global applicability, has been the most broadly international, multilingual, multidisciplinary and participative revision process ever implemented for a classification of mental disorders. Innovations in the ICD-11 include the provision of consistent and systematically characterized information, the adoption of a lifespan approach, and culture-related guidance for each disorder. Dimensional approaches have been incorporated into the classification, particularly for personality disorders and primary psychotic disorders, in ways that are consistent with current evidence, are more compatible with recovery-based approaches, eliminate artificial comorbidity, and more effectively capture changes over time. Here we describe major changes to the structure of the ICD-11 classification of mental disorders as compared to the ICD-10, and the development of two new ICD-11 chapters relevant to mental health practice. We illustrate a set of new categories that have been added to the ICD-11 and present the rationale for their inclusion. Finally, we provide a description of the important changes that have been made in each ICD-11 disorder grouping. This information is intended to be useful for both clinicians and researchers in orienting themselves to the ICD-11 and in preparing for implementation in their own professional contexts.
Caspani G, Corbet Burcher G, Garralda ME, et al., 2018, Inflammation and psychopathology in children following PICU admission: an exploratory study, Evidence-Based Mental Health, Vol: 21, Pages: 136-144, ISSN: 1362-0347
Background: Survivors of critical illness in childhood commonly display subsequent psychiatric symptoms including emotional and behavioural difficulties, and manifestations of post-traumatic stress disorder (PTSD). Anomalies in inflammatory profiles are an established finding in these childhood psychiatric conditions.Objective: This exploratory study aimed to investigate whether abnormal peripheral blood inflammatory markers measured during paediatric intensive care unit (PICU) admission were associated with psychiatric symptoms after discharge.Methods: We performed a prospective observational cohort study on 71 children with septic illness, meningoencephalitis and other critical disorders admitted to two PICUs between 2007 and 2010. 3–6 months following discharge, subjects were assessed for global psychiatric risk (ie, presence of emotional and behavioural difficulties on the parental Strengths and Difficulties Questionnaire (SDQ)), and for PTSD risk using the child-rated Impact of Events Scale (IES-8). Inflammatory and related biological markers were transcribed from PICU admission notes (white cell count, lymphocytes, neutrophils, C reactive protein (CRP), platelets, fibrinogen and lactate).Findings: Global psychiatric risk at follow-up was associated with abnormal lymphocyte count during admission (χ2=6.757, p=0.014, n=48). In children with sepsis, partial correlation analyses controlling for age and gender highlighted associations between (i) SDQ scores and low lymphocyte count (r=−0.712; p=0.009, n=14), and (ii) IES-8 score and high CRP levels (r=0.823; p=0.006, n=11). These associations remained after correction for multiple comparisons.Conclusion: These results support the hypothesis that acute inflammation may play a role in determining the development of psychopathology following PICU admission.Clinical implications: If the findings are replicated, they may help to better highlight which children are at risk of post-PICU psychopathology and
Corbet Burcher G, Picouto M, Als L, et al., 2018, Post-traumatic stress after PICU and corticosteriod use, Archives of Disease in Childhood, Vol: 103, Pages: 887-889, ISSN: 1468-2044
Aim To examine the association between corticosteroid use in paediatric intensive care units (PICU) and subsequent symptoms of post-traumatic stress disorder (PTSD).Methods The subjects were children aged 8–16 years admitted to PICU with sepsis, meningoencephalitis (ME) and other disorders. Illness information was extracted from case notes; 3–6 months post discharge children completed a PTSD symptom questionnaire (eight-item Impact of Events Scale (IES-8)) assessing intrusion and avoidance symptoms. Saliva samples were also collected for cortisol profile analysis.Results 53 children completed the IES-8 questionnaires. 33 provided saliva samples. 19 (36%) received corticosteroids. In children with sepsis (n=15), corticosteroid use was associated with significantly lower PTSD intrusion symptom scores. There was a trend towards an association between corticosteroid use and lower evening cortisol levels. There was a comparable but weaker trend in children with ME.
Garralda Hualde ME, 2017, Functional somatic symptoms and syndromes in children and young people - a psychiatric perspective, Oruen - The CNS Journal, Vol: 3, Pages: 64-67, ISSN: 2059-2442
Functional symptoms are common reasons for paediatric consultations. When severe, continuing and impairing they may be expected to be linked to a psychiatric disorder. The paper outlines the nosology and the bio-psychosocial framework that helps understand the origins and maintenance of these disorders; it addresses management strategies.
Chandra P, Kozlowska K, Cruz C, et al., 2017, Hyperventilation-Induced Non-epileptic Seizures in an Adolescent Boy with Pediatric Medical Traumatic Stress, Harvard Review of Psychiatry, Vol: 25, ISSN: 1465-7309
Garralda Hualde ME, 2017, New perspectives on the classification of child psychiatric disorders, Child Psychology and Psychiatry: frameworks for clinical training and practice, Editors: Skuse, Bruce, Dowdney, Publisher: Wiley Blackwell
Garralda Hualde ME, 2017, Anxiety disorders in children and adolescents, Child Psychology and Psychiatry: frameworks for clinical training and practice, Editors: Skuse, Bruce, Dowdney, Publisher: Wiley Blackwell
Als L, Picouto MD, O'Donnell KJ, et al., 2016, Stress hormones and posttraumatic stress symptoms following paediatric critical illness: an exploratory sudy, European Child & Adolescent Psychiatry, Vol: 26, Pages: 511-5119, ISSN: 1435-165X
In this exploratory case-control study we investigatedbasalcortisol regulation in 5-16 year-old children, 3-6 months following PICU (paediatric intensive care) admission.Thiswas nested within a study of child psychological and cognitivefunction; 47 children were assessed alongside 56 healthy controls. Saliva samples were collected three times per day (immediately after waking, waking +30min, and waking +12h)over two consecutive weekdays. In addition, data on posttraumatic stress symptoms were ascertained from 33 PICU admitted children using the Impact of Events Scale-8(IES-8).Primary analysis revealed no significantdifferences in basal cortisol concentrations between PICU discharged children and healthy controls (p > 0.05). Secondary analysis in the PICU group identifieda significant positive association between posttraumatic stress symptoms and evening (waking+12h) cortisol concentrations (p = 0.004). However when subject to multivariate analysis,evening cortisol was a modest independent predictor of IES-8 scores, relative to the presence of septic illness and poor pre-morbid health.We conclude that paediatric critical illness does not appear toresult in marked perturbations to basal cortisol at 3-6 monthfollowing discharge. There was evidence of a link between evening cortisol and symptoms of PTSD, but this was not a robust effectandrequiresfurther elucidation.
de Gracia Dominguez M, Garralda Hualde ME, 2016, Assessing and managing hallucinations in children and adolescents, British Journal of Psychiatry Advances, Vol: 22, Pages: 380-390, ISSN: 2056-4686
Children and young people who disclose sensory experiences suggestive of hallucinations do pose a diagnostic and therapeutic challenge to mental health clinicians in their daily practice. Hallucinations, defined as erroneous percepts in the absence of identifiable stimuli, are a key feature of psychotic states, but they had also long been known to present in children with non-psychotic psychiatric disorders. The recent upsurge of interest in childhood hallucinations has arisen out of epidemiological studies of child populations, where comprehensive symptom enquiry has included screening questions on abnormal perceptions. This has resulted in what seemed surprisingly high rates of hallucinatory experiences among other psychotic-like symptoms. Children and adolescents show a prevalence rate of self-reported hallucinatory experiences of about 10% and are reported as more common in childhood than in adolescence. These hallucinatory phenomena are most likely to occur in the absence of any psychiatric disorder and would be expected more often than not to be simpler, less elaborate and distressing than those observed in clinical samples of children with psychiatric disorders. Longitudinal studies have in fact shown that only a small proportion of children in the general population with hallucinations (less than 10%) will suffer from a psychotic disorder later in life. In clinical settings, presentations with hallucinations can be an expression of a psychotic state, or alternatively of a symptom constellation co-occurring along other psychiatric conditions. Associations have been found between hallucinations and traumatic stressors (i.e. bullying and sexual assault),severity of psychopathology and suicidal symptoms. These associations could be mediated by individual vulnerability, involving neurodevelopmental anomalies and a tendency to mental dissociation and mood dysregulation. This review details the clinical assessment of hallucinations in children and adolescents takin
Garralda ME, 2016, ICD-11-Comparison With DSM-5 and Implications for Child & Adolescent Psychiatric Disorders, Positive Mental Health, Fighting Stigma and Promoting Resiliency for Children and Adolescents, Pages: 15-35, ISBN: 9780128043943
In the past few decades there has been a steady growth of research and knowledge on the nature and treatment of child and youth mental disorders. This chapter addresses the classification of child and adolescent mental health disorders in the recently published 5th edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5, and as proposed for the 11th version of the International Classification of Diseases, or ICD-11. It describes the rationale and historical context for classification in mental health, and the recent changes in the classification of child and adolescent psychiatric disorders, with a special emphasis on the neurodevelopmental and disruptive/dissocial disorders. It considers proposals for alternative classifications and outlines challenges in implementing diagnostic procedures in child and adolescent mental health clinics.
Garralda Hualde ME, 2016, Hospital management of paediatric functional somatic symptoms, Acta paediatrica, Vol: 105, Pages: 452-453, ISSN: 0803-5253
Garralda Hualde ME, Slaveska-Hollis K, 2016, What is special about a paediatric liaison child and adolescent mental health service?, Child and Adolescent Mental Health, Vol: 21, Pages: 96-101, ISSN: 1475-3588
BackgroundThe paediatric population is known to be at high risk for psychiatric problems. Paediatric liaison child/adolescent mental health services (PL-CAMHS) have been developed to help increase recognition and management of psychiatric morbidity in the paediatric setting. This report describes clinical activity by a psychological medicine PL-CAMHS and considers specificity by comparing this with community/general CAMHS activity.MethodClinical information was obtained on consecutive patients seen by a PL-CAMHS in a UK tertiary specialist hospital. Where feasible this was compared with published data on national/community CAMHS work.ResultsData was obtained on 800 patients (mean age 11.9, SD 3.8). Most referrals came from a variety of paediatric teams, nearly two-thirds were for psychosomatic problems or difficulties adjusting to physical illness. The majority had an ICD-10 psychiatric diagnosis (mostly adjustment, mood and anxiety, and somatoform disorders); problems were often complex and in about half, family difficulties were also noted; one-third had received prior mental health treatment. Virtually all children were seen by the PL service within a month of referral and only 2% of families failed to attend for assessment. Some level of clinical improvement was noted for the majority. There were indications of differences from national/community CAMHS work in referral source, take up rates and psychiatric diagnoses.ConclusionsPaediatric liaison child and adolescent mental health services users commonly have characteristic psychiatric problems, interventions appear potentially effective and the work is specific and complementary of community CAMHS. Thus PL-CAMHS make a distinct contribution to the provision of truly comprehensive CAMHS.
Garralda Hualde ME, 2016, Research into hallucinations and psychotic-like symptoms in children: implications for child psychiatry practice, British Journal of Psychiatry, Vol: 208, Pages: 4-6, ISSN: 0007-1250
There is a growing research interest in childhood hallucinations as predictors of psychotic states. This work appears to have limited direct relevance for clinical child psychiatric practice, but it highlights the continuing relevance of research into precursors of psychotic states and into the determinants of clinically relevant hallucinations in children.
Als L, Nadel S, Cooper M, et al., 2015, A supported psychoeducational intervention to improve family mental health following discharge from paediatric intensive care: feasibility and pilot randomised controlled trial, BMJ Open, Vol: 5, ISSN: 2044-6055
Objective To assess feasibility and pilot a supported psychoeducational tool to improve parent and child mental health following discharge from a paediatric intensive care unit (PICU), in preparation for a large randomised controlled trial (RCT).Design Feasibility assessment and single-centre, parallel group, pilot RCT. A concealed computer generated list was used to randomise participants, with an allocation of 2:1 in favour of the intervention.Setting A PICU in an acute care hospital in London, UK.Participants 31 parents of children aged 4–16 years-old admitted to PICU.Intervention Parents received a psychoeducational tool supported by a telephone call. The psychoeducational tool outlined the possible psychological reactions in children and parents alongside management advice. The telephone call addressed each family's postdischarge experience, reinforced the psychoeducational material and encouraged parents to put into practice the advice given.Main outcome measures The primary outcome was the number of feasibility criteria successfully met (linked to the intervention and the study design). Secondary outcomes were questionnaire data collected at 3–6-month follow-up assessing mental health in parents and children.Results 31 parents were randomised (intervention n=22; treatment as usual, TAU n=9). 23 parents were included in the analysis of secondary outcomes (intervention n=17; TAU n=6). 3 (of 6) intervention and 1 (of 6) study design feasibility criteria were fully met. All unmet criteria could be addressed with minor or significant modifications to the protocol. At follow-up there was a tendency for parents who received the intervention to report lower post-traumatic stress symptoms in themselves and fewer emotional and behavioural difficulties in their children than TAU parents. This needs to be explored in a fully powered trial.Conclusions This feasibility and pilot RCT provided valuable information on the intervention and trial design for a full R
Nadel S, Als LC, Garralda ME, 2015, Treatment of Parental Post-Traumatic Stress Disorder After PICU Admission: Who, What, Where, When?, Pediatric Critical Care Medicine, Vol: 16, Pages: 877-878, ISSN: 1529-7535
Garralda ME, 2015, Answers to the quiz., Archives of Disease in Childhood-Education and Practice Edition, Vol: 100, ISSN: 1743-0593
Als LC, Tennant A, Nadel S, et al., 2015, Persistence of Neuropsychological Deficits Following Pediatric Critical Illness., Critical Care Medicine, Vol: 43, Pages: e312-e315, ISSN: 1530-0293
OBJECTIVE: To study 12-month persistence of neuropsychological deficits in PICU survivors. DESIGN: Prospective follow-up study. SETTING: Two PICUs. PARTICIPANTS: Children 5-16 years old with neuropsychological deficits 3-6 months following PICU care for meningoencephalitis, sepsis, and other critical illnesses (excluding other primary neurological disorders). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Neuropsychological function was assessed using the Cambridge Neuropsychological Test Automated Battery, the Children's Memory Scale, and the Wechsler Abbreviated Scale of Intelligence or Wide Range Intelligence Test. Forty-seven of 88 PICU admitted children (53%) were identified as neuropsychologically impaired 3-6 months after discharge; of these, 23 provided 12-month follow-up data. In spite of significant improvements in measures of memory, there was little change in intelligence quotient and visual attention over the study period, and children's educational progress remained below expectation. CONCLUSIONS: We found persistently reduced neuropsychological function following PICU admission in the critical illnesses under study.
Als LC, Picouto MD, Hau SM, et al., 2015, Mental and Physical Well-Being Following Admission to Pediatric Intensive Care, Pediatric Critical Care Medicine, Vol: 16, Pages: E141-E149, ISSN: 1529-7535
Objective: To assess mental and physical well-being in school-aged children following admission to pediatric intensive care and to examine risk factors for worse outcome.Design: A prospective cohort study.Setting: Two PICUs.Subjects: A consecutive sample of 88 patients 5–16 years old (median age, 10.00 yr; interquartile range, 6.00–13.00 yr) admitted to PICU from 2007 to 2010 with septic illness, meningoencephalitis, or other critical illnesses were assessed a median of 5 months following discharge and outcomes compared with 100 healthy controls.Interventions: None.Measurements and Main Results: Parents completed questionnaires documenting child mental and physical well-being, including the Strengths and Difficulties Questionnaires, Chalder Fatigue Scale, and Child Sleep Habits Questionnaire. Children over 8 years completed the Impact of Event Scale -8. The children admitted to PICU scored worse on all measures in comparison with the healthy controls, with 20% scoring at risk for psychiatric disorder, 34% with high levels of post-traumatic stress symptoms, 38% at risk for fatigue disorder, and 80% scoring at risk for sleep disturbance. In the PICU group, multivariable regression analyses identified septic illness as an independent predictor of post-traumatic stress symptoms and family status, past child health problems, and PICU length of stay as predictors of reduced general mental well-being.Conclusions: Our findings indicate that a significant minority of school-aged children admitted to PICU are at risk for reduced mental and physical well-being in the short term. Symptoms of poor mental well-being were linked to both vulnerability factors and critical illness factors.
Kramer T, Als L, Garralda ME, 2015, Challenges to primary care in diagnosing and managing depression in children and young people., BMJ, Vol: 350, Pages: h2512-h2512, ISSN: 0959-8138
Garralda ME, 2015, Fifteen minute consultation on children 'hearing voices': when to worry and when to refer., Archives of Disease in Childhood-Education and Practice Edition, Vol: 100, Pages: 233-237, ISSN: 1743-0593
Auditory hallucinations are uncommon paediatric presentations, but they can be alarming and lead to emergency consultations. This review outlines the phenomenology of auditory hallucinations, their assessment and clinical significance. Auditory hallucinations are seen in the course of acute medical disorders, often together with decreased levels of consciousness, as in febrile illness and in toxic, neurologically compromised states; they can also be a feature of episodic neurological conditions such as migraine and temporal lobe epilepsy. Auditory hallucinations are key symptoms in psychiatric disorders such as schizophrenic and other psychotic states, but they can also present with depressive and anxiety disorders, and in the context of virtually every psychiatric disorder of childhood. In fact hallucinations-usually simple and transient-are common in the general child populations. Auditory hallucinations become clinically significant when they occur as part of a medical disorder or in the context of acute psychotic states and schizophrenia, when they are frequent, complex, distressing and cause impairment. The treatment of clinically relevant hallucinations is that of the primary medical or psychiatric disorder. Occasionally they require treatment in their own right with psychological treatments, and only when these have been tried and fail, a careful trial of antipsychotic medication may be appropriate.
Lochman JE, Evans SC, Burke JD, et al., 2015, An empirically based alternative to DSM-5's disruptive mood dysregulation disorder for ICD-11, World Psychiatry, Vol: 14, Pages: 30-33, ISSN: 1723-8617
The World Health Organization (WHO)’s priorities forthe development of the classification of mental and behaviouraldisorders in the ICD-11 include increasing its clinicalutility in global mental health settings (1) and improving theidentification and diagnosis of mental disorders among childrenand adolescents (2).An issue that has been hotly debated in the area of childhoodpsychopathology is the assessment, diagnosis andtreatment of children with severe irritability and anger (3,4).Although virtually all children display irritable and angrybehaviours at times, some children exhibit them more frequentlyand more intensely, to the extent that they becomean impairing form of emotional dysregulation. Recent findingsindicate that these children with chronic and severe irritability/angerhave not been adequately identified throughexisting classification systems, are at an increased risk forparticular negative outcomes, and have not received appropriatetreatment. To the extent that ICD-11 can help clarifythe clinical picture of irritability/anger, children and familieswill benefit from more accurate diagnoses, more useful prognoses,and more effective interventions.This paper provides a brief overview of the issue, followedby several possible options and the current proposal for theclassification of childhood irritability/anger in ICD-11. Thisproposal represents a markedly different – but we believemore scientifically justifiable – solution to the problems inthis area than that selected for DSM-5 (5).
Garralda ME, 2014, Measurement of environmental complexity by CAMHS., Psychiatr Bull (2014), Vol: 38, ISSN: 2053-4868
Garralda ME, 2014, Combined infant regulatory problems and early maternal psychiatric illness predict risk of functional somatic symptoms in later childhood., Evid Based Nurs, Vol: 17, Pages: 17-18
Kramer T, Iliffe S, Bye A, et al., 2013, Testing the Feasibility of Therapeutic Identification of Depression in Young People in British General Practice, JOURNAL OF ADOLESCENT HEALTH, Vol: 52, Pages: 539-545, ISSN: 1054-139X
Gledhill J, Garralda ME, 2013, Sub-syndromal depression in adolescents attending primary care: frequency, clinical features and 6 months outcome, SOCIAL PSYCHIATRY AND PSYCHIATRIC EPIDEMIOLOGY, Vol: 48, Pages: 735-744, ISSN: 0933-7954
Garralda ME, McConachie H, Le Couteur A, et al., 2013, Emotional impact of genetic trials in progressive paediatric disorders: a dose-ranging exon-skipping trial in Duchenne muscular dystrophy, CHILD CARE HEALTH AND DEVELOPMENT, Vol: 39, Pages: 449-455, ISSN: 0305-1862
Als LC, Nadel S, Cooper M, et al., 2013, Neuropsychologic Function Three to Six Months Following Admission to the PICU With Meningoencephalitis, Sepsis, and Other Disorders: A Prospective Study of School-Aged Children, CRITICAL CARE MEDICINE, Vol: 41, Pages: 1094-1103, ISSN: 0090-3493
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