Impact of Novel Coronavirus Disease-19 (COVID-19) Pandemic in Italian Pediatric Emergency Departments: A National Survey

doi:10.21203/rs.3.rs-77422/v1

Download PDF

Research

Impact of Novel Coronavirus Disease-19 (COVID-19) Pandemic in Italian Pediatric Emergency Departments: A National Survey

https://doi.org/10.21203/rs.3.rs-77422/v1

This work is licensed under a CC BY 4.0 License

Journal Publication

published 03 Mar, 2021

Read the published version in Italian Journal of Pediatrics →

You are reading this older preprint version

Read the latest preprint version →

BACKGROUND: Coronavirus Disease-19 (COVID-19) has rapidly become a pandemic emergency, distressing health systems in each affected country. Preparation strategies for managing this pandemic have been keys to face the COVID-19 surge all over the world and all levels of care.

MATERIAL and METHODS: During the epidemic, the Italian society of pediatric emergency-urgency (SIMEUP) promoted a national survey aiming to evaluate preparedness and response of pediatric emergency departments (PED) critical in ensuring optimal management of COVID-19 cases.

RESULTS: Our results suggest that Italian PED have promptly set a proactive approach to the present emergency. 96.6% of the hospitals have defined special pathways and assistive protocols concerning the management of pediatric COVID-19 cases. The highest percentage of application of the measures for preventive and protective for COVID-19 concerned the use of personal protective equipments.

CONCLUSIONS: Results show that the following measures for pediatric patients, admitted in PED, have been promptly implemented throughout the whole country: eg. use of protective devices, pre-triage of patients accessing the hospital. Despite COVID-19 being a new threat, we have shown that by developing an easy-to-follow decision algorithm and clear plans for the interventional platform teams, we can ensure optimal health care workers and patients’ safety.

Pediatrics

pediatric emergency

COVID-19

personal protective equipment

healthcare workers

A novel coronavirus belonging to beta-coronavirus genera (named as 2019-nCoV by World Health Organization [WHO]) was identified as the causative agent associated with a cluster of cases of pneumonia detected in Wuhan City by Chinese authorities on 7 January [1,2]. On January 2, 2020, the first 2 cases, two Chinese tourists, were identified in Italy; on January 30, 2020, WHO re-evaluated the potential effects of 2019-nCoV infection in global public health,and declared this epidemic as a “Public Health Emergency of International Concern (PHEIC)”. Since the discovery of 2019-nCoV, the virus has been rapidly spreading all over the word [3,4]. Infected children might appear asymptomatic or have mild clinical manifestations: fever, dry cough, and fatigue, and few have upper respiratory symptoms including nasal congestion and running nose; some patients presented with gastrointestinal symptoms including abdominal discomfort, nausea, vomiting, abdominal pain, and diarrhea [5-8]. However, cases of major systemic inflammation (Kawasaki-Like Hyperinflammatory Syndrome) have recently been reported in children infected with coronavirus [9]. A study that involved a cohort of 100 Italian children younger than 18 years of age (The Coronavirus Infection in Pediatric Emergency Departments, CONFIDENCE) who were assessed between March 3 and March 27 in 17 Pediatric Emergency Departments (PED) (median age 3,3 years) observed that common symptoms were cough (in 44% of the patients) and no feeding or difficulty feeding (in 23%). A total of 54 children (54%) had a temperature of at least 37.6°C and 12 (12%) appeared ill, and 38 children (38%) were admitted to the hospital; 20 of them had moderate or severe disease (19 and 1 respectively) [10]. Another study that involved 102 centers from 18 countries found a wide variation on personal protective equipment (PPE) use at pre-triage and for patient assessment [11]. Preparation strategies for managing this pandemic have been needed all over the world and in all the hospitals. Reallocation of resources in the management of this crisis implied careful planning, the interruption of scheduled hospitalizations, and the training of health workers. Strict adherence to infection control such as PEE and disinfection are the keys to contain the transmission of the disease. In particular, the key interventions of the PED for the management of this pandemic have been different. Mandatory hospitalization in isolation wards for all suspected cases presenting to the PED and the segregation of PED into high-risk, intermediate-risk, and low-risk areas are crucial elements for reduction the possible rate of infection [12].

The provision of qualified PPE to health care workers plays an essential role in preventing occupational exposure and infection. US Centers for Disease Control and Prevention for COVID-19 infection control of healthcare personnel recommended gloves, gowns, respiratory protection, and eye protection as standardized PPE [13].

The Italian society of pediatric emergency-urgency (SIMEUP) brings together various professional figures who manage children in the acute care setting, belonging to both general and pediatric hospitals. During the COVID-19 epidemic in Italy, the SIMEUP promoted a national survey aiming to evaluate the impact of COVID-19 on the clinical acute pediatric practice and the strategies activated at the hospital level for the management, infectious containment and reorganization of the work in the acute care pediatric setting during this pandemic.

We carried out an observational study on organizational changes that took place in Italy pediatric departments following the COVID-19 pandemic. The survey was launched online on 1st April 2020 and closed on 30th April 2020. It includeda total of 15 questions, whose key points were:

-implementation of organizational protocol for the management of "suspected" or "confirmed" cases of pediatric COVID-19;

-re-organization of spaces, creation of dedicated pre-triage, with trained and qualified personnel;

- use of PPE, before and after the pandemic, and ease of their procurement;

- modification of the emergency and planned work activities.

During the study period, we received the questionnaire replies from about 92 hospitals, of 19 Italian Region. We received a total of 140 responses from different health professionals (110 doctors, 25 nurses and 5 others).

Descriptive statistics were used to analyze the data through the SPSS statistical program (SPSS Inc., Chicago, USA)

The creation of specific organizational plans defined at a regional level, for the management of pediatric COVID-19 cases, occurred in about 63.8% Italian pediatric departments. However, almost 96.6% of the individual hospitals contributed to the creation of special pathways and assistive protocols concerning the management of COVID-19 cases for both adult and pediatric age (Fig 1 a,b). 90.8% of the hospital has created a special pre-triage, but only in 35.2% of cases,it was dedicated to the pediatric age.

The highest percentage of applications in hospitals of the measures envisaged by the national and regional directive for preventive and protective for COVID-19 concerned the use of PPE (Fig 2).

About PPE, table 1 shows the changes in the usual use of PPE before and after the pandemic. A positive trend is evident in the use of all devices, in particular the surgical mask (3.16% variation). This trend of greatest use is uniform for both medical and nursing figures (Table 2). The percentage of use of PPE in the "Suspected" and "Confirmed" cases of COVID-19 was correctly distributed throughout the national territory (Table 3).

The comparison of PED visits and the number of admissions between March 2019 and 2020, showed that there was an overall reduction of 75.58% for emergency visits (-72.566) and 68,42% for admissions (-8.188) (Table 4).

People of all ages are susceptible to 2019-nCoV infection. The incubation period of 2019-nCoV infections ranges from 1 to 14 days, mostly ranging from 3 to 7 days. In children, the age of disease onset ranges from 1.5 months to 17 years, most of whom had close contact with infected cases or are family cluster cases [14].

One of the most important actions that have been activated to manage the emergency from coronavirus has been to take urgent actions to reorganize health services and protect health workers to take care of patients with COVID-19 in safety and save lives.

The COVID-19 outbreak has highlighted a gap between infectious disease healthcare and epidemiologist advice for preventing the spread of the disease versus the actions taken by the state authorities that in many cases have been too late and inadequate [15].

The hospital preparedness for epidemics and pandemics of COVID-19 has taught us several lessons, which deviate from the classical safety and protection protocols for healthcare personnel those who remain on the frontline, fighting against the further spread and tirelessly treating those who are diseased [15]. Due to a lack of sufficient awareness of the COVID-19 in the early stages of the epidemic, some healthcare workers (HCWs) have been infected [16].

Following the Chinese model, containment measures to reduce the risk of COVID-19 in Italy have been promptly activated and implemented [17]. Due to the necessity to set up emergency management protocols for the prevention and control novel coronavirus (2019-nCoV) infection spread, various hospitals have completely reorganized their work and space.

As highlighted in our work, almost all Italian hospitals have defined specific pathways for pediatric cases of COVID-19 (96.6%), with the creation of dedicated pre-triage structures, sometimes only for children (32.5%).

To prevent the spread of COVID-19 to healthcare workers, additional infection control measures were implemented. Mask fitting exercises and PPE training was provided to all healthcare personnel. The most important PPE includes an N95 mask, eye protection with goggles or an eye shield, gown, and gloves [18].

The type and amount of PPE that should be used when treating a patient with COVID19 varies based on clinical job and setting [19]. For HCWs providing direct inpatient care for patients with COVID-19, a medical mask, gown, gloves, and eye protection in the form of goggles or a face shield should be used. If aerosol-generating procedures are being performed, healthcare workers should also wear an apron and use an N95 respirator in the place of a surgical mask [20]. All these indications have been respected in all pediatric departments in our nation; as can be seen in Table 1, there has been an increase in the use of PPE after the pandemic in all HCWs.

Finally, another important fact that emerges from our investigation was the reduction of pediatric emergency visits hospitalizations across the nation. The substantial decreases in pediatric care access in Italy might reflect the scarcity of available resources due to pandemic-related redistribution, or reticence on the part of parents and caregivers to risk exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in a health-care setting, in addition to lower rates of acute infections and trauma [21]. There is a need to prevent delays in accessing hospital care and to increase the provision of high-quality coordinated care by health-care providers. Both of these aspects should be considered as part of the overall public health impact of the COVID-19 pandemic, as evident in other epidemics [22] and must be adequately monitored. Both the general population and health-care workers need clear guidance and information. Specifically, parents should be made fully aware that the risks of delayed access to hospital care for emergency conditions can be much higher than those posed by COVID-19.

This new global challenge, represented by COVID-19, has proven how fundamental it is to strengthen health systems and has produced a rapid reorganization of the provision of services to respond to COVID-19, while at the same time the basic essential services worked through the continuous care in so that nobody is left behind. As we refine our understanding of COVID-19, a high degree of active surveillancein the community and dynamic reassessment of pediatric department workflow processes, inconjunction with the hospital and nationwide public health response, may help usbetter manage this ongoing pandemic and prepare for the next.

COVID-19: Coronavirus Disease-19

HCWs: healthcare workers

PEE: personal protective equipment

PED: pediatric emergency departments

SARS-CoV-2: severe acute respiratory syndrome coronavirus 2

SIMEUP: Italian society of pediatric emergency-urgency

Ethical Approval and Consent to participate: We obtain ethical approval and consent of all centers to participate to the study.

Consent for publication: All the information provided have been approved by all the authors.

Availability of data and materials: This manuscript has not been published and is not under consideration for publication elsewhere. The data presented are original.

Competing interests: The authors declared no potential conflicts of interests with respect to the authorship and/or publication of this article.

Funding: Authors also declare any financial support.

Authors' contributions:VT, LP, AC, AN, RL, SZ contributed to the conception and writing of this manuscript; VT, GLM, CC, RR, and SZ critically reviewed the manuscript and supervised the whole study process. SIMEUP study group are the managers of centers that provided the data. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content. All authors read and approved the final manuscript.

Acknowledgements

SIMEUP research group

Alberto Arrighini, MD⁸, Maria Antonietta Barbieri, MD⁹, Claudia Bondone¹⁰, MD, Silvia Bressan, MD¹¹, Vincenza Corsi, MD¹², Massimo Chiossi, MD¹³, Elisabetta Cortis, MD¹⁴, Laura Crespin,MD¹⁵, Antonio Cualbu, MD¹², Liviana Da Dalt, Phd¹¹, Valeria De Donno, MD¹⁶, Maria De Filippo, MD³, Antonella Di Stefano, MD¹⁷, Pasquale Ferrante,MD¹⁸, Battista Guidi, MD¹⁹, Adima Lamborghini, MD²⁰, Marcello Lanari, PhD²¹, Cristina Malorgio, MD²², Sergio Manieri, MD²³, Stefano Masi, MD²⁴, Susanna Masiero, MD¹¹, Beatrice Messini, MD¹⁴, Maria Pia Mirauda, MD²³, Anna Maria Musolino, MD⁹, Rosaria Nigro, MD²⁵, Giuseppe Parisi, MD²⁶, Niccolò Parri, MD²⁴,Massimo Pettoello-Mantovani, PhD²⁷, Flavio Quarantiello, MD²⁸, Eduardo Ponticiello, MD²⁹, Stefano Romero, MD³⁰, Salvatore Savasta, MD³¹, Eurilla Sequi, MD³¹, Debora M.L. Simonetti, MD³³, Eleonora Tappi, MD³⁴, Antonio Francesco Urbino¹⁰, MD, Patrizia Vianelli, MD³⁵, Tiziana Zangardi, MD¹⁰

Affiliations

⁸Pediatric Emergency Department, Presidio Ospedale dei Bambini, A.O. Spedali Civili, Brescia, Italy

⁹ Pediatric Emergency Department, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy.

¹⁰ Department of Pediatric Emergency, Regina Margherita Children's Hospital - A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy

¹¹ Division of Pediatric Emergency Medicine, Department of Women's and Children's Health, University of Padova, Italy

¹²Department of Pediatrics, San Francesco Hospital of Nuoro, Italy

¹³ Department pof Pediatrics and Neonatology, Hospital of Lavagna, Italy

¹⁴ Paediatric Unit, San Giovanni Battista Hospital of Foligno, Italy

¹⁵Department of Pediatrics, Valle del Serchio Hospital, Italy

¹⁶Department of Pediatrics, S. Croce e Carle Hospital of Cuneo, Italy

¹⁷Department of Pediatrics, Cannizzaro Hospital of Catania, Italy

¹⁸Department of Pediatrics and Neonatology, “L Bonomo” Hospital of Andria, ASL BT, Italy

¹⁹ Paediatric Unit, AUSL of Modena, Pavullo nel Frignano , Italy

²⁰Department of Pediatrics, Asl di Teramo, Italy

²¹Pediatric Emergency Department, S.Orsola Hospital , Bologna, Italy

²² Department of pediatrics and neonatology, Valduce Hospital, Como, Italy

²³ Department of Pediatrics, San Carlo Hospital, Potenza, Italy

²⁴ Department of Pediatric Emergency Medicine and Trauma Center, Meyer University Children's Hospital, Florence, Italy

²⁵ Department of Pediatrics, Iannelli Hospital of Cetraro, Italy

²⁶Department of Pediatrics, Anna Rizzoli Hospital, Ischia Island, ASL Naples 2 Nord, Italy

²⁷ Department of Pediatrics, Scientific Institute "Casa Sollievo della Sofferenza", University of Foggia, Foggia, Italy

²⁸ Department of Pediatric and Adolescent Medicine, A.O San Pio, Benevento, Italy

²⁹Pediatric Emergency Department, Santobono-Pausilipon Hospital, Napoli, Italy

³⁰ Department of pediatrics, San Pietro Fatebenefratelli Hospital, Roma, italy

³¹ Pediatric Unit, Senior Hospital of Crema, Italy

³² Department of Neonatology, “Nostra Signora Bonaria” San Gavino Monreale, Italy

³³ Pediatric Unit, “A. Cardarelli” Hospital. ASREM- Campobasso ,Italy

³⁴ Department of Pediatric, “S.Croce e Carle” Hospital of Cuneo, Italy

³⁵Department of Pediatric, Salesi Hospital of Ancona, Italy

1) World Health Organization. WHO Statement Regarding Cluster of Pneumonia Cases in Wuhan, China. Available from URL: www.who.int/china/news/detail/09-01-2020

2) Weiguo Li, Qi Zhou, Yuyi Tang, et al. COVID-19 evidence and recommendations working group. Protocol for the Development of a Rapid Advice Guideline for Prevention, Management and Care of Children With 2019 Novel Coronavirus Infection. Ann Palliat Med. 2204;24;apm.2020.02.33

3) National Health Commission of The People’s Republic of China. Interim protocol of diagnosis and treatment of 2019 novel coronavirus-associated pneumonia (the second version). Available from URL: www.nhc.gov.cn/jkj/s3577/202001/c67cfe29ecf1470e8c7fc47d3b751e88.shtml.

4) Zhu N, Zhang D, Wang W, et al. A Novel Coronavirus from Patients with Pneumonia in China, 2019. N Engl J Med. 2020;382:727-733. doi: 10.1056/NEJMoa2001017.

5) Chan JF, Yuan S, Kok KH, et al. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. Lancet. 2020; 395(10223):514-523. doi: 10.1016/S0140-6736(20)30154-9

6) Cai JH, Wang XS, Ge YL, et al. The first case report of 2019 novel coronavirus infection in children in Shanghai. Zhonghua Er Ke Za Zhi. 2020;58(2):86-87. doi: 10.3760/cma.j.issn.0578-1310.2020.02.002

7) Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395(10223):497-506. doi: 10.1016/S0140-6736(20)30183-5

8) Castagnoli R, Votto M, Licari A, et al. Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection in Children and Adolescents: A Systematic Review. JAMA Pediatr. 2020;Apr 22. doi: 10.1001/jamapediatrics.2020.1467

9) Verdoni L, Mazza A, Gervasoni A, et al. An outbreak of severe Kawasaki-like disease at the Italian epicentre of the SARS-CoV-2 epidemic: an observational cohort study. Lancet. 2020;395(10239):1771-1778. doi: 10.1016/S0140-6736(20)31103-X

10) Parri M, Lenge M, Buonsenso D, Coronavirus Infection in Pediatric Emergency Departments (CONFIDENCE) Research Group. Children With Covid-19 in Pediatric Emergency Departments in Italy. N Engl J Med. 2020;c2007617. doi: 10.1056/NEJMc2007617

11) Bressan S, Buonsenso D, Farrugia R, et al. Preparedness and response to Pediatric CoVID-19 in European Emergency Departments: a survey of the REPEM and PERUKI networks. Ann Emerg Med. 2020;May 15. doi: 10.1016/j.annemergmed.2020.05.018

12) Ren Tan RM, Yong-Kwang Ong G, Chong SL, et al. Dynamic Adaptation to COVID-19 in a Singapore Paediatric Emergency Department. Emerg Med J. 2020;37(5):252-254. doi: 10.1136/emermed-2020-209634

13) Cao Y, Li Q, Chen J, Guo X, Miao C, Yang H, Chen Z, Li C, Li L. Hospital Emergency Management Plan During the COVID-19 Epidemic. Acad Emerg Med. 2020;27(4):309-311. doi: 10.1111/acem.13951

14) The Society of Pediatrics of Hubei Medical Association, The Society of Pediatrics of Wuhan Medical Association, Hubei Pediatric Medical Quality Control Center. Suggestions on the diagnosis and treatment of novel coronavirus infection in children in Hubei province (trial version 1). CJCP. 2020;22(2):96–99. doi: 10.7499/j.issn.1008-8830.2020.02.003

15) Petrovski BE, LumiX, Znaor L, Ivastinović D, Confalonieri F, Petrovič MG, Petrovski G. Reorganize and Survive-A Recommendation for Healthcare Services Affected by COVID-19-the Ophthalmology Experience. Eye (Lond). 2020;34(7):1177-1179. doi: 10.1038/s41433-020-0871-7

16) data, G.F.b.o.I., Coronavirus: 2,629 infected docs, nurses. 2020. https://www.ansa.it/english/news/general_news/2020/03/18/coronavirus-2629-infected-docs-nurses _1bc5c6dc-baf0-467c-9ac8-e08bead819e0.html.

17) Indini A, Aschele C, Cavanna L, Clerico M, Daniele B, Fiorentini G, et al. Reorganization of Medical Oncology Departments During the Novel Coronavirus disease-19 Pandemic: A Nationwide Italian Survey. Eur J Cancer. 2020;132:17-23. doi: 10.1016/j.ejca.2020.03.024

18) World Health Organization. Infection prevention and control during health care when COVID-19 is suspected: interim guidance, 19 March 2020. Institutional Repos Inf Shar 2020:7.

19) Godoy LRA, Jones AE, Anderson TN, Fisher CL, Seeley KML, Beeson EA, et al. Facial Protection for Healthcare Workers During Pandemics: A Scoping Review. BMJ Glob Health. 2020;5(5):e002553. doi: 10.1136/bmjgh-2020-002553

20) World Health Organization. Rational use of personal protective equipment (PPE) for coronavirus disease (COVID-19): interim guidance, 19 March 2020. Institutional Repos Inf Shar 2020:7.

21) Lazzerini M, Barbi E, Apicella A, Marchetti F, Cardinale F, Trobia G. Delayed Access or Provision of Care in Italy Resulting From Fear of COVID-19. Lancet Child Adolesc Health. 2020;4(5):e10-e11. doi: 10.1016/S2352-4642(20)30108-5

22) Chang HJ, Huang N, Lee CH, Hsu YJ, Hsieh CJ, Chou YJ. The impact of the SARS epidemic on the utilization of medical services: SARS and the fear of SARS. Am J Public Health. 2004;94(4):562–64. doi: 10.2105/ajph.94.4.562

Tab. 1 Usual use of PPE before and after the onset of COVID-19

min 1(never)- max 5 (always)

Tab. 2. Usual use of PPE before and after the onset of COVID-19 for different healthcare workers
min 1 (never)- max 5 (always)

	Nurse				Doctor
PPE	Before		After		Before		After
PPE	Media	St. Dev	Media	St. Dev.	Media	St. Dev.	Media	St. Dev.
Double gloves	3,88	1,09	4,40	1,15	2,50	1,07	4,39	0,96
Disposablegown	2,16	1,03	3,80	1,32	1,87	1,04	3,86	1,20
Surgicalmask	1,68	1,04	4,28	1,40	1,34	0,74	4,72	0,83
Waterproof gown	1,25	0,64	3,17	1,47	1,16	0,41	2,78	1,33
FFP2 without valve	2,39	1,08	2,72	1,28	2,23	1,03	2,23	1,21
FFP2 with valve	1,30	0,63	3,04	1,55	1,25	0,56	2,64	1,35
FFP3	1,52	0,85	2,64	1,41	1,23	0,55	2,02	1,26
Surgical head cap	2,12	1,01	3,92	1,35	1,64	0,99	3,43	1,31
Glasses	1,88	0,93	3,52	1,29	1,48	0,88	3,39	1,28
Protectivevisor	1,59	0,85	3,23	1,38	1,74	1,10	3,10	1,43
Shoe covers	1,41	0,85	3,27	1,42	1,34	0,80	2,73	1,40

PPE: personal protective equipment

Tab. 3. Use of PPE in “suspected” and confirmed” case of COVID-19

CASE	Double gloves	Disposablegown	Waterproof gown	Surgicalfacialmask	FFP2 without valve	FFP2 with valve	FFP3	Glasses	Surgical head cap	ProtectiveVisor	Shoe covers
Suspected	96,24	83,33	85,04	71,82	56,64	73,83	41,24	92,13	94,49	82,79	76,27
Confirmed	99,20	67,96	96,72	51,52	58,76	62,22	58,42	89,74	98,33	90,08	89,26
Variation (%)	2,96	-15,37	11,68	-20,30	2,13	-11,61	17,18	-2,38	3,85	7,30	12,99

PPE: personal protective equipment

Tab. 4 Distribution of pediatric emergency room visits and hospitalizations rate

Pediatricemergency room visits

march 2019

Pediatricemergency room visits

march 2020

Reduction rate

Pediatric recovery

march 2019

Pediatric recovery

march 2020

Reduction rate

96.006

23.440

-72.566

75.58%

11.968

3.780

-8.188

68.42%

Download PDF

Journal Publication

published 03 Mar, 2021

Read the published version in Italian Journal of Pediatrics →

Review #2 received at journal
03 Nov, 2020
Editorial decision: Major revision
03 Nov, 2020
Reviewer #2 agreed at journal
24 Oct, 2020
Reviewer #1 agreed at journal
18 Oct, 2020
Review #1 received at journal
18 Oct, 2020
Reviewers invited by journal
21 Sep, 2020
Editor assigned by journal
19 Sep, 2020
Editor invited by journal
18 Sep, 2020
Submission checks completed at journal
17 Sep, 2020
First submitted to journal
16 Sep, 2020

You are reading this older preprint version

Read the latest preprint version →

Impact of Novel Coronavirus Disease-19 (COVID-19) Pandemic in Italian Pediatric Emergency Departments: A National Survey

Status:

Journal Publication

Version 1

Abstract

Figures

Background

Material And Methods

Results

Discussion

Conclusions

List Of Abbreviations

Declarations

References

Tables

Status:

Journal Publication

Version 1