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Children — Open Access Journal

Children (ISSN 2227-9067) is an international peer-reviewed open access journal of pediatrics published monthly online by MDPI. The publication focuses on sharing clinical, epidemiological and translational science relevant to children’s health.

Open Access free for readers, with article processing charges (APC) paid by authors or their institutions.
High visibility: Indexed in the Emerging Sources Citation Index (ESCI - Web of Science) from Vol. 3. Citations available in PubMed, full-text archived in PubMed Central .
Rapid publication: manuscripts are peer-reviewed and a first decision is provided to authors approximately 23 days after submission; after acceptance the final manuscripts are published online within 5 days (median values for papers published in this journal in the second half of 2018).
Recognition of reviewers: reviewers who provide timely, thorough peer-review reports receive vouchers entitling them to a discount on the APC of their next publication in any MDPI journal, in appreciation of the work done.
Scope: General Pediatrics, Pediatric Subspecialties, Global Health, Ethics, Health Service and Health Policy Research, Pediatric Hospitalist Medicine, Public Health and Epidemiology

Full Imprint Information | Download Journal Flyer

Latest Articles

Open AccessArticle

Child Morbidity and Disease Burden in Refugee Camps in Mainland Greece

by Asterios Kampouras, Georgios Tzikos, Eustathios Partsanakis, Konstantinos Roukas, Stefanos Tsiamitros, Dimitrios Deligeorgakis, Elisavet Chorafa, Maria Schoina and Elias Iosifidis

Children 2019, 6(3), 46; https://doi.org/10.3390/children6030046 - 17 March 2019

Abstract

The crisis conflicts in Syria have forced a lot of people to relocate and live in mainland Greece, where they are hosted in refugee camps. In the present study, our aim was to assess child morbidity and overall disease burden in two camps in northern Greece during a six-month winter period. A primary health care office was founded in each camp. Refugees of all ages with health problems were examined daily by specialty doctors. Cases were classified into two categories: Infectious or non-infectious. In total, 2631 patients were examined during this period (out of the 3760 refugees hosted). Of these patients, 9.8% were infants, 12.7% were toddlers, and 13.4% were children. Most of the visits for children aged less than 12 years old were due to infectious diseases (80.8%). The most common sites of communicable diseases among children were the respiratory tract (66.8%), the skin (23.2%), and the urinary (3.2%) and gastrointestinal tracts (6.2%). Non-communicable diseases were mostly due to gastrointestinal (20.2%), respiratory (18.2%), surgical (13.1%), and allergic (10.3%) disorders. Infants, toddlers, and children suffered more frequently from respiratory infections, while in adolescents and adults, non-infectious diseases were more common. Toddlers and children were more likely to fall ill in comparison to infants. Conclusions: During the winter period, infectious diseases, especially of the respiratory tract, are the main reason for care seeking among refugees in Greek camps, with toddlers suffering more than other age groups. The overall mortality and referral percentage were low, indicating that adequate primary care is provided in this newly established refugee hosting model. Full article

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Open AccessArticle

Longitudinal Fibular Deficiency: A Cross-Sectional Study Comparing Lower Limb Function of Children and Young People with That of Unaffected Peers

by Joshua W. Pate, Mark J. Hancock, Louise Tofts, Adrienne Epps, Jennifer N. Baldwin, Marnee J. McKay, Joshua Burns, Eleanor Morris and Verity Pacey

Children 2019, 6(3), 45; https://doi.org/10.3390/children6030045 - 15 March 2019

Abstract

Longitudinal fibular deficiency (LFD), or fibular hemimelia, is congenital partial or complete absence of the fibula. We aimed to compare the lower limb function of children and young people with LFD to that of unaffected peers. A cross-sectional study of Australian children and young people with LFD, and of unaffected peers, was undertaken. Twenty-three (12 males) children and young people with LFD (74% of those eligible) and 213 unaffected peers, all aged 7–21 years were subject to the Knee Osteoarthritis Outcome Score (KOOS/KOOS-Child) and the Cumberland Ankle Instability Tool (CAIT/CAIT-Youth). Linear regression models compared affected children and young people to unaffected peers. Participants with LFD scored lower in both outcomes (adjusted p < 0.05). The difference between participants with LFD and unaffected peers was significantly greater among younger participants than older participants for KOOS activities and sports domain scores (adjusted p ≤ 0.01). Differences in the other KOOS domains (pain/symptoms/quality of life) and ankle function (CAIT scores) were not affected by age (adjusted p ≥ 0.08). Children and young people with LFD on average report reduced lower limb function compared to unaffected peers. Knee-related activities and sports domains appear to be worse in younger children with LFD, and scores in these domains become closer to those of unaffected peers as they become older. Full article

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Open AccessArticle

Smoke-Free Ordinances and Policies Protect Youth, but Ordinances Appear to Have Little Impact on Non-Combustible Tobacco Use

by Nell Valentine, Emily McClelland and Robert McMillen

Children 2019, 6(3), 44; https://doi.org/10.3390/children6030044 - 11 March 2019

Abstract

Smoke-free ordinances and policies protect youth from exposure to secondhand smoke (SHS) and cigarette use. This study investigated whether smoke-free ordinances also protect youth from the use of other tobacco products. We compared the prevalence of SHS exposure, cigarette smoking, cigar smoking, smokeless tobacco use, and e-cigarette use among high school students living in a municipality with or without a smoke-free ordinance and in homes with and without smoke-free policies. Data were analyzed using the 2017 Mississippi Youth Tobacco Survey (n = 1923). Smoke-free ordinances were found to be associated with lower prevalence of SHS exposure (41.9% vs. 51.5%), cigarette smoking (5.1% vs. 11.4%), and cigar smoking (7.2% vs. 10.9%). There were no differences in smokeless tobacco use (6.6% vs. 6.5%) or e-cigarette use (11.2% vs 12.1%). Smoke-free homes were associated with lower prevalence of SHS exposure (38.0% vs 74.6%), cigarette smoking (4.8% vs. 17.6%), cigar smoking (6.4% vs. 16.4%), smokeless tobacco use (4.9% vs. 13.2%), and e-cigarette use (9.6% vs. 19.5%), p < 0.05 for all comparisons. The results suggest that smoke-free ordinances and policies protect against exposure to tobacco smoke and use of combustible tobacco products, but smoke-free ordinances do not protect from smokeless tobacco and e-cigarette use. Tobacco-free, rather than smoke-free, ordinances might offer more protection. Full article

Open AccessReview

Morphological and Advanced Imaging of Epilepsy: Beyond the Basics

by Aikaterini Fitsiori, Shivaprakash Basavanthaiah Hiremath, José Boto, Valentina Garibotto and Maria Isabel Vargas

Children 2019, 6(3), 43; https://doi.org/10.3390/children6030043 - 11 March 2019

Abstract

The etiology of epilepsy is variable and sometimes multifactorial. Clinical course and response to treatment largely depend on the precise etiology of the seizures. Along with the electroencephalogram (EEG), neuroimaging techniques, in particular, magnetic resonance imaging (MRI), are the most important tools for determining the possible etiology of epilepsy. Over the last few years, there have been many developments in data acquisition and analysis for both morphological and functional neuroimaging of people suffering from this condition. These innovations have increased the detection of underlying structural pathologies, which have till recently been classified as “cryptogenic” epilepsy. Cryptogenic epilepsy is often refractory to anti-epileptic drug treatment. In drug-resistant patients with structural or consistent functional lesions related to the epilepsy syndrome, surgery is the only treatment that can offer a seizure-free outcome. The pre-operative detection of the underlying structural condition increases the odds of successful surgical treatment of pharmacoresistant epilepsy. This article provides a comprehensive overview of neuroimaging techniques in epilepsy, highlighting recent advances and innovations and summarizes frequent etiologies of epilepsy in order to improve the diagnosis and management of patients suffering from seizures, especially young patients and children. Full article

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Open AccessArticle

Management of Congenital Heart Disease: State of the Art; Part I—ACYANOTIC Heart Defects

by P. Syamasundar Rao

Children 2019, 6(3), 42; https://doi.org/10.3390/children6030042 - 8 March 2019

Abstract

Since the description of surgery for patent ductus arteriosus in late 1930s, an innumerable number of advances have taken place in the management of congenital heart defects (CHDs). In this review the current status of treatment of seven of the most common acyanotic CHDs was reviewed. The discussion included indications for, and timing of, intervention and methods of intervention. The indications are, by and large, determined by the severity of the lesion. Pressure gradients in obstructive lesions and the magnitude of the shunt in left-to-right shunt lesions are used to assess the severity of the lesion. The timing of intervention is different for each lesion and largely dependent upon when the criteria for indications for intervention were met. Appropriate medical management is necessary in most patients. Trans-catheter methods are preferable in some defects while surgery is a better option in some other defects. The currently available medical, trans-catheter, and surgical methods to treat acyanotic CHD are feasible, safe, and effective. Full article

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Open AccessBrief Report

Does Peer Rejection Moderate the Associations among Cyberbullying Victimization, Depression, and Anxiety among Adolescents with Autism Spectrum Disorder?

by Michelle F. Wright and Sebastian Wachs

Children 2019, 6(3), 41; https://doi.org/10.3390/children6030041 - 4 March 2019

Abstract

While the consequences of cyberbullying victimization have received some attention in the literature, to date, little is known about the multiple types of strains in adolescents’ lives, such as whether cyberbullying victimization and peer rejection increase their vulnerability to depression and anxiety. Even though some research found that adolescents with disabilities show higher risk for cyberbullying victimization, most research has focused on typically developing adolescents. Thus, the present study focused on examining the moderating effect of peer rejection in the relationships between cyberbullying victimization, depression, and anxiety among adolescents with autism spectrum disorder. There were 128 participants (89% male; ages ranging from 11–16 years old) with autism spectrum disorder in the sixth, seventh, or eighth grade at 16 middle schools in the United States. Participants completed questionnaires on cyberbullying victimization, peer rejection, depression, and anxiety. Results revealed that cyberbullying victimization was associated positively with peer rejection, anxiety, and depression among adolescents with autism spectrum disorder. Further, peer rejection was linked positively with depression and anxiety. Peer rejection moderated the positive relationship between cyberbullying victimization and depression, but not anxiety. Implications for prevention programs and future research are discussed. Full article

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Open AccessCommunication

Regulation of E-Cigarettes in the United States and Its Role in a Youth Epidemic

by Mark A. Gottlieb

Children 2019, 6(3), 40; https://doi.org/10.3390/children6030040 - 4 March 2019

Abstract

During the first decade of federal regulation of electronic nicotine delivery systems (ENDS), the e-cigarette industry has rapidly grown. Recently, the U.S. Surgeon General and Commissioner of the Food and Drug Administration each declared the rapid rise in rates of youth using these products to be an “epidemic.” While a foundational basis for regulating ENDS has been in effect since 2016, deferred enforcement has contributed to acute rise in use by youth. The Agency has undertaken several initiatives to address the problem and warned manufacturers that if current youth trends continue, it will be “game over.” Full article

Open AccessArticle

Japanese Systems to Support Inclusive Education for Children Requiring Medical Care, Current Status of Such Support, and Related Challenges—Based on the Results of Surveys Involving Departments of Education Supporting their Enrollment in General Schools

by Tomoko Yamamoto and Koichi Moriwaki

Children 2019, 6(3), 39; https://doi.org/10.3390/children6030039 - 4 March 2019

Abstract

Based on the results of our surveys involving several municipal departments of education that support the enrollment of children requiring medical care in general schools, this report describes Japanese systems to support inclusive education for these children, the current status of such support, and related challenges. The municipal departments of education that systematically support inclusive education for children requiring medical care began to promote such education in their communities before the initiation of nationwide enrollment support for the children. In addition, their sections in charge of enrollment support also manage affairs related to human rights education, rather than general affairs for special support and education. Such a variation in the sections in charge resulted in differences in the purposes of support. Further nationwide surveys should be conducted to develop universal design principles and comprehensively support inclusive education for children requiring medical care. Full article

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Open AccessArticle

Reference Ranges for Hemoglobin and Hematocrit Levels in Neonates as a Function of Gestational Age (22–42 Weeks) and Postnatal Age (0–29 Days): Mathematical Modeling

by Felix Scholkmann, Daniel Ostojic, Helene Isler, Dirk Bassler, Martin Wolf and Tanja Karen

Children 2019, 6(3), 38; https://doi.org/10.3390/children6030038 - 1 March 2019

Abstract

Hematological values of neonates need to be interpreted taking into account the fact that the reference ranges depend on the age of the neonate. We aimed to derive two general mathematical models for reference ranges for hemoglobin concentration (cHb) and hematocrit (Hct) levels in neonates as a function of gestational age (GA) and postnatal age (PNA), since it is known that GA and PNA are independent factors determining cHb and Hct. For this purpose, cHb and Hct values from the data set of Henry and Christensen (2015, Clin. Perinatol., 42, 483–497) from about 100,000 neonates (GA: 22–42 weeks, PNA: 0–28 days) were used and general models with two quadratic functions were derived. To the best of our knowledge, the models we have developed are the first published ones to provide reference ranges for cHb and Hct for neonates incorporating the parallel dependence on GA and PNA. Full article

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Open AccessArticle

Quality Improvement Project to Improve Screening for Tobacco Use in Adolescent Inpatients at a Children’s Hospital

by Lauren A. Wagner, Adolfo L. Molina, Karisa Grizzle, Meghan E. Hofto, Lauren B. Nassetta, Mary M. Orr, Nichole Samuy, Erinn O. Schmit, Cassi Smola, Kathleen F. Harrington and Susan C. Walley

Children 2019, 6(3), 37; https://doi.org/10.3390/children6030037 - 28 February 2019

Abstract

Tobacco use begins in adolescence for the majority of smokers. The purpose of this study was to increase screening and reporting of tobacco use in hospitalized adolescents at a tertiary care children’s hospital. We completed a nursing focus group to understand challenges and completed four iterative Plan-Do-Study-Act cycles, which included: (1) in-person nursing education regarding tobacco use screening, (2) addition of an e-cigarette-specific screening question, (3) the creation and dissemination of an educational video for nursing, and (4) adding the video as a mandatory component of nursing orientation. Run charts of the percentage of patients screened who reported tobacco use were created. Absolute counts of tobacco products used were also captured. From January 2016 to September 2018, 12,999 patients ≥13 years of age were admitted to the hospital. At baseline, 90.1% of patients were screened and 4.8% reported tobacco use. While the absolute number of adolescents reporting e-cigarette use increased from zero patients per month at baseline to five, the percentage of patients screened and reporting tobacco use was unchanged; the majority of e-cigarette users reported use of other tobacco products. This study demonstrates that adding e-cigarettes to screening increases reporting and suggests systems level changes are needed to improve tobacco use reporting. Full article

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Open AccessArticle

Assessing the Linkage between Exposure to Violence and Victimization, Coping, and Adjustment among Urban Youth: Findings from a Research Study on Adolescents

by Zina McGee, Chelsea Alexander, Khasya Cunningham, Celine Hamilton and Courtney James

Children 2019, 6(3), 36; https://doi.org/10.3390/children6030036 - 27 February 2019

Abstract

From examinations of the literature on the influence that exposure to violence and coping strategies have on delinquent behavior and emotional outcomes, this study addresses the association between violent victimization and the moderating effects of coping strategies among 500 African-American adolescents who exhibit both externalizing behaviors such as delinquency and internalizing symptoms, including anxiety and depression. The investigation examines the development of the aforementioned adjustment problems in response to victimization, and the findings indicate a relationship between the specific indices of victimization, including peer violence, and the symptomatology and coping mechanisms utilized by the youth in this study. Suggestions for future research in this area are discussed. Full article

Open AccessArticle

Description of an Innovative Pediatric Individualized Therapeutics Clinic: Working toward Precision Drug Therapy

by Tracy L. Sandritter, Jean C. Dinh, Jennifer A. Wagner and Jennifer A. Lowry

Children 2019, 6(2), 35; https://doi.org/10.3390/children6020035 - 25 February 2019

Abstract

The GOLDILOKs^® (Genomic and Ontogeny-Linked Dose Individualization and cLinical Optimization for KidS) Clinic aims to provide families and physicians with data to make more informed decisions with regard to pharmacological therapy by using innovative therapy and genomic technologies. The objectives are two-fold: (1) To describe the utility of the GOLDILOKs^® Clinic to referring prescribers by evaluating the type of referrals made to the GOLDILOKs^® Clinic and (2) to assess the most often utilized technologies (e.g., genotyping) completed to formulate therapy recommendations. Patient data from July 2010 to June 2016 was retrospectively reviewed following Institutional Review Board (IRB) approval. The GOLDILOKs^® Clinic evaluated 306 patients and had increases in annual referrals from 14 in 2010–2011 to 84 in 2016–2017. The children that were referred were predominately Caucasian (82%) and male (59%) with an average age of 12.4 ± 5.9 years. Subspecialty versus primary care referrals accounted for 82% and 18% of referrals, respectively. Adverse drug reactions (n = 166) and poor medication response (n = 179) were the major reasons for referral. However, it must be noted that patients could have multiple reasons for referral. Pharmacogenetic results were extensively used to provide guidance for future therapy in patients with medication-related problems. Genotyping of drug metabolizing enzymes and drug target receptors was performed in 221 patients (72.2%). Recommendations were fully accepted by 63% and partially accepted by 22% of internal provider referrals. Full article

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Open AccessReview

Status of Pediatric Cardiac Care in Developing Countries

by Anita Saxena

Children 2019, 6(2), 34; https://doi.org/10.3390/children6020034 - 25 February 2019

Abstract

About 1.35 million babies are born with congenital heart disease each year globally. Most of these are expected to lead normal, productive lives if they are treated in time. However, 90% of babies born with congenital heart disease live in regions where medical care is inadequate or unavailable. The privilege of early diagnosis and timely intervention is restricted to only those born in developed countries. Added to the burden of congenital heart disease is rheumatic heart disease, which remains a global health problem in many low-income and middle-income countries. Providing optimal care for all these children is a daunting task, and requires funds and proper planning at various levels of the health care system. This article describes the burden of pediatric heart disease, including lacunae in the current state, as well as challenges and opportunities for providing optimal care to this large population of children. Full article

Open AccessReview

Multidisciplinary Pain Management for Pediatric Patients with Acute and Chronic Pain: A Foundational Treatment Approach When Prescribing Opioids

by Anava A. Wren, Alexandra C. Ross, Genevieve D’Souza, Christina Almgren, Amanda Feinstein, Amanda Marshall and Brenda Golianu

Children 2019, 6(2), 33; https://doi.org/10.3390/children6020033 - 21 February 2019

Abstract

Opioid therapy is the cornerstone of treatment for acute procedural and postoperative pain and is regularly prescribed for severe and debilitating chronic pain conditions. Although beneficial for many patients, opioid therapy may have side effects, limited efficacy, and potential negative outcomes. Multidisciplinary pain management treatments incorporating pharmacological and integrative non-pharmacological therapies have been shown to be effective in acute and chronic pain management for pediatric populations. A multidisciplinary approach can also benefit psychological functioning and quality of life, and may have the potential to reduce reliance on opioids. The aims of this paper are to: (1) provide a brief overview of a multidisciplinary pain management approach for pediatric patients with acute and chronic pain, (2) highlight the mechanisms of action and evidence base of commonly utilized integrative non-pharmacological therapies in pediatric multidisciplinary pain management, and (3) explore the opioid sparing effects of multidisciplinary treatment for pediatric pain. Full article

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Open AccessReview

Cardiac Catheterization in Assessment and Treatment of Kawasaki Disease in Children and Adolescents

by Hitesh Agrawal and Athar M. Qureshi

Children 2019, 6(2), 32; https://doi.org/10.3390/children6020032 - 21 February 2019

Abstract

Cardiac catheterization has become a promising tool to assess and treat coronary artery lesions in patients with Kawasaki disease. Significant coronary artery lesions can now be treated via transcatheter route even in small children. Further development and miniaturization of this technology will help to promote widespread use to the benefit of small children suffering from coronary artery disease. The role of diagnostic and interventional coronary artery procedures in children and adolescents are discussed in this article. Full article

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Open AccessArticle

Tobacco Use as a Health Disparity: What Can Pediatric Clinicians Do?

by Jyothi Nagraj Marbin and Valerie Gribben

Children 2019, 6(2), 31; https://doi.org/10.3390/children6020031 - 20 February 2019

Abstract

Tobacco use is a global health crisis, and has a tremendous and negative impact on health and wellbeing. Tobacco use disproportionately affects members of vulnerable populations, and by acting on multiple socioecological levels, serves to perpetuate and reinforce cycles of poverty. Members of the pediatric medical community can play a key role in interrupting cycles of tobacco use. Providers can serve as powerful allies to vulnerable communities by treating tobacco use in caregivers, counseling youth against using tobacco products, protecting children from the impact of secondhand smoke exposure, and advocating for economic, social, and health policies to disrupt intergenerational smoking. Full article

Open AccessReview

Electronic Cigarettes and Youth in the United States: A Call to Action (at the Local, National and Global Levels)

by Brian P. Jenssen and Rachel Boykan

Children 2019, 6(2), 30; https://doi.org/10.3390/children6020030 - 20 February 2019

Abstract

E-cigarettes have emerged and soared in popularity in the past ten years, making them the most common tobacco product used among youth in the United States (US). In this review, we discuss what the Surgeon General has called a public health “epidemic”—the precipitous increase in youth use of e-cigarettes and the health consequences of this behavior. Further, we review tobacco control policy efforts (e.g., Tobacco 21, banning flavors, advertising restrictions, and clean indoor air laws)—efforts proven to be critical in reducing cigarette smoking and smoking-related disease and death among US children and adults—including their potential and challenges regarding managing and mitigating the emergence of e-cigarettes. Finally, we close with a discussion of the efforts of transnational tobacco companies to rebrand themselves using e-cigarettes and other new products. Full article

Open AccessReview

Optimal Inspired Fraction of Oxygen in the Delivery Room for Preterm Infants

by Inmaculada Lara-Cantón, Alvaro Solaz, Anna Parra-Llorca, Ana García-Robles and Máximo Vento

Children 2019, 6(2), 29; https://doi.org/10.3390/children6020029 - 19 February 2019

Abstract

Postnatal adaptation of preterm infants entails a series of difficulties among which the immaturity of the respiratory system is the most vital. To overcome respiratory insufficiency, caregivers attending in the delivery room use positive pressure ventilation and oxygen. A body of evidence in relation of oxygen management in the delivery room has been accumulated in recent years; however, the optimal initial inspired fraction of oxygen, the time to achieve specific oxygen saturation targets, and oxygen titration have not been yet clearly established. The aim of this review is to update the reader by critically analyzing the most relevant literature. Full article

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Open AccessArticle

Strategies for Coping with Time-Related and Productivity Challenges of Young People with Learning Disabilities and Attention-Deficit/Hyperactivity Disorder

by Consuelo M. Kreider, Sharon Medina and Mackenzi R. Slamka

Children 2019, 6(2), 28; https://doi.org/10.3390/children6020028 - 13 February 2019

Abstract

Learning disabilities (LD) and attention deficit hyperactivity disorder (ADHD) are characterized by neurological differences that result in difficulties meeting learning and productivity expectations. Young people with LD and ADHD experience difficulties in self-managing academic, social, daily living, and health/wellness demands. Students with LD/ADHD must work longer and harder than peers, which makes managing time and productivity a critical skill for school success. This study examined the strategies that college students with LD/ADHD used to overcome obstacles related to time and productivity within their everyday life contexts. A qualitative phenomenological design was used to examine the phenomenon of coping and productive-task performance through strategy use among 52 college students with LD/ADHD. Strategies classified as habit and routine use, reframing, and symptom-specific strategies were identified. Strategy use for addressing time-related and productivity challenges are multidimensional and entailed a mix of cognitive, behavioral, psychological, and socio-environmental strategies. Effective strategy use across life’s contexts was critical to self-managing as a young person with a chronic developmental condition within a college context. The findings provide a much-needed understanding of the multi-faceted challenges and solutions within young adult contexts that are important for guiding the development of interventions for young people with LD/ADHD. Full article

Open AccessReview

The Evolution of Risk Classification for Neuroblastoma

by Elizabeth Sokol and Ami V. Desai

Children 2019, 6(2), 27; https://doi.org/10.3390/children6020027 - 11 February 2019

Abstract

Neuroblastoma is a tumor with great clinical heterogeneity. Patients in North America are risk-stratified using a number of features including age at diagnosis, disease stage, tumor histology, MYCN status (amplified versus nonamplified), and tumor cell ploidy. In this paper, we review the evidence for utilizing these features in the risk classification of neuroblastic tumors. Additionally, we review the clinical and biologic criteria used by various cooperative groups to define low, intermediate, and high-risk disease populations in clinical trials, highlighting the differences in risk classification internationally. Finally, we discuss the development of the International Neuroblastoma Risk Group classification system, designed to begin worldwide standardization of neuroblastoma pretreatment risk classification and allow comparison of clinical trials conducted through different cooperative groups. Full article

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