Video Abstract

Video Abstract

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BACKGROUND:

Management of pediatric emergencies is challenging for ambulatory providers because these rare events require preparation and planning tailored to the expected emergencies. The current recommendations for pediatric emergencies in ambulatory settings are based on 20-year-old survey data. We aimed to objectively identify the frequency and etiology of pediatric emergencies in ambulatory practices.

METHODS:

We examined pediatric emergency medical services (EMS) runs originating from ambulatory practices in the greater Indianapolis metropolitan area between January 1, 2012, and December 31, 2014. Probabilistic matching of pickup location addresses and practice location data from the Indiana Professional Licensing Agency were used to identify EMS runs from ambulatory settings. A manual review of EMS records was conducted to validate the matching, categorize illnesses types, and categorize interventions performed by EMS. Demographic data related to both patients who required treatment and practices where these events occurred were also described.

RESULTS:

Of the 38 841 pediatric EMS transports that occurred during the 3-year period, 332 (0.85%) originated from ambulatory practices at a rate of 42 per 100 000 children per year. The most common illness types were respiratory distress, psychiatric and/or behavioral emergencies, and seizures. Supplemental oxygen and albuterol were the most common intervention, with few critical care level interventions. Community measures of low socioeconomic status were associated with increased number of pediatric emergencies in ambulatory settings.

CONCLUSIONS:

Pediatric emergencies in ambulatory settings are most likely due to respiratory distress, psychiatric and/or behavioral emergencies, or seizures. They usually require only basic interventions. EMS data are a valuable tool for identifying emergencies in ambulatory settings when validated with external data.

What’s Known on This Subject:

Pediatric emergencies have been reported to occur weekly in ambulatory practice settings. Current epidemiology and standards with regard to preparedness are based on 20-year-old survey data.

What This Study Adds:

We define the frequency of pediatric emergencies occurring in ambulatory practices requiring emergency medical services transport. We also characterize the illness types and interventions needed by patients during their transport from an office-to-hospital setting.

The management of pediatric emergencies in an ambulatory care setting can be challenging because they are rare events requiring specialized skills that need to be performed in a time-sensitive manner. Few data exist regarding the frequency and etiology of these events for providers to use, likely because of their infrequent nature and lack of a widely accepted definition for emergency in an ambulatory care setting. The authors of previous literature published from 1989 to 1995 indicated that >50% of pediatric offices reported seeing between 1 and 5 patients per week requiring emergency treatment or emergency hospitalization, and similarly, a mailed questionnaire revealed that 62% of physicians in pediatric offices reported seeing at least 1 patient per week requiring urgent treatment or hospitalization.1,2 The most common types of illnesses identified included respiratory emergencies, seizures, and dehydration. Given the potential impact of these events on patient care, the American Academy of Pediatrics (AAP) published a set of recommendations for ambulatory care providers regarding the training of their staff in basic life support skills at minimum along with lists of equipment to have on hand, including supplemental oxygen and necessary delivery devices, albuterol and nebulizer equipment, and epinephrine.3 

In addition to the AAP’s recommendations, other groups have detailed strategies for preparing ambulatory care offices for pediatric emergencies, all based on retrospective survey data.2,6 Retrospective surveys are useful and commonly employed tools in gathering information from a large group of practitioners in a small window of time, but inherent in their design is the risk of errors due to provider recollection and response rate.7,10 More recently, the authors of 2 studies looking at emergency medical services (EMS) encounters data in pediatric patients attempted to better define types of illnesses and required interventions. The authors of 1 study looked specifically at specialty pediatric critical care transports originating from outpatient medical locations but did not include any general EMS transports.11 The authors of the other study evaluated all EMS encounters for school-aged children (age ≥5 years) from public locations (including a subgroup of patients from medical facilities) but did not identify types of medical facilties.12 The authors of both of these studies used aggregated EMS data that were neither validated through manual review nor confirmed with other data sources.

Because of the potential gaps and inaccuracies in existing analyses, we aimed to more precisely define the epidemiology of pediatric emergencies in ambulatory practices by matching EMS pickup locations to known addresses of ambulatory providers across a major metropolitan area and then manually reviewing the matched records to confirm the locations. We hypothesized that ambulatory-based emergencies in pediatric patients occur at a different frequency and are caused by other etiologies than what is currently described in the medical literature.

This study was a retrospective observational study of EMS data from the Indianapolis metropolitan area, which includes Marion County and small portions of surrounding counties and is divided into 9 townships. Marion County contains 18 hospitals, with a total of 4616 beds with a density of 1 bed per 201 people.13 All patients <18 years old who were transported from an ambulatory practice by Indianapolis EMS or the Indiana University Health critical care transport team (ie, Lifeline) between January 1, 2012, and December 31, 2014, were eligible. Most patients (98.7%) were transported by the Indianapolis EMS system. Indianapolis EMS is the main EMS provider in the Indianapolis metropolitan area, with a transport volume of >100 000 calls per year. It is a 2-tiered system and serves the entire metropolitan area. The Indianapolis EMS data contained 6 patient records with incomplete address information, which were excluded. This study was approved by the Indiana University Institutional Review Board.

The primary source from which EMS transport data were obtained was the Indianapolis EMS system. It contains basic demographic data of patients (age, sex, race, and ethnicity), patient descriptions (including chief complaint), EMS interventions before and during transport, and times from call to arrival on scene and from leaving the scene to hospital arrival. The pickup address is determined by the address given to the EMS dispatch by the individual requesting transport. The EMS providers also describe the pickup location both in a standardized description field (reported to the national EMS registry) and often in the free-text description of the run. The same data were obtained from Indiana University Health Lifeline. These data sets are reformatted before being sent to the National Emergency Medical Services Information System (NEMSIS), the national EMS data registry.

EMS encounters originating in ambulatory practices were identified by matching EMS pickup locations to known provider practice addresses obtained from the Indiana Professional Licensing Agency and maintained for research and reporting by the Bowen Center for Health Workforce Research and Policy.14 This data set is collected at the time of provider medical license renewal and is updated every 2 years. Because providers, such as nurse practitioners and physician assistants, are not currently allowed to operate without oversight by a licensed physician, the data set also includes urgent care facilities not primarily staffed by a physician. These addresses were then analyzed through geocoding procedures in SAS 9.4 (SAS Institute, Inc, Cary, NC). Addresses were first compared with a TIGER/Line file, which returned geographical coordinates for each address and were then matched using geographical coordinates of ambulatory practices in the 2015 medical license renewal survey. This process was used to identify 191 matched addresses of medical facilities, with a total of 1180 patient runs potentially originating from those locations. A manual review was then performed to separate the encounters originating from ambulatory practices versus those that were interhospital transports (originating from an emergency department or inpatient facility) or encounters originating in a nearby location to a medical practice. The EMS pickup location description (health care facility, hospital, school, etc), which has been used in previous studies to determine encounter origination, was categorized as probable medical facility or not. Agreement between EMS pickup location description and final identification (after matching and manual review) of an ambulatory practice was determined, including sensitivity and specificity of EMS description of pickup location. Two geographic information system maps were produced comparing all pediatric EMS transports during the specified time frame with pediatric EMS transports originating at an ambulatory practice to demonstrate an appropriate geographical distribution across the Indianapolis metro area (Figs 1 and 2). Addresses were plotted in a map of Marion County by using ArcGIS 10.4 and delineated by township to better demonstrate their distribution across the metropolitan area.

FIGURE 1

All pediatric EMS runs from 2012 to 2014.

FIGURE 1

All pediatric EMS runs from 2012 to 2014.

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FIGURE 2

Pediatric EMS runs originating from ambulatory facilities from 2012 to 2014.

FIGURE 2

Pediatric EMS runs originating from ambulatory facilities from 2012 to 2014.

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Although urgent visit centers in the metropolitan area were included as ambulatory practices, we did identify 1 urgent visit center with a unique practice pattern. This facility was located within the local county hospital and has a triage system integrated with that hospital’s main emergency department. Because this hospital does not provide care for pediatric inpatients, any patient that may potentially need hospitalization is transported from that location to the nearby children’s hospital. These patients are transported primarily by Lifeline and comprised the majority of patients transported by Lifeline within the metropolitan area. Because of the differences in this practice pattern with respect to both transport team and practice of the originating facility, the patient transports originating from this location were collected but analyzed as a separate data set because this practice pattern may be reproduced in other communities.

Population data obtained from the most recent US census were used to calculate the frequency of pediatric ambulatory emergencies for the township in which the facilities are located because individual facility patient panel data were not available. Correlations between socioeconomic characteristics defined by US census estimates of the townships and frequency of these events were also assessed.

Illness categories were assigned to each patient on the basis of manual review of the free-text chief and secondary complaints recorded in the EMS record as well as general descriptions of the patient and reason for the emergency call, all documented by EMS personnel caring for the patient. All pediatric cases arising from a validated medical facility were reviewed and categorized. Assigned illness categories included respiratory distress, psychiatric and/or behavioral emergencies, seizure, febrile illness, syncope, trauma, allergic reaction, procedural complications, abdominal pain, and diabetes complications. If an illness category was unable to be determined because of incomplete or unclear EMS documentation, a generic category of “unknown” was assigned. All medical interventions documented by EMS during transport were categorized a priori as either standard or critical care. Standard interventions included most medication administration (albuterol, diphenhydramine, ondansetron, dextrose, and steroids), obtaining intravascular access, and administration of supplemental oxygen. Critical care interventions included use of an artificial airway, cardiopulmonary resuscitation, administration of a fluid bolus, obtaining intraosseous access, bag mask ventilation, and administration of epinephrine or a benzodiazepine. Time from the call to EMS’s arrival on scene and the time from scene to arrival at the hospital were abstracted from the EMS record.

Descriptive statistics were used to describe patient characteristics such as age, sex, race, type of illness, and interventions administered by EMS during transport. Pearson correlations were used to compare markers of low socioeconomic status (including median household income, percentage of the population below poverty level, and percentage of population with at least a high school diploma) with the frequency of pediatric outpatient emergencies at the township level.

Between January 1, 2012, and December 31, 2014, there were 38 841 pediatric EMS transports in the Indianapolis metropolitan area. Of these, 1180 transports were identified by geocode matching as originating from a medical facility. A total of 332 were manually verified as originating from 1 of 101 ambulatory practices, with the remainder originating from a hospital (inpatient unit or emergency department) (41%) or a location close to a medical facility (27%). Forty-three additional runs originated from the urgent visit center associated with a county hospital (discussed separately).

Patient characteristics for emergencies occurring in ambulatory practices are displayed in Table 1. The vast majority of emergencies were due to respiratory distress (58.1%), with the next most common emergency types being psychiatric and/or behavioral emergencies (6.3%), seizure (6.3%), and syncope (5.4%) (Table 2). The most common interventions were use of supplemental oxygen (27.4%), albuterol (26.5%), and intravascular access (10.5%). Limited critical care interventions were employed. Among critical care interventions, fluid bolus administration (2.1%), benzodiazepine administration (1.5%), or racemic or intramuscular epinephrine (1.2%) were the most common (Table 3). No patients transported from an ambulatory care facility during the study period required bag mask ventilation, an artificial airway, intraosseous access, or cardiopulmonary resuscitation. The average time from EMS notification to arrival on scene was 6 minutes (ranging from <1–15 minutes), and the average patient transport time was 13 minutes (ranging from <1–38 minutes).

TABLE 1

Patient Characteristics

Characteristicn (%)
Median age, y 
Age categories  
 Infant or neonate, birth to 12 mo 126 (38) 
 Toddler, 13 mo to 2 y 18 (5) 
 Early childhood, 2–5 y 51 (15) 
 Middle childhood, 6–11 y 70 (21) 
 Early adolescence, 12–18 y 67 (20) 
 Female sex 155 (47) 
Race  
 White 150 (45) 
 African American 118 (36) 
 Other 56 (17) 
 Missing 8 (2) 
Ethnicity  
 Hispanic 50 (15) 
 Non-Hispanic 271 (82) 
 Missing 11 (3) 
Characteristicn (%)
Median age, y 
Age categories  
 Infant or neonate, birth to 12 mo 126 (38) 
 Toddler, 13 mo to 2 y 18 (5) 
 Early childhood, 2–5 y 51 (15) 
 Middle childhood, 6–11 y 70 (21) 
 Early adolescence, 12–18 y 67 (20) 
 Female sex 155 (47) 
Race  
 White 150 (45) 
 African American 118 (36) 
 Other 56 (17) 
 Missing 8 (2) 
Ethnicity  
 Hispanic 50 (15) 
 Non-Hispanic 271 (82) 
 Missing 11 (3) 
TABLE 2

Illness Categories

Categoryn (%)
Respiratory distress 193 (58.1) 
Psychiatric and/or behavioral 21 (6.3) 
Seizures 21 (6.3) 
Syncope 18 (5.4) 
Febrile illness 16 (4.8) 
Unknown etiology 15 (4.5) 
Trauma 13 (3.9) 
Allergic reaction 12 (3.6) 
Procedural complication 6 (1.8) 
Abdominal pain 6 (1.8) 
Diabetes complications 4 (1.2) 
OB or GYN 2 (0.6) 
General pain 2 (0.6) 
Poisoning 1 (0.3) 
Chest pain 1 (0.3) 
Nausea and/or vomiting 1 (0.3) 
Categoryn (%)
Respiratory distress 193 (58.1) 
Psychiatric and/or behavioral 21 (6.3) 
Seizures 21 (6.3) 
Syncope 18 (5.4) 
Febrile illness 16 (4.8) 
Unknown etiology 15 (4.5) 
Trauma 13 (3.9) 
Allergic reaction 12 (3.6) 
Procedural complication 6 (1.8) 
Abdominal pain 6 (1.8) 
Diabetes complications 4 (1.2) 
OB or GYN 2 (0.6) 
General pain 2 (0.6) 
Poisoning 1 (0.3) 
Chest pain 1 (0.3) 
Nausea and/or vomiting 1 (0.3) 

GYN, gynecology; OB, obstetrics.

TABLE 3

Interventions

n (%)
Critical care interventions  
 Fluid bolus 7 (2.1) 
 Benzodiazepine administration 5 (1.5) 
 Epinephrine (IM and/or racemic) 4 (1.2) 
Standard interventions  
 Supplemental oxygen 91 (27.4) 
 Albuterol administration 88 (26.5) 
 IV access 35 (10.5) 
 Diphenhydramine administration 3 (0.9) 
 Ondansetron administration 2 (0.6) 
 Prednisone administration 1 (0.3) 
n (%)
Critical care interventions  
 Fluid bolus 7 (2.1) 
 Benzodiazepine administration 5 (1.5) 
 Epinephrine (IM and/or racemic) 4 (1.2) 
Standard interventions  
 Supplemental oxygen 91 (27.4) 
 Albuterol administration 88 (26.5) 
 IV access 35 (10.5) 
 Diphenhydramine administration 3 (0.9) 
 Ondansetron administration 2 (0.6) 
 Prednisone administration 1 (0.3) 

IM, intramuscular.

Among the 43 patients transported from the county hospital’s urgent visit center, respiratory distress was also the most common illness type requiring emergent transport (81.4%), with the remainder of patients falling into the illness categories of general febrile illness, seizures, poisoning, complications related to diabetes mellitus, and abdominal pain. These patients were younger (median age 1.9 years) and received greater and more frequent interventions, including fluid boluses (54%), albuterol (39.5%), and intravascular access (100%).

When compared with township population data, the frequency of pediatric outpatient emergencies varied from 0 to 94 per 100 000 people <18 years old per year, with an average of 42 emergencies per 100 000 people <18 years old per year (Table 4). Townships with lower measures of socioeconomic status were correlated with increased frequency of EMS encounters originating at ambulatory care facilities (Table 5). Of facilities that had at least 1 EMS run during the 3-year period, the median number of runs per facility was 0.7 per year, with 75% of facilities seeing ≤2 runs per year. We were not able to obtain data on the number of ambulatory facilities treating pediatric patients who did not have an EMS run over the 3-year period.

TABLE 4

EMS Runs by Township Population

TownshipAverage Runs Per yRuns Per 100 000 Persons <18 Per y
Center 29 88.9 
Warren 25.3 94.5 
Washington 15 56.2 
Perry 14.7 54.6 
Lawrence 11.3 35.7 
Pike 5.3 25.1 
Franklin 2.7 16.3 
Wayne 2.7 7.5 
Decatur 
TownshipAverage Runs Per yRuns Per 100 000 Persons <18 Per y
Center 29 88.9 
Warren 25.3 94.5 
Washington 15 56.2 
Perry 14.7 54.6 
Lawrence 11.3 35.7 
Pike 5.3 25.1 
Franklin 2.7 16.3 
Wayne 2.7 7.5 
Decatur 
TABLE 5

EMS Run Frequency Compared With Socioeconomic Markers

Township CharacteristicsPearson’s rCI (95%)
Median household income −0.78 (−0.95 to −0.23) 
Percent of population below the poverty level 0.72 (0.11 to 0.94) 
Percent of population with minimum of a high school diploma −0.6 (−0.9 to 0.11) 
Township CharacteristicsPearson’s rCI (95%)
Median household income −0.78 (−0.95 to −0.23) 
Percent of population below the poverty level 0.72 (0.11 to 0.94) 
Percent of population with minimum of a high school diploma −0.6 (−0.9 to 0.11) 

CI, confidence interval.

The accuracy of EMS identification of medical facilities was also assessed to permit extrapolation to other studies. EMS providers correctly identified 267 of 327 pickup locations as ambulatory care facilities in their location descriptions, with a sensitivity of 81%. There were few locations labeled incorrectly as ambulatory care facilities, with a specificity of 97%. The ambulatory facilities were divided into 3 categories, with 35 identified as single specialty primary care practices, 33 as subspecialty practices, and 33 as practices with multiple specialties present. Specific specialty types were not reported.

We demonstrate an innovative approach using geocode matching and validation of EMS data to more precisely estimate the disease incidence, treatment strategies, and population-based factors that lead to pediatric emergencies in ambulatory care facilities. With our results, we not only reiterate that respiratory illness and seizures are among the most common pediatric emergencies in ambulatory settings but also identify psychiatric and behavioral emergencies to be common events.1,2,11 Psychiatric and behavioral emergencies were not listed in any previous survey data but were recently identified as the most common identifiable complaint requiring EMS activation from a health care facility in school-aged children.12 This is supported by our data because patients in our study were 57% female and ranged in age from 6 to 17 years (average 14 years). Our results also support an AAP publication whose authors describe the significant increase in mental health complaints made by pediatric patients in both emergency department and primary care settings.15 

Observed emergencies matched well with required interventions. Significantly, almost no critical care interventions were required by patients being transported from ambulatory practices during our study period. There is no specific EMS protocol to govern intravenous (IV) access, although it is typically obtained when parenteral medications are required (including dextrose solutions) and in trauma. There is no pediatric behavioral emergency protocol for EMS, but providers may apply their general protocol to pediatric patients, which allows for chemical restraint with midazolam. Providers are permitted to give benzodiazepines via IV, intramuscular, and intranasal routes. Despite respiratory distress being the most common of pediatric ambulatory emergencies, no patients required advanced airway management. Our study further supports findings from Joyce et al11 that patients infrequently needed critical care interventions when presenting to an outpatient provider with an emergency.

Locations from which patients were transported are well distributed across the metropolitan area. This implies there are no significant areas from which we were unable to obtain patient data and shows good representation of pediatric ambulatory emergencies across the metropolitan area. Indianapolis is the 15th most populous city in the United States, with a population of >800 000, and thus a reasonable example for large urban and/or suburban centers.16 The association between markers of low socioeconomic status and increased number of pediatric ambulatory emergencies supports previous studies whose authors report that children living in poverty have more chronic medical conditions (specifically asthma and mental health conditions), more severe chronic conditions, and more associated comorbidities.17,19 Ambulatory providers who serve these populations may need to be even more prepared to handle pediatric emergencies.

The low rate of EMS transports from ambulatory settings and the lack of patients requiring critical care interventions suggest that pediatric ambulatory care providers and their support staff will have a difficult time maintaining protocols and skills necessary to manage critically ill patients through exposure alone. Ambulatory providers located in urban and/or suburban settings who care for children should focus their office preparedness on deployment of resources to expedite EMS notification. Efforts should be made to maintain the skills necessary to care for patients in respiratory distress (ie, nebulized therapy when appropriate, oxygen, and the use of a bag mask in rare situations). Psychiatric and behavioral emergencies are also an area that merits preparation, in which guidelines already developed by the AAP are used.15,20,21 

Our findings in this study also help clarify the reliability of EMS data when characterizing pickup locations. The authors of most existing studies have used NEMSIS as their data source. NEMSIS is a national repository of standardized data collected from EMS providers throughout the country with the goal of allowing larger-scale analysis of data at multiple levels to facilitate training, outcomes research, and needs assessments. In previous studies, researchers using this data source have relied on pickup location descriptions when identifying transport origination. We show that the pickup location description is specific but not as sensitive in capturing ambulatory care facilities and show that many sites were found by using geocode matching that would otherwise not have been identified. This methodology could potentially be used to more precisely identify other types of locations and could also be used to overlay EMS data with more detailed socioeconomic data to better describe associated health care delivery disparities.

This study has some limitations. Data were collected from urban and suburban areas of a single large metropolitan area and may not be generalizable to all populations, especially rural settings. There are also 2 significantly smaller EMS providers operating within the study area, each accounting for ∼1000 pediatric transports annually, from which we were not able to obtain medical records. The additional patients would not likely have changed the distribution of illness types, although they may have slightly increased the overall incidence of emergencies. All data that were reported rely on EMS records, limiting the ability to determine if interventions were employed before their arrival and making it difficult to determine definitive diagnosis for individual patients. Because EMS patient identifiers are different from those used in hospitals, we were also unable to document outcomes of patients after reaching definitive care. The reliance on EMS records may also result in underestimation of the number of ambulatory care emergencies. Although the data again rely on retrospective surveys and are almost 20 years old, the reported percentage of patients transported by EMS from a pediatric office for an emergency was 48%, with 53.8% of physicians reporting they preferred allowing the patient’s family to transport to the nearest hospital.22,23 These practices may have changed in recent years, and this topic warrants further study. The patient data were collected from 2012 to 2014 but compared with the most recent Indiana Professional Licensing Agency data from 2015, so some changes in locations of ambulatory medical facilities could not be accounted for. We could not provide a temporal pattern of the transports throughout the year because transport dates were not collected.

The results of this study have broad implications regarding ambulatory practice emergency readiness, planning, and equipment and medication availability. There are also potential implications regarding the ongoing education of pediatric providers, especially regarding psychiatric and behavioral emergencies. The results can impact the interpretation of studies in which EMS data are used as well. Further studies in other urban and/or suburban locations, as well as rural settings, would help with this study’s limitations, having been done in a single urban and/or suburban location.

In the setting of a large metropolitan population, pediatric emergencies in ambulatory practices resulting in EMS activation are predominantly due to respiratory distress, psychiatric and/or behavioral emergencies, and seizures. They occur infrequently, with most facilities seeing <2 annually, and patients required only basic interventions including those for respiratory distress. These findings update and clarify existing literature with regard to the frequency of pediatric emergencies in the ambulatory setting, the conditions these patients present with, and the use of EMS data to define these events. This study can inform future decisions regarding necessary equipment and procedures for office-based preparedness and can help identify areas of ongoing training for ambulatory providers. Additional studies are needed to characterize the nature of pediatric ambulatory emergencies in rural settings.

AAP

American Academy of Pediatrics

EMS

emergency medical services

IV

intravenous

NEMSIS

National Emergency Medical Services Information System

Dr Yuknis conceptualized and designed the study, performed the preliminary data analysis, and drafted and revised the initial manuscript; Dr Weinstein coordinated and supervised the collection of data and critically reviewed the manuscript; Dr Maxey coordinated and supervised the collection of data, designed and performed data analysis, and critically reviewed the manuscript; Dr Price advised with the design of the study and critically reviewed the manuscript; Ms Vaughn coordinated and supervised the collection of data and designed and performed data analysis; Mr Arkins coordinated and supervised the collection of data; Dr Benneyworth designed and performed data analysis and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted.

FUNDING: No external funding.

We thank the Bowen Center for Health Workforce Research and Policy and the Indiana University School of Medicine Departments of Pediatrics and Emergency Medicine for their collaboration and sharing of data. We also acknowledge Yumin Wang for data analysis.

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.