Received: 4 June 2023 | Revised: 29 August 2023 | Accepted: 4 September 2023

DOI: 10.1111/pan.14760

PERSPECTIVE

The role of WhatsApp™ in pediatric difficult airway

management: A study from the PeDI Collaborative

Evelina Pankiv1,2 | Kira Achaibar1,2 | Alomgir Hossain3 | John E. Fiadjoe4 |

Clyde T. Matava1,2 | PeDI-­C Collaborators

1
Department of Anesthesia, The Hospital
for Sick Children, Toronto, Ontario, Abstract
Canada
Background: Management of the pediatric difficult airway can present unique clini-
2
Department of Anesthesiology and Pain
Medicine, University of Toronto, Toronto,
cal challenges. The Pediatric Difficult Intubation Collaborative (PeDI-­C) is an interna-
Ontario, Canada tional collaborative group engaging in quality improvement and research in children
3
Research Institute, Hospital for Sick with difficult airways. The PeDI-­C established a WhatsApp™ group to facilitate real-­
Children, Toronto, Ontario, Canada
4 time discussions around the management of the difficult airway in pediatric patients.
Department of Anesthesiology and
Critical Care Medicine, Children's The goals of this study were to evaluate the patterns of use of the WhatsApp™ group,
Hospital of Philadelphia, Philadelphia,
themes on messages posted on pediatric difficult airway management and to assess
Pennsylvania, USA
the perceived usefulness of the WhatsApp™ group by the PeDI-­C members.
Correspondence
Method: Following research ethics approval, we performed a database analysis on
Clyde T. Matava, Department of
Anesthesia and Pain Medicine, Hospital the archived discussion of the PeDI-­C WhatsApp™ group from 2014 to 2019 and sur-
for Sick Children, 555 University Avenue,
veyed members to assess the perceived usefulness of the PeDI-­C WhatsApp™ group.
Toronto, ON M5G 1X8, Canada.
Email: [email protected] Results: 5781 messages were reviewed with 350 (6.0%) original stems. The three

Section Editor: Britta S von

most common original stem types were advice seeking 98 (28%), announcements 85
Ungern-­Sternberg (24.2%), and clinical case-­sharing 78 (22.2%). The median number of responses to
original stems was 9 [2–­21.3]. Post types associated with increased responses included
those seeking advice on medication/equipment (regression coefficient 0.78, 95% CI
[0.41–­1.16]; p < .0001); seeking advice on patient care (regression coefficient 1.16,
95% CI [0.86–­1.45]; p < .0001), sharing advice on medication/equipment availability
(regression coefficient 0.87, 95% CI [0.33–­1.40], p < .0016), and clinical case-­sharing
(regression coefficient 1.2547, 95% CI [0.9401–­1.5693] p < .0001). 46/64 members
of the group responded to the survey. Replies offering advice regarding patient man-
agement scenarios were found to be of most interest and 77% of surveyed members
found the discussion translatable into their own clinical practice.
Discussion: The PeDI-­C WhatsApp™ group has facilitated timely knowledge exchange
on pediatric difficult airway management across the world. Participants are satisfied
with the role the Whatsapp™ group is playing.

KEYWORDS
airway, difficult airway, network, pediatric anesthesia, social network, WhatsApp™

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in
any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
© 2023 The Authors. Pediatric Anesthesia published by John Wiley & Sons Ltd.

Pediatric Anesthesia. 2023;33:1001–1011.  wileyonlinelibrary.com/journal/pan | 1001

 |

14609592, 2023, 12, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/pan.14760, Wiley Online Library on [27/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1002 PANKIV et al.

1 | I NTRO D U C TI O N
What is already known about this topic?
The management of the difficult airway in pediatric patients re-
• The management of the difficult airway in pediatric pa-
mains a challenge. Experienced personnel and appropriate equip-
tients remains a challenge. Experienced personnel and
ment are paramount to safely managing children with difficult
appropriate equipment are paramount to safely manag-
airways. Several groups, including the Pediatric Difficult Intubation
ing children with difficult airways.
Collaborative(PeDI-­C),1 a special interest group of the Society for
• Clinicians face real-­world clinical situations that are
Pediatric Anesthesia in the United States (https://pedsa​nethe​sia.
challenging, dynamic and may require advice from or
org), the Difficult Airway Society in the United Kingdom, 2 and the
discussion with colleagues and difficult airway experts.
American Society for Anesthesiologists,3 have published guidelines
on evidence-­based and consensus-­based techniques for improving
What new information does this study add?
outcomes in the pediatric difficult airway population. While these
guidelines offer frameworks and algorithms for managing difficult • The study shows that a real-­time peer advice PeDI-­C
3 4,5
airways in adult and pediatric patients, clinicians face real-­world WhatsApp™ group has facilitated timely knowledge ex-
clinical situations that are challenging and dynamic and may require change on pediatric difficult airway management across the
advice from or discussion with colleagues and difficult airway ex- world.
perts. The PeDI-­C group includes 45 hospitals from over five coun- • Participants perceive high value and are highly satisfied
tries with members across several time zones. The group meets with the role the WhatsApp™ group is playing in difficult
twice a year at the spring and fall meetings of the Society of Pediat- airway clinical care.
ric Anesthesia to discuss ongoing research initiatives. In addition, in
2014, the PeDI-­C established a WhatsApp™ group to facilitate real-­
time discussions around the management of the difficult airway in categorized this into four themes: advice seeking, clinical case shar-
pediatric patients. Participants can post a case for discussion or seek ing, educational content, administrative content, and miscellaneous
advice on strategies to assess, diagnose, and manage upcoming dif- content that did not fit the above four categories.
ficult intubation cases and can share pictures and images provided In each category, the initial message or question was coded as an
they obtain consent from the patients to do so. Sharing and contact- “original stem” and assigned a unique identification number. The the-
ing peers with varied experience and expertise may be essential in matic subject of the stem was coded using one of the four categories
advancing the field and disseminating evidence-­based information above. All responses or comments related to the stem were coded
on pediatric difficult airways. as “replies” and counted. Uninterrupted comments made by a single
The goals of this study were twofold. First, to evaluate the pat- individual were counted as one “reply.” We also calculated the time
terns of use of the WhatsApp™ group, themes on messages posted duration between the stem and the final reply.
on pediatric difficult airway management, and second, to assess
the perceived usefulness of the WhatsApp™ group by the PeDI-­
Collaborative members. 2.2 | Survey of PeDI-­C WhatsApp™ members

To gather information on the perceived benefits and utility of the

2 | M E TH O D O LO G Y PeDI-­C WhatsApp™ group, we conducted an online survey of mem-
bers. We adapted the survey instrument used by Carmona et al.
Following ethics approval (Hospital for Sick Children #1000062868), 2018,6 and as per similar surveys, we formally tested using a con-
we performed the study in two parts: (a) analysis of PeDI-­C What- venience sample of three pediatric anesthesia fellows and three
sApp™ data and (b) a survey of PeDI-­C WhatsApp™ members. pediatric anesthesiologists, members of the PeDI-­C WhatsApp™
group.7–­12 The survey did not require changes following feedback.
We identified survey participants from the members of the PeDI-
2.1 | PeDI-­C WhatsApp™ data analysis ­C WhatsApp™ group and the PeDI-­C Google™ group collaborative
email list. Eligible members were invited to complete the survey via
Data posted on the PeDI-­C WhatsApp™ chat between January 2014 an initial post to the WhatsApp™ group. The post included a link to
and January 2019 were downloaded onto a Microsoft Excel spread- an online survey hosted at the Hospital for Sick Children's Redcap
sheet (Microsoft Inc.). Using methods previously described by Car- Server.13,14 A first reminder to complete the survey was posted after
6
mona et al. (2018), the content was analyzed to provide insights into 2 weeks, and a final reminder 2 weeks later. The online survey re-
the following: characteristics of users and patterns of usage, type mained open for 2 weeks after the final reminder. Similar posts were
of content shared (text only, images, videos, weblinks, and file at- made via email sent to the PeDI-­C mailing list. All survey responses
tachments). Also, we performed a thematic analysis of content and were anonymous.
 |

14609592, 2023, 12, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/pan.14760, Wiley Online Library on [27/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
PANKIV et al. 1003

TA B L E 1 PeDI Collaborative WhatsApp™ message content and

With a membership of 64 at the time of the study, all mem-
response generation.
bers were invited to complete the survey. The completion of the
survey implied consent. We performed a thematic analysis of the Responses per stem
Message (N = 5781) n (%) type
WhatsApp™ data and categorized each original stem into one of the
following categories: advice seeking (clinical or equipment), clin- Original stem 350 (6.0)

ical case sharing, educational content, administrative content, and First-­generation response 2360 (40.8)
miscellaneous. Second-­generation 1284 (22.2)
response
Third-­generation response 712 (12.3)
2.3 | Statistical analysis >Third-­generation 930 (16.0)
response

Data were analyzed following procedures that were determined a Administrative content 145 (2.5)
priori. Original stem theme n (%)
Categorical variables are presented as frequency and percent- (n = 350)

ages. According to the results of the Kolmogorov–­Smirnov test, Advice seeking 98 (28) 15 (6.8–­29, [1, 94])

normally and nonnormally distributed variables were presented Patient related (n = 68) 17.5 (8.3–­33, [1, 94])
as the mean (SD) and the median [1st–­3rd Quartiles], respectively. Medications/equipment 8 (6–­19.5, [1, 90])
Multiple linear regression models were performed to assess the re- related (n = 30)

lationship between the independent predictors and responses to Advice sharing 19 (5.4) 6 (3–­15, [2, 69])
link the stem after considering the effect within each unique user Patient related (n = 4) 6 (2–­10, [2, 10])
correlation. A standard model building approach was used to fit the Medications/equipment 6 (3–­21, [2, 69])
multiple linear regression models. The interaction and confounding related (n = 15)

factors were adjusted during the model building stages. The out- Clinical case sharing 78 (22.3) 18.5 (9–­36, [0, 170])
come variable was transformed using the cubic root function to Educational content 27 (7.7) 3 (1–­9, [0, 25])
assess the normality assumption. The statistical significances were Announcements 85 (24.3) 3 (0–­9.5, [0, 30])
defined as p-­value ≤ .05 with a two-­t ailed test. Statistical analyses Miscellaneous 43 (12.3) 5 (1–­12, [0, 42])
were conducted using SAS (version 9.4 SAS Institute Inc.). (nonmedical related)

Note: Data are expressed as the mean (SD), median (first quartile to
third quartile [range]), or number of responses (proportion).
3 | R E S U LT S

3.1 | Analysis of PeDi WhatsApp™ Data generated more responses (median 17.5 responses [8.3–­33]) than
seeking advice on medications/equipment (median 8 responses [6–­
3.1.1 | Type and frequency of content shared 19.5]). The post with the highest response of 170 was one sharing
experiences from a clinical case.
5781 messages were archived in the PeDI-­C WhatsApp group, A total of 447 responses in the chat included media. Most media
from September 30, 2014 to March 23, 2019. These dates spanned responses were images, 382/447 (85.0%), with videos attached in
1636 days, averaging 3.5 posts per day. During the study period, 27/447 (6.0%) of media responses. An image or video that featured
there were a total of 71 participants joined the PeDI-­C WhatsApp a patient was included in 155/447 (37.9%) of media responses, and
group with seven participants leaving the group resulting in 64 those that featured equipment were included in 62/447 (15.1%).
members. 350/5781 (6.1%) messages were original stems (Table 1). Only 38/447 (8.5%) of the posts included a link to a website/article/
Of these original stems, 125/350 (35.7%) included one or more social media.
media files. The three most common original stem types were advice
seeking 98/350 (28%) announcements 85/350 (24.2%), and clinical
case sharing 78/250 (22.2%) (Table 1). 3.1.2 | Influence of chat on clinical
The median [IQR] number of responses to original stems was 9 decision-­making and management
[2–­21.3]. All content of the chat was analyzed and dealt primarily
with difficult airway management but also contained miscellaneous In 49/350 (14.0%) of original stems, the original poster did indeed
content such as announcements. The three original stem categories acknowledge all comments with a final post but did not make explicit
that generated the most responses were advice seeking, median of or implied changes to their practice (Table S1). There were 29/350
15 responses, IQR [6.8–­29]; advice sharing, median of 6 responses, (8.2%) original stems where the original poster provided an update,
IQR [3–­15], and clinical case sharing, median of 18.5 responses, suggesting that they used the advice provided in the chat to influ-
IQR [9–­36] (Table 2). When seeking advice, patient-­related queries ence their management.
 |

14609592, 2023, 12, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/pan.14760, Wiley Online Library on [27/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1004 PANKIV et al.

TA B L E 2 Multiple linear regression

Original stem factors Regression coefficient (95% CI) p-­Value
analysis for factors in the original stem
Advice seeking medication/equipment 0.78 (0.41 to 1.16) <.0001 associated with increased responses.
availability (not related to a case under
discussion)
Advice-­seeking patient care 1.16 (0.86 to 1.45) <.0001
Advice sharing non-­medical related 0.47 (−0.43 to 1.38) .3066
Advice sharing-­medication/equipment 0.87 (0.33 to 1.40) .0016
availability
Clinical case sharing 1.25 (0.94 to 1.57) <.0001
Educational content 0.55 (0.08 to 1.01) .02
Emoji −0.29 (−0.92 to 0.33) .354
Image attached/linked 0.08 (−0.42 to 0.59) .7502
Image/video depicts Colleagues 0.09 (−0.52 to 0.70) .7619
Image/video depicts is Equipment focused −0.39 (−1.16 to 0.38) .3185
image
Image/video depicts patient/case −0.13 (−0.72 to 0.45) .6539
Link to website −0.83 (−1.38 to −0.28) .0031
Link to article −0.84 (−1.39 to −0.29) .0029
Link to social media −0.89 (−1.68 to −0.09) .0293
Miscellaneous objects depicted in the photo −0.09 (−0.88 to 0.71) .8281
Miscellaneous—­nonmedical related 0.18 (−0.15 to 0.51) .2781
Video attached/linked −0.5 (−1.38 to 0.34) .2341

F I G U R E 1 Geographical representation of the location of PeDi Collaborative WhatApp™ group survey respondents.
 |

14609592, 2023, 12, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/pan.14760, Wiley Online Library on [27/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
PANKIV et al. 1005

TA B L E 3 Demographics of the PeDi Collaborative WhatsApp™

3.1.3 | Factors influencing responses survey respondents.
to the original stem
Demographics n (%)

In the multiple linear regression analysis, the following post types Age (n = 44)
were associated with increased responses included those seeking 21–­29 1 (2.2)
advice on medication/equipment (regression coefficient 0.78, 95% 30–­49 30 (68.1)
CI [0.41–­1.16]; p < .0001) seeking advice on patient care (regression 50–­59 7 (15.9)
coefficient 1.16, 95% CI [0.86–­1.45]; p < .0001); and those sharing
>60 6 (13.6)
advice on medication/equipment availability (regression coefficient
Gender (n = 44)
0.87, 95% CI [0.33–­1.40], p < .0016), and clinical case-­sharing (re-
Male 21 (47.7)
gression coefficient 1.25, 95% CI [0.94–­1.57] p < .0001) (Table 2).
Female 22 (50.0)
Other 1 (2.2)
a
3.2 | Survey of PeDI-­C WhatsApp Members Hospital designation (n = 43)
Tertiary, teaching pediatric hospital 27 (62.8)

3.2.1 | Demographics of responders Tertiary teaching mixed pediatric/adult hospital 12 (27.9)

Nontertiary, nonteaching pediatric hospital 1 (2.3)
There were 46/64 survey respondents, with an overall completion Nontertiary, nonteaching mixed pediatric/adult 3 (6.9)
rate of 71.9%. Responders were from a total of 14 countries, with hospital
26/46 (56.8%) responders from the United States (Figure 1; Table 3). Academic Designation (n = 44)
The majority of responders identified their sites as tertiary, teaching Lecturer 11 (25.0)
pediatric hospitals 28/46 (60.9%), or tertiary teaching mixed pedi- Assistant Professor 11 (25.0)
atric/adult hospitals 13/46 (28.2%). The academic designation of Associate Professor 7 (15.9)
responders was split between lecturer 11/46 (23.9%) and assistant Full Professor 8 (18.1)
professor 11/46 (23.9%) (Table 3).
Professor Emeritus 0 (0)
No academic affiliation 7 (15.9)

Note: Data are represented or number of respondents (proportion),

3.2.2 | WhatsApp PeDi group chat participation
n = 35, unless otherwise stated.
a
Frequency is presented as the proportion of the 44 survey
The majority of respondents, 28/46 (60.9%), reported posting in the respondents, except for hospital designation where 43 replies were
group. 18/46 (39.1%) of respondents reported not posting on the received.
PeDI-­C WhatsApp™ group. The most frequently reported reason
for not posting was “I don't like participating in mass chat groups,
but I enjoy reading the discussions that take place” 9/18 (45.0%) in the chat is high quality, 31/35 (88.5%) and is evidence based,
(Table S2). 25/35 (71.5%) (Table 4).

3.2.3 | Perceptions regarding the advice offered 4 | DISCUSSION

on the PeDi Collaborative WhatsApp group
This study analyzed the use of a WhatsApp™ group by the Pediat-
27/35 (77.1%) responders either agreed or strongly agreed that ric Difficult Intubation Collaborative (PeDI-­C) and assessed its per-
they find it easy to translate the discussion into their own clinical ceived usefulness by its members. Our findings indicate that the
practice (Table 4). 16 /35(45.7%) responders agreed or strongly PeDI-­C WhatsApp™ group is a valuable resource for advice seeking,
agreed that they had changed a plan based on the advice pro- clinical case sharing, and educational content across several geo-
vided. 32/35 (91.4%) responders agreed or strongly agreed with graphical areas. The survey results also suggest that the majority of
each statement that the group informed them of the variance in the group members find the advice provided in the chat to be of high
practice across the globe and that the group chat is professional. quality and useful for their clinical practice.
29/35 (85.2%) responders agreed or strongly agreed that they feel The PeDI-­C group demonstrates the value of WhatsApp™
connected to peers via the group, 33/35 (94.2%) that they will groups for the sharing of information on managing pediatric diffi-
continue to be a part of the group, and 33/35 (94.2%) that they cult airways among this closed international group. The high pro-
will recommend others to join the group. The majority of respond- portion of advice seeking and clinical case sharing posts reflects
ers, 31/35 (88.5%) either agreed or strongly agreed that the advice the group's primary purpose to facilitate discussions around the
 |

14609592, 2023, 12, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/pan.14760, Wiley Online Library on [27/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1006 PANKIV et al.

TA B L E 4 Pedi Collaborative
Opinions in the PeDi Collaborative WhatsApp™ group n = 35(%)
WhatsApp™ Group Survey—­perceived use
I find it easy to translate the discussion into my own clinical practice 27 (77.1) and quality of advice.
I have changed a plan based on the advice provided in this group 16 (45.7)
I have instituted a change in my practice/group practice as a result of discussions 15 (42.8)
in this group
Has informed me of the variance in practice across the globe 32 (91.4)
I find the group's etiquette to be professional 32 (91.4)
The group helps disseminate new practice guidelines 23 (65.7)
I feel connected to peers via this WhatsApp group 29 (85.2)
I will continue to be a part of this WhatsApp group 33 (94.2)
I will recommend others to join this WhatsApp group 33 (94.2)
I do not have another way of getting timely advice outside of this group 4 (11.4)
I like this group as I get responses almost immediately no matter the time of day 25 (71.4)
I have experienced academic benefits from participating in this WhatsApp group 18 (51.4)
(publications, presentations, collaborations)
Opinions on advice in the PeDi Collaborative WhatsApp™ group
The advice is high quality 31 (88.5)
The advice is evidence based, n = 34 25 (73.5)
The advice is translatable to my clinical practice, n = 34 28 (82.3)
The advice is well balanced 28 (80.0)

Note: Data are represented or number of respondents (proportion), n = 35, unless otherwise stated.
Respondents were allowed to skip questions.

management of difficult airways in pediatric patients. Instant mes- While most responders found that advice received was high
saging applications have been used to share medical knowledge quality, slightly less than half of the responders reported that they
and improve patient safety and delivery of care across a wide changed their management based on advice provided. One explana-
range of disciplines.6,15–­18 Clinical collaboration in maternal-­fetal tion is that some of the feedback received was support or agreement
medicine has been reported using a closed international group from other PeDI-­Collaborative members, serving to validate a par-
on WhatsApp™ with responses influencing specialist patient care ticipant's clinical plan.
and promoting education.6,15 Bakshi et al. report on the use of Most of the survey respondents agreed that the advice provided in
Whatsapp™ to complement a formal acute pain teaching program the chat is high quality, evidence-­based, and easy to translate into their
with positive student feedback.16 Timely communication via mes- own clinical practice. This suggests that the PeDI-­C WhatsApp™ group
saging platforms can be a powerful tool to help seek clinical advice is an effective platform for disseminating information and promoting
when triaging patients to the appropriate healthcare service, in best practices in pediatric difficult airway management. However, it is
particular, in remote locations and this is relevant to seeking advice possible that some members may use the platform for self-­promotion.
17
on pediatric difficult airways. Astarcioglu et al. reported reduc- The group's international composition enables members to gain in-
tion in time to re-­perfusion after STEMI when standard clinical care sights into global variance in practice, fostering a sense of connection
was paired with the use of real-­time messaging by increasing ac- among peers. A high percentage of respondents reported their inten-
cess to senior clinical advice and influencing emergency team plan- tion to continue participating in the group and recommending it to
18
ning and efficiency. Our findings also reveal that patient-­related others, demonstrating the perceived value of the group.
queries generated more responses than medication-­/equipment-­ Limitations of instant messaging platforms need to be con-
related queries, indicating a stronger focus on patient care among sidered carefully in clinical medicine. Privacy and data protection
the group members. This aligns with the group's overall goal of im- should be paramount, and precautions taken to avoid disclosing
proving patient outcomes. any patient identifying information as the PeDi-­C group have
The influence of the WhatsApp™ group on clinical decision-­ done. Expert medical groups using this technology as a form of
making and management was evident in the 29 stems where the communication need to review how to communicate appropriately
original poster used the advice provided to guide their practice. outside of the remit of clinical care to ensure professionalism.
However, it is important to note that this number may not fully rep- Concerns around data security, the ownership of the data shared,
resent the impact of the group on clinical practice, as some members and the duration of which it is kept by a platform should all be con-
might not explicitly report changes in their approach. sidered. WhatsApp™ uses end-­to-­e nd encryption and stores data
 |

14609592, 2023, 12, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/pan.14760, Wiley Online Library on [27/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
PANKIV et al. 1007

for 30 days or less on their servers. Nonetheless, despite patient on difficult airway management in children. The PeDI-­C What-
consent some regional privacy protection policies prohibit shar- sApp™ group's ability to facilitate the exchange of experiences,
ing of patient data of any sort over platforms like WhatsAppTM . techniques, and best practices among experts from different
This may limit certain users' degree of participation in the group, in countries is crucial in advancing the field and may improve patient
particular, when they would appreciate international expert input outcomes.
on specific patient cases. Anesthesiologists will need to take into
consideration local rules and policies on data privacy as deter- AU T H O R C O N T R I B U T I O N S
mined by their jurisdictions. Exploring a platform that conforms Evelina Pankiv, MD, implemented the study, performed data anal-
to privacy policies on an international scale is an appealing step ysis, and wrote and edited the manuscript. Kira Achaibar, MBBS,
forward toward increasing participant engagement. Further, par- performed data analysis and wrote and edited the manuscript.
ticipants need to be wary of unrecognized biases in response pat- Alomgir Hassan MBChB, performed the analysis and reviewed
terns, which may influence the discussion and viewpoints, as well and edited the manuscript. John E. Fiadjoe MD, implemented
as unsolicited publicity shared via external links. the study and reviewed and edited the manuscript. Clyde T. Mat-
Last, it is key to maintain perspective on how users engage ava, MBCHB, MMed, MHSC, conceived the study, implemented
with instant messaging platforms, as we found some experts find the study, performed data analysis, and wrote and edited the
active engagement in discussion helpful and others prefer passive manuscript.
information gathering. The current study was unable to explore the
influence of factors such as the participants' experience, and aca- F U N D I N G I N FO R M AT I O N
demic affiliation as the archive data was de-­identified as per ethics This work was funded from institutional resources.
approval and study protocol.
However, it is important to recognize some users may not C O N FL I C T O F I N T E R E S T S TAT E M E N T
feel comfortable to actively participate in clinical discussions as John F. Fiadjoe is Associate Editor at the journal Pediatric Anesthesia.
demonstrated in our study. In addition, it is possible for advice Clyde T. Matava is Section Editor at the journal Pediatric Anesthesia.
that is inaccurate or not clinically sound to potentially lead to pa- The remaining authors have no disclosures.
tient harm. While none of the respondents specifically reported
harm occurring as a result of advice given, there was no obliga- DATA AVA I L A B I L I T Y S TAT E M E N T
tion to report outcomes to the group. There is certainly potential The data that support the findings of this study are available on re-
for negative outcomes being underreported, considering the is- quest from the corresponding author. The data are not publicly avail-
sues of stigma and legal consequences of discussing patient harm able due to privacy or ethical restrictions.
in an open forum. Further, most responses referenced existing
evidence. Since the study, the PeDi-­C WhatsApp™ group mem- E T H I C A L A P P R OVA L
bership has grown to 125 members and the opinions of the new This study received Human Ethics Committee approval.
members have not been captured.
Our study has several limitations. The study was performed on ORCID
the WhatsApp™ platform so is limited in analysis to this platform. It Clyde T. Matava https://orcid.org/0000-0002-9502-0981
is possible that other groups may exist on the same platform or other
social networks; the interactions on these platforms were not cap- REFERENCES
19–­23
tured in this study. The COVID pandemic may have changed the 1. Fiadjoe JE, Nishisaki A, Jagannathan N, et al. Airway management
perceptions and patterns of use of WhatsApp™ or social media among complications in children with difficult tracheal intubation from
the pediatric difficult intubation (PeDI) registry: a prospective
pediatric anesthesiologists, and its impact has yet to be determined.
cohort analysis. Lancet Respir Med. 2016;4(1):37-­48. doi:10.1016/
However, current usage of the PeDi-­C WhatsApp™ suggests a S2213-­2600(15)00508-­1
doubling in members since the pandemic started and continued dis- 2. Frerk C, Mitchell VS, McNarry AF, et al. Difficult airway society 2015
cussions. Nevertheless, our survey was able to provide additional guidelines for management of unanticipated difficult intubation in
adults. Br J Anaesth. 2015;115(6):827-­848. doi:10.1093/bja/aev371
context on the use of the Pedi-­C WhatsApp™ chat group. Future
3. Apfelbaum JL, Hagberg CA, Connis RT, et al. American Society
studies could explore the impact of such communication platforms of Anesthesiologists Practice Guidelines for management of the
on specific clinical outcomes and the potential for their application difficult airway. Anesthesiology. 2022;136(1):31-­81. doi:10.1097/
in other areas of medical practice. ALN.0000000000004002
4. Matava CT, Kovatsis PG, Lee JK, et al. Pediatric airway manage-
ment in COVID-­19 patients: consensus guidelines from the Society
for Pediatric Anesthesia's pediatric difficult intubation collabora-
5 | CO N C LU S I O N S tive and the Canadian pediatric anesthesia society. Anesth Analg.
2020;131(1):61-­73. doi:10.1213/ANE.0000000000004872
In conclusion, the PeDI-­C WhatsApp™ group offers a valuable 5. Stein ML, Park RS, Afshari A, et al. Lessons from COVID-­19: a
reflection on the strengths and weakness of early consensus
platform for pediatric anesthesiologists to discuss and seek advice
 |

14609592, 2023, 12, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/pan.14760, Wiley Online Library on [27/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1008 PANKIV et al.

recommendations for pediatric difficult airway management during 20. Gai N, Matava C. Twitter Hashtags for Anesthesiologists: Building
a respiratory viral pandemic using a modified Delphi method. Global Communities. A A Pract. 2019;12(2):59-­62. doi:10.1213/
Paediatr Anaesth. 2021;31(10):1074-­1088. doi:10.1111/pan.14272 XAA.0000000000000853
6. Carmona S, Alayed N, Al-­Ibrahim A, D'Souza R. Realizing the po- 21. Downing L, Mariano ER, Kou A, Matava C. An exploratory anal-
tential of real-­time clinical collaboration in maternal-­fetal and ob- ysis of pediatric anesthesia activity on twitter using the #ped-
stetric medicine through WhatsApp. Obstet Med. 2018;11(2):83-­89. sanes hashtag. Paediatr Anaesth. 2023;33(8):657-­664. doi:10.1111/
doi:10 .1177/1753495X18754457 pan.14690
7. Petre MA, Bahrey L, Levine M, van Rensburg A, Crawford M, 22. De Cassai A, Geraldini F, Mariano ER, Kou A, Matava C. Believe
Matava CT. Anesthesia environmental sustainability programs-­a the hype? An evaluation of twitter activity and publication
survey of Canadian department chiefs and residency program trends related to the erector spinae plane block. J Clin Anesth.
directors. Can J Anaesth. 2020;67(9):1190-­1200. doi:10.1007/ 2021;75:110499. doi:10.1016/j.jclinane.2021.110499
s12630-­020-­01738-­w 23. Udani AD, Moyse D, Peery CA, Taekman JM. Twitter-­
8. Alcaraz Garcia-­Tejedor G, Le M, Tackey T, Watkins J, Caldeira-­ augmented journal Club: educational engagement and expe-
Kulbakas M, Matava C. Experiences of parental presence in the rience so far. A A Case Rep. 2016;6(8):253-­256. doi:10.1213/
induction of anesthesia in a Canadian tertiary pediatric hospital: XAA.0000000000000255
a cross-­sectional study. Cureus. 2023;15(3):e36246. doi:10.7759/
cureus.36246
9. Petre MA, Bahrey L, Levine M, van Rensburg A, Crawford M, S U P P O R T I N G I N FO R M AT I O N
Matava C. A national survey on attitudes and barriers on recy- Additional supporting information can be found online in the
cling and environmental sustainability efforts among Canadian Supporting Information section at the end of this article.
anesthesiologists: an opportunity for knowledge translation.
Can J Anaesth. 2019;66(3):272-­286. Enquete nationale sur les
attitudes et obstacles envers le recyclage et les efforts pour
la protection de l'environnement parmi les anesthesiologistes
canadiens: une opportunite de transfert des connaissances. How to cite this article: Pankiv E, Achaibar K, Hossain A,
doi:10.1007/s12630-­018-­01273-­9 Fiadjoe JE, Matava CT, . The role of WhatsApp™ in pediatric
10. Kazemi P, Lau F, Simpao AF, Williams RJ, Matava C. The state difficult airway management: A study from the PeDI
of adoption of anesthesia information management systems
Collaborative. Pediatr Anesth. 2023;33:1001-1011.
in Canadian academic anesthesia departments: a survey. Can J
Anaesth. 2021;68(5):693-­705. Etat de l'adoption des systemes de
doi:10.1111/pan.14760
dossiers informatiques en anesthesie dans les departements uni-
versitaires d'anesthesie canadiens: une enquete. doi:10.1007/
s12630-­021-­01924-­4
11. Passmore C, Dobbie AE, Parchman M, Tysinger J. Guidelines for
constructing a survey. Fam Med. 2002;34(4):281-­286. APPENDIX
12. Nguyen VT. The perceptions of social media users of digital
detox apps considering personality traits. Educ Inf Technol (Dordr).
PeDI Collaborative investigators to be indexed on PubMed
2022;27:1-­24. doi:10.1007/s10639-­022-­11022-­7
13. Harris PA, Taylor R, Minor BL, et al. The REDCap consortium: The following collaborators do not meet all authorship criteria but
building an international community of software platform meet those for nonauthor contributors and are members of the PeDI
partners. J Biomed Inform. 2019;95:103208. doi:10.1016/j. Collaborative.
jbi.2019.103208
From the Department of Anesthesiology, Alberta Children's Hos-
14. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG.
Research electronic data capture (REDCap)—­a metadata-­driven pital, Calgary, Alberta, Canada:
methodology and workflow process for providing translational re- David Lardner, M.B.B.S., contributed as an investigator, collected
search informatics support. J Biomed Inform. 2009;42(2):377-­381. data, and provided care for study patients.
doi:10.1016/j.jbi.2008.08.010
From the Department of Anesthesia and Pain Management, Perth
15. Binyamin Y, Weiniger CF, Heesen P, et al. Israel National Obstetric
Anesthesia WhatsApp group as a communication tool, before and Children's Hospital, Nedlands, Western Australia, Australia:
during the COVID-­19 pandemic. Int J Obstet Anesth. 2021;45:154-­ Britta S. von Ungern-­Sternberg, M.D., Ph.D., contributed as an in-
155. doi:10.1016/j.ijoa.2020.10.001 vestigator, collected data, and provided care for study patients.
16. Bakshi SG, Doctor JR, Trivedi B, Chatterjee AS, Thota RS, Jain PN.
David Sommerfield, M.D., contributed as an investigator, col-
WhatsApp-­based teaching module for acute pain management: a
prospective educational project. Can J Anaesth. 2019;66(6):736-­ lected data, and provided care for study patients.
737. doi:10.1007/s12630-­019-­01339-­2 From the Department of Anesthesia and Pain Management, Royal
17. Astarcioglu MA, Sen T, Kilit C, et al. Time-­to-­reperfusion in STEMI Children's Hospital, Melbourne, Victoria, Australia:
undergoing interhospital transfer using smartphone and WhatsApp
Chris Holmes, M.D., contributed as an investigator, collected data,
messenger. Am J Emerg Med. 2015;33(10):1382-­1384. doi:10.1016/j.
and provided care for study patients.
ajem.2015.07.029
18. Johnston MJ, King D, Arora S, et al. Smartphones let surgeons Stefano Sabato, M.D., contributed as an investigator, collected
know WhatsApp: an analysis of communication in emergency data, and provided care for study patients.
surgical teams. Am J Surg. 2015;209(1):45-­51. doi:10.1016/j. From the Department of Anesthesiology and Pain Medicine, UC
amjsurg.2014.08.030
Davis Children's Hospital, Davis, California:
19. Mariano ER, Kou A, Stiegler MA, Matava C. The rise and fall of the
COVID-­19 aerosol box through the lens of twitter. J Clin Anesth Niroop Ravula, M.D., contributed as an investigator, collected
2021;69:110145. doi:10.1016/j.jclinane.2020.110145 data, and provided care for study patients.
 |

14609592, 2023, 12, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/pan.14760, Wiley Online Library on [27/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
PANKIV et al. 1009

From the Department of Anesthesiology, Perioperative and Pain Eugenie Heitmiller, M.D., contributed as an investigator, collected
Medicine, Stanford University. data, and provided care for study patients.
Medical Center, Stanford, California: From the Department of Anesthesia, Johns Hopkins All Children's
Christine Jette, M.D., contributed as an investigator, collected Hospital, St. Petersburg, Florida:
data, and provided care for study patients. Mohamed Rehman, M.D., contributed as an investigator, col-
Sam Mireles, M.D., contributed as an investigator, collected data, lected data, and provided care for study patients.
and provided care for study patients. Allison Fernandez, M.D., contributed as an investigator, collected
From the Department of Anesthesia, Hospital for Sick Children, data, and provided care for study patients.
Toronto, Ontario, Canada: From the Department of Anesthesiology, Spectrum Health Part-
Julia Olsen, M.D., contributed as an investigator, collected data, ners Maine, South Portland, Maine:
and provided care for study patients. Jonathan Meserve, M.D., contributed as an investigator, collected
Eric Greenwood, M.D., contributed as an investigator, collected data, and provided care for study patients.
data, and provided care for study patients. Charles (Ted) Lord, M.D., contributed as an investigator, collected
From the Department of Anesthesiology, Pharmacology and data, and provided care for study patients.
Therapeutics, British Columbia Children's Hospital, Vancouver, Brit- From the Department of Anesthesiology and Critical Care Medi-
ish Columbia, Canada: cine, Johns Hopkins University, Baltimore, Maryland:
Simon Whyte, M.B.B.S., F.R.C.A., F.R.C.P.C., contributed as an in- John McCloskey, M.D., contributed as an investigator, collected
vestigator, collected data, and provided care for study patients. data, and provided care for study patients.
From the Department of Anesthesia, School of Medicine, Pontifi- Nicholas Dalesio, M.D., M.P.H., contributed as an investigator,
cal Catholic University of Chile, Santiago, Chile: collected data, and provided care for study patients.
Eduardo Vega, M.D., contributed as an investigator, collected Rahul Koka, M.D., M.P.H., contributed as an investigator, col-
data, and provided care for study patients. lected data, and provided care for study patients.
From the Department of Anesthesiology and Perioperative Care, Robert Greenberg, M.D., contributed as an investigator, collected
West China Medical Center of Sichuan University, Chengdu, China: data, and provided care for study patients.
Lei Yang, M.D., contributed as an investigator, collected data, and From the Department of Anesthesiology, Perioperative and Pain
provided care for study patients. Medicine, Children's Hospital of Boston, Harvard Medical School,
From the Department of Anesthesiology, Instituto de Ortopedia Boston, Massachusetts:
Infantil Roosevelt, Bogotá, Colombia: Raymond Park, M.D., contributed as an investigator, collected
Piedad Echeverry-­Marin, M.D., contributed as an investigator, data, and provided care for study patients.
collected data, and provided care for study patients. James Peyton, M.B.Ch.B., M.R.C.P., F.R.C.A., contributed as an in-
Carolina Pérez-­Pradilla, M.D., contributed as an investigator, col- vestigator, collected data, and provided care for study patients.
lected data, and provided care for study patients. Mary Lyn Stein, M.D., contributed as an investigator, collected
From the Department of Pediatric Anesthesiology, Ann and Rob- data, and provided care for study patients.
ert H. Lurie Children's Hospital of Chicago, Feinberg School of Medi- Chinyere Egbuta, M.D., contributed as an investigator, collected
cine, Northwestern University, Chicago, Illinois: data, and provided care for study patients.
Narasimhan Jagannathan, M.D., M.B.A., contributed as an investi- Stephen Flynn, M.D., contributed as an investigator, collected
gator, collected data, and provided care for study patients. data, and provided care for study patients.
Nicholas E. Burjek, M.D., contributed as an investigator, collected From the Department of Anesthesia, Critical Care and Pain, Mas-
data, and provided care for study patients. sachusetts General Hospital, Boston, Massachusetts:
From the Department of Anesthesiology, Children's Hospital of Somaletha Bhattacharya, M.B.B.S., contributed as an investigator,
Colorado, Aurora, Colorado: collected data, and provided care for study patients.
David Polaner, M.D., contributed as an investigator, collected From the Department of Pediatric Anesthesiology, University of
data, and provided care for study patients. Michigan Health Center, Ann Arbor, Michigan:
Elizabeth Starker, M.D., contributed as an investigator, collected Paul Reynolds, M.D., contributed as an investigator, collected
data, and provided care for study patients. data, and provided care for study patients.
Judit Szolnoki, M.D., contributed as an investigator, collected Ian Lewis, M.D., contributed as an investigator, collected data, and
data, and provided care for study patients. provided care for study patients.
Melissa Brooks-­Peterson, M.D., contributed as an investigator, Bishr Haydar, M.D., contributed as an investigator, collected data,
collected data, and provided care for study patients. and provided care for study patients.
From the Department of Anesthesiology, Pain and Perioperative From the Department of Anesthesiology, National Institute of
Medicine, Children's National Medical Center, Washington, D.C.: Pediatrics, Mexico City, Mexico:
Angela Lee, M.D., contributed as an investigator, collected data, Lina Sarmiento, M.D., contributed as an investigator, collected
and provided care for study patients. data, and provided care for study patients.
 |

14609592, 2023, 12, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/pan.14760, Wiley Online Library on [27/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1010 PANKIV et al.

From the Department of Anesthesiology, University of Minne- Ralph Beltran, M.D., contributed as an investigator, collected
sota, Minneapolis, Minnesota: data, and provided care for study patients.
Martina Richtsfeld, M.D., contributed as an investigator, collected Tarun Bhalla, M.D., contributed as an investigator, collected data,
data, and provided care for study patients. and provided care for study patients.
Kumar Belani, M.D., contributed as an investigator, collected data, From the Department of Anesthesiology and Critical Care Medi-
and provided care for study patients. cine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania:
From the Department of Anesthesiology, University of Missis- Annery Garcia-­Marcinkiewicz M.D., contributed as an investiga-
sippi Medical Center, Jackson, Mississippi: tor, collected data, and provided care for study patients.
Sara Robertson, M.D., contributed as an investigator, collected Benjamin B. Bruins, M.D., contributed as an investigator, collected
data, and provided care for study patients. data, and provided care for study patients.
Madhankumar Sathyamoorthy, M.D., contributed as an investiga- Paul Stricker, M.D., contributed as an investigator, collected data,
tor, collected data, and provided care for study patients. and provided care for study patients.
From the Department of Anesthesiology, Washington University Justin L. Lockman, M.D., M.S.Ed., contributed as an investigator,
School of Medicine in St. Louis, St. Louis, Missouri: collected data, and provided care for study patients.
Charles Schrock, M.D., contributed as an investigator, collected Brian Struyk, M.D., contributed as an investigator, collected data,
data, and provided care for study patients. and provided care for study patients.
From the Department of Anesthesia, Erasmus Medical Center Christopher Ward, M.D., contributed as an investigator, collected
Sophia's Children Hospital Rotterdam, Rotterdam, The Netherlands: data, and provided care for study patients.
Jurgen C. de Graaff, M.D. Ph.D., contributed as an investigator, Akira Nishisaki, M.D., M.S.C.E., contributed as an investigator,
collected data, and provided care for study patients. collected data, and provided care for study patients.
From the Department of Anesthesiology, University of New Mex- Ramesh Kodavatiganti, M.D., contributed as an investigator, col-
ico, Albuquerque, New Mexico: lected data, and provided care for study patients.
Codruta Soneru, M.D., contributed as an investigator, collected Rodrigo J. Daly Guris, M.D., contributed as an investigator, col-
data, and provided care for study patients. lected data, and provided care for study patients.
From the Department of Anesthesiology, Perioperative Care and Mark S. Teen, M.D., contributed as an investigator, collected data,
Pain Medicine, New York University School of Medicine, New York, and provided care for study patients.
New York: From the Department of Anesthesiology, Instituto de Ortopedia
Neeta Singh, D.O., contributed as an investigator, collected data, Infantil Roosevelt, Bogotá, Colombia:
and provided care for study patients. Piedad C. Echeverry Marín, M.D., contributed as an investigator,
From the Department of Anesthesiology, New York Presbyterian collected data, and provided care for study patients.
Hospital–­Weill Cornell Medical College, New York, New York: From the Department of Anesthesiology, Vanderbilt University
Franklin Chiao, M.D., contributed as an investigator, collected School of Medicine, Nashville, Tennessee:
data, and provided care for study patients. Scott Watkins, M.D., contributed as an investigator, collected
From the Department of Anesthesiology, Duke University, Dur- data, and provided care for study patients.
ham, North Carolina: Christy Crockett, M.D., contributed as an investigator, collected
Brad Taicher, D.O., contributed as an investigator, collected data, data, and provided care for study patients.
and provided care for study patients. John Moore, M.D., contributed as an investigator, collected data,
From the Department of Anesthesiology, Wake Forest School of and provided care for study patients.
Medicine, Wake Forest, North Carolina: From the Department of Anesthesiology and Pain Management,
Thomas Templeton, M.D., contributed as an investigator, col- University of Texas Southwestern, Dallas, Texas; the Children's
lected data, and provided care for study patients. Health System of Texas, Dallas, Texas; and the Outcome Research
From the Department of Anesthesiology and Pain Management, Consortium, Cleveland, Ohio:
Children's Hospital of Cleveland Clinic, Cleveland, Ohio: Tally Goldfarb, M.D., contributed as an investigator, collected
Pilar Castro, M.D., contributed as an investigator, collected data, data, and provided care for study patients.
and provided care for study patients. Patrick Olomu, M.D., contributed as an investigator, collected
N. Ricardo Riveros Perez, M.D., contributed as an investigator, data, and provided care for study patients.
collected data, and provided care for study patients. Peter Szmuk, M.D., contributed as an investigator, collected data,
From the Department of Anesthesiology and Pain Medicine, and provided care for study patients.
Nationwide Children's Hospital, Ohio State University, Columbus, From the Department of Anesthesiology, Texas Children's Hospi-
Ohio: tal, Baylor College of Medicine, Houston, Texas:
Vidya T. Raman, M.D., contributed as an investigator, collected Paul Hopkins, M.D., contributed as an investigator, collected data,
data, and provided care for study patients. and provided care for study patients.
 |

14609592, 2023, 12, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/pan.14760, Wiley Online Library on [27/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
PANKIV et al. 1011

Chris Glover, M.D., M.B.A., contributed as an investigator, col- From the Department of Anesthesiology, University of Wisconsin
lected data, and provided care for study patients. School of Medicine and Public Health, Madison, Wisconsin:
Kim Nguyen, M.D., contributed as an investigator, collected data, Guelay Bilen-­Rosas, M.D., contributed as an investigator, col-
and provided care for study patients. lected data, and provided care for study patients.
Thomas L. Shaw, M.D., contributed as an investigator, collected From the Department of Anesthesiology, University of Washing-
data, and provided care for study patients. ton in St. Louis, St. Louis, Missouri:
Olutoyin Olutoye, M.D., contributed as an investigator, collected James Fehr, M.D., contributed as an investigator, collected data,
data, and provided care for study patients. and provided care for study patients.
From the Department of Anesthesiology, University of Texas From the Department of Anesthesia, University of California Los
Medical School at Houston, Houston, Texas: Angeles, Los Angeles, California:
Ranu Jain, M.D., contributed as an investigator, collected data, Lisa K. Lee, M.D., contributed as an investigator, collected data,
and provided care for study patients. and provided care for study patients.
Maria Matuszczak, M.D., contributed as an investigator, collected Ihab Ayad, M.D., contributed as an investigator, collected data,
data, and provided care for study patients. and provided care for study patients.
From the Department of Anesthesiology and Pain Medicine, Se- From the Department of Anesthesiology, Albert Einstein College
attle Children's Hospital, University of Washington School of Medi- of Medicine, New York, New York:
cine, Seattle, Washington: Roshan Patel, M.D., contributed as an investigator, collected data,
Agnes Hunyady, M.D., contributed as an investigator, collected and provided care for study patients.
data, and provided care for study patients. From the Department of Anesthesiology, Yale New Haven Hospi-
Adrian Bosenberg, M.D., contributed as an investigator, collected tal, New Haven, Connecticut:
data, and provided care for study patients. Cheryl Gooden, M.D., contributed as an investigator, collected
See Tham, M.D., contributed as an investigator, collected data, data, and provided care for study patients.
and provided care for study patients.
Daniel Low, M.D., contributed as an investigator, collected data,
and provided care for study patients.