Expert consensus on unmet needs, referral criteria and treatment goals for hidradenitis suppurativa in Saudi Arabia.

Purpose: There is limited information about the diagnosis and treatment of hidradenitis suppurativa (HS) in the Kingdom of Saudi Arabia (KSA). This Delphi consensus study was conducted to develop recommendations for the management of HS in the KSA.Methods: The expert panel including 12 dermatologists with extensive experience treating HS patients provided nine consensus statements and recommendations on diagnosis and assessment, management, comorbidities and multidisciplinary approach, and education. The experts also developed clinical questions pertaining to the management of HS and rolled out as a survey to 119 dermatologists practising in the KSA.Results: The topics covered included: referring physicians' awareness of HS; referral criteria for HS; definition of moderate-to-severe HS; treatment goals; definition of treatment success; treatment and biologic initiation; comorbidities and multidisciplinary approach; patient education and awareness of HS. Full consensus (100%) from the expert dermatologists was received on all the topics except referring physicians' awareness of HS, definition of treatment success, and treatment and biologic initiation. The survey results resonated with the expert opinion.Conclusion: As HS is a chronic disease with negative impact on quality-of-life, timely diagnosis and treatment, early identification of comorbid conditions and a multidisciplinary care approach are crucial for effective management of HS.

Consensus methodology to investigate the crucial referral criteria to pharmacist-led counseling clinics in Makkah City.

Aim: Identifying and prioritizing criteria for referring patients to a counseling clinic managed by hospital pharmacists in the tertiary care setting in Saudi Arabia (SA). Method: A two-phase consensus Delphi methodological approach was adopted in this study. Data was collected from physicians and pharmacists from different specialties working in different hospitals in Makkah City. In Phase 1, semi-structured interviews were conducted with physicians and pharmacists to discuss and develop the initial list of potential referral criteria for post-discharge counseling. Phase 2 consisted of two rounds of online surveys where participants were asked to independently rank the referral criteria using a 5-point Likert Scale. Results: In Phase 1, four participants undertook the interviews (two physicians and two pharmacists). Overall, no major comments were given on the suggested criteria. In Phase 2, most suggested referral criteria to the counseling clinic reached participants' consensus agreement of >70 % in both rounds for all three domains. Among all criteria that achieved consensus agreement, two demographic criteria were top-ranked by the participants; the elderly patients (100 %) and those who needed help with their devices (96 %). These were followed by five medication-related criteria, which are medication-related problems, polypharmacy, medication that needs monitoring, high-risk medication, and medication with special formulations. All had a consensus agreement of 96 %. Conclusion: This study suggests that a counseling clinic led by pharmacists is particularly advisable for the elderly, individuals requiring assistance with their devices, and those encountering medication issues. It is essential to prioritize specific patient demographics when contemplating the extensive establishment and integration of such clinics across various hospitals in SA.

Comprehensive Ophthalmological Evaluation in Atopic Dermatitis.

INTRODUCTION: Atopic dermatitis (AD), a chronic type 2 inflammatory skin disease, is frequently associated with ocular surface diseases (OSD) which may appear or worsen under anti-type 2-targeted treatments. However, the exact prevalence of OSD and the ophthalmology referral criteria remain ill-defined in AD patients before initiating such biotherapies. We aimed to characterize the prevalence, the nature and the factors related to OSD development in AD that may justify an ophthalmological management. METHODS: A total of 98 consecutive AD inpatients without biological treatment were retrospectively included. These were systematically evaluated by an ophthalmologist during their dermatological care. Clinical and laboratory data were analysed to characterize OSD and their risk factors. RESULTS: OSD were found in 83/98 AD patients (85%); mainly dry eye syndrome (64%, 63/98), allergic conjunctivitis (42%, 41/98), posterior (33%, 32/98), and anterior blepharitis (27%, 26/98). In AD patients without ocular symptoms, OSDs were also frequently found (63%, 12/19) and were mostly mild. Risk factors for OSD were history of allergic rhinitis, allergic sensitization, head and neck AD, ocular symptoms (foreign body sensation in the eye, burning, itching, photophobia), and total IgE level >3,000 kU/L. CONCLUSION: The prevalence of OSD was high, even in asymptomatic patients. The risk factors identified may indicate the need for ophthalmological examination for therapeutic management, especially when biological agents targeting type 2 inflammation are considered.

[Comprehensive approach to vertigo: Diagnostic algorithm, causes, treatments, and referral criteria from the perspective of primary care. SEMERGEN consensus document]. / Abordaje integral del vértigo: algoritmo diagnóstico, causas, tratamientos y criterios de derivación desde la perspectiva de atención primaria. Documento de consenso SEMERGEN.

Vertigo is a common symptom that can have various causes and may require a comprehensive approach for its diagnosis and treatment from primary care. A diagnostic algorithm based on the classification proposed by the Otoneurology Commission of the SEORL-PCF is suggested, which facilitates the classification of the different types of vertigo and provides referral criteria for patients from primary care to other specialties. A review of the available treatments based on the underlying cause is conducted for appropriate therapeutic management. This document is expected to become a valuable tool for professionals treating patients with vertigo. The document is based on scientific evidence and on the experience of experts in the field from various medical specialties; and seeks to improve the understanding and clinical approach to acute vertigo from primary care.

Clinical Features Associated with the Demand of In-Person Care by Dermatologists: An Observational Cross-Sectional Study.

Background: The factors necessitating the need for referrals for in-person evaluations by a dermatologist are not adequately understood and have not been studied using automated text mining so far. The objective of this study was to compare the prevalence of required in-person dermatologist care in the presence or absence of certain clinical features. Methods: Observational cross-sectional study of 11,661 teledermatology reports made from February 2017 to March 2020. Results: The need for dermoscopy was associated with a 348% increase in the possibility of referral for in-person dermatologist evaluations (prevalence ratio [PR]: 4.48, 95% confidence interval [CI]: 4.17-4.82). Infectious diseases were associated with a 64% lower possibility of referral (PR: 0.36, 95% CI: 0.30-0.43). Discussion: Some lesions and poorly documented cases are challenging to assess remotely. This study presents a different approach to research more detailed data from teledermatology reports, using text mining, and points out the risk magnitude for demanding dermatologic in-person care of which feature analyzed. As limitations, the variables related to lesion location, size, and extension were not analyzed and the dictionaries used were originally in Brazilian Portuguese. Conclusions: Teledermatology seems sufficient for the management of 75% of clinical cases, especially acute in young patients with inflammatory or infectious lesions. Referrals for in-person dermatologist consultations were not only strongly associated with the need for dermoscopy, but also for therapeutic reasons like surgical procedures, phototherapy, and the use of some systemic medications.

Clinical Genetics Assessment Triangle (CGAT): A simple tool to identify patients with genetic conditions.

OBJECTIVE: The objective of this study was to develop a simple tool for general physicians to promptly identify and refer pediatric patients with a higher probability of having a genetic condition. STUDY DESIGN: This retrospective, descriptive study was conducted at a tertiary pediatric hospital's Clinical Genetics Unit from June 2019 to January 2020. We included patients under 18 years of age who visited the unit, excluding those without genetic testing. Epidemiological, clinical, and genetic variables were collected from electronic medical records. The primary outcome was the diagnosis of a genetic condition based on genetic testing. RESULTS: Among 445 patients, 304 were included; 163 (53.6%) were male, and mean age was 7.4 years (SD 5.1 years). A genetic condition was diagnosed in 139 patients (45.7%). Using a multiple logistic regression model, five variables significantly contributed to reaching a diagnosis: suspected diagnosis at referral (OR 3.45, P < 0.001), short stature (OR 3.11, P < 0.001), global developmental delay/intellectual disability (OR 2.65, P < 0.001), dysmorphic craniofacial features (OR 1.99, P = 0.035), and multiple congenital anomalies (OR 2.54, P = 0.033). The association strength (OR) increased when these variables were paired with each other. The study's findings are presented in the form of a triangle, known as the Clinical Genetics Assessment Triangle (CGAT), which summarizes the results. A decision tree model is applied to guide clinical department referrals based on the affected sides of the triangle. CONCLUSIONS: The CGAT has the potential to enable general physicians to promptly identify pediatric patients with an increased probability of having a genetic condition.

Genetic testing increases the likelihood of a diagnosis of familial hypercholesterolaemia among people referred to lipid clinics: Danish national study.

BACKGROUND AND AIMS: It is unclear to what extent genetic testing improves the ability to diagnose familial hypercholesterolaemia (FH). We investigated the percentage with FH among individuals referred to Danish lipid clinics, and evaluated the impact of genetic testing for a diagnosis of FH. METHODS: From September 2020 through November 2021, all patients referred for possible FH to one of the 15 Danish lipid clinics were invited for study participation and >97% (n = 1488) accepted. The Dutch Lipid Clinical Network criteria were used to diagnose clinical FH. The decision of genetic testing for FH was based on local practice. RESULTS: A total of 1243 individuals were referred, of whom 25.9% were diagnosed with genetic and/or clinical FH. In individuals genetically tested (n = 705), 21.7% had probable or definite clinical FH before testing, a percentage that increased to 36.9% after genetic testing. In individuals with unlikely and possible FH before genetic testing, 24.4% and 19.0%, respectively, had a causative pathogenic variant. CONCLUSIONS: In a Danish nationwide study, genetic testing increased a diagnosis of FH from 22% to 37% in patients referred with hypercholesterolaemia suspected of having FH. Importantly, approximately 20% with unlikely or possible FH, who without genetic testing would not have been considered having FH (and family screening would not have been undertaken), had a pathogenic FH variant. We therefore recommend a more widespread use of genetic testing for evaluation of a possible FH diagnosis and potential cascade screening.

Safely omitting bone isotope scans in a cohort of grade group 2 prostate cancer.

OBJECTIVE: A retrospective review conducted in our urology unit to assess the efficiency for requesting bone scans for newly diagnosed prostate cancer patients, aiming to minimize radiation exposure and avoiding unnecessary investigations as cost effective measure. METHODS: A retrospective observational study included 360 patients with newly diagnosed prostate cancer within urology department at Calderdale and Huddersfield NHS Trust from April 2016 to March 2018. Parameters observed were: the prostatic specific antigen (PSA) on diagnosis, Gleason score, staging magnetic resonance imaging, and bone scans. We analyzed the possible correlation of the Gleason score and PSA to determine the risk of bony metastasis. Regarding PSA: Patients were categorized as with PSA <15, PSA ≥15. Regarding Gleason score: Patients were categorized as patients with grade group 1 or 2 and patients with grade group 3 and above. Data recorded was then analyzed using χ2  analysis to determine if results were deemed significant or not. RESULTS: A total of 360 patients: 91 patients (25%) had positive bony metastasis. While 269 patients (75%) had a clear bone scan. Among patients with grade group 3 or above or having PSA ≥15, 90 patients out of 324 patients had bony metastasis (38%). Among patients with grade group 1 or 2 and PSA <15, only 1 patient out of 36 had bony metastasis (2.7%). Negative predictive value of grade group 1 or 2 and PSA <15 for bony metastasis was 97.22%. CONCLUSION: Using a cutoff level of PSA <15 in grade group 1 and 2 seems to be a safe and efficient tool to exclude newly diagnosed prostate cancer patients from having an isotope bone scan for staging purpose.

Instrument referral criteria for PlusoptiX and SureSight based on 2021 AAPOS guidelines: A population-based study.

Objective: The study aims to assess two refractive instrument-based methods of vision screening (SureSight and PlusoptiX) to detect refractive amblyopia risk factors (ARFs) and significant refractive errors in Chinese preschool children and to develop referral criteria according to the 2021 AAPOS guidelines. Methods: Eye examinations were conducted in children aged 61 to 72 months (n = 1,173) using a PlusoptiX photoscreener, SureSight autorefractor, and cycloplegic retinoscopy (CR). The Vision Screening Committee of AAPOS's preschool vision screening guidelines from 2021 were adopted for comparison. Paired t-test analysis and Bland-Altman plots were used to assess the differences and agreement between the PlusoptiX photoscreener, SureSight autorefractor, and CR. In addition, the validity of the cut-off values of the several ARFs measured with the SureSight and PlusoptiX was estimated using receiver operating characteristic (ROC) curves and compared to the age-based 2021 AAPOS examination failure levels. Results: A total of 1,173 children were tested with comprehensive eye examinations. When the referral numbers based on the 2013 (43/3.67%) and 2021 (42/3.58%) AAPOS guidelines were compared, significant differences between the values of astigmatism (72.09 vs. 52.38%) and anisometropia (11.63 vs. 38.10%) were found. The 95% limits of agreement (LOA) of the spherical value and the cylindrical value between PlusoptiX and CR were 95.08 and 96.29%. It was 93.87 and 98.10% between SureSight and CR. Considering refractive failure levels, the ROC curves obtained the optimal cut-off points. However, the PlusoptiX and the SureSight showed lower efficiency in hyperopia (Youden index, 0.60 vs. 0.83) and myopia (Youden index, 078 vs. 0.93), respectively. After adjusting the above cut-off points, the optimized NES (Nanjing Eye Study) referral criteria for myopia, hyperopia, astigmatism, and anisometropia were -0.75, 1.25, -1.0, and 0.5 with PlusoptiX and -1.25, 2.75, -1.5, and 0.75 with SureSight. Conclusions: SureSight and PlusoptiX showed a good correlation with CR and could effectively detect refractive ARFs and visually significant refractive errors. There were obvious advantages in detecting hyperopia using SureSight and myopia using PlusoptiX. We proposed instrumental referral criteria for age-based preschool children based on AAPOS 2021 guidelines.

Integrated palliative care: triggers for referral to palliative care in ICU patients.

INTRODUCTION: Palliative care within intensive care units (ICU) benefits decision-making, symptom control, and end-of-life care. It has been shown to reduce the length of ICU stay and the use of non-beneficial and unwanted life-sustaining therapies. However, it is often initiated late or not at all. There is increasing evidence to support screening ICU patients using palliative care referral criteria or "triggers". The aim of the project was to assess the need for palliative care referral during ICU admission using "trigger" tools. METHODS: Electronic record review of cancer patients who died in or within 30 days of discharge from oncology ICU, between 2016 and 2018. Patients referred to palliative care before or during ICU admission were identified. Three sets of palliative care referral "triggers" were applied: one that is being tested locally and two internationally derived tools. The proportion of patients who met any of these triggers during their final ICU admission was calculated. RESULTS: Records of 149 patients were reviewed: median age 65 (range 20-83). Most admissions (89%) were unplanned, with the most common diagnoses being haemato-oncology (31%) and gastrointestinal (16%) cancers. Most (73%) were unknown to palliative care pre-ICU admission; 44% were referred between admission and death. The median time from referral to death was 0 day (range 0-19). On ICU admission, 97-99% warranted referral to palliative care using locally and internationally derived triggers. CONCLUSION: All "trigger" tools identified a high proportion of patients who may have warranted a palliative care referral either before or during admission to ICU. The routine use of trigger tools could help streamline referral pathways and underpin the development of an effective consultative model of palliative care within the ICU setting to enhance decision-making about appropriate treatment and patient-centred care.

Comparing Characteristics of Endometrial Cancer in Women of South Asian and White Ethnicity in England.

Differences in patient demographic and tumour characteristics between patients of South Asian and White ethnicity diagnosed with an endometrial cancer (EC) and currently living in England are not well described. We undertook a retrospective study of EC cases diagnosed at the University Hospitals of Leicester, UK. A total of 1884 cases were included, with 13% of the patients being of South Asian ethnicity. South Asian women were diagnosed at a significantly younger age (mean age of 60.3 years) compared to women of White ethnicity (mean age of 66.9 years) with a mean difference of 6.6 years (95% CI 5.1 to 8.1, p < 0.001). Rising body mass index (BMI) in the White patient group was significantly correlated with younger age at diagnosis (p < 0.001); however, this association was not seen in South Asian patients. A linear regression that adjusted for diabetes status, BMI, and the interaction terms of diabetes status with BMI and ethnicity with BMI, highlighted a younger age of diagnosis in South Asian patients with a BMI less than 45 kg/m2. The difference was greatest at lower BMIs for both non-diabetics and diabetics. Further investigation is needed to explain these differences and to determine their impact on suspected cancer referral criteria.

Referral criteria: perceptions and experiences of district nursing students in Northern Ireland.

An ever-ageing population and widening health inequalities intensify the complexity of care that is now delivered within community settings by district nurses. Appropriate referral criteria are required to facilitate the enhancement of efficient and equitable district nursing service provision. This study aimed to explore district nursing students' perceptions and experiences of district nursing referral criteria in Northern Ireland. A qualitative phenomenological approach was adopted using a purposive convenience sample of 10 district nursing students. Data were collected during online focus group interviews and analysed using a thematic framework. Four themes emerged: referral criteria; insight and inconsistency; task versus patient-centred care; and misunderstanding the service and referral quality. The themes reflect a lack of consensus with respect to referral criteria, contributing to inappropriate and poor-quality referrals. Appropriate and quality referrals to district nursing services are key to assuring sustainable service provision. Suitable access to district nursing services may be enhanced by developing consensus referral criteria.

Are We Facing a New Colposcopic Practice in the HPV Vaccination Era? Opportunities, Challenges, and New Perspectives.

The combination of primary and secondary prevention has already influenced the colposcopic practice by reduction in HPV (human papillomavirus) vaccine-type HSIL (HIGH-GRADE SIL), colposcopy referral numbers, colposcopic positive predictive value (PPV) for CIN2+, and by modification of referral pattern, colposcopic performance, and procedures. Different strategies, both isolated and combined, have been proposed in order to maintain the diagnostic accuracy of colposcopy: patient risk stratification based on immediate or future risk of CIN3+ or on HPV genotyping after a positive screening test. Data are needed to support alternative colposcopic strategies based on vaccination status and on the application of artificial intelligence where the patient's risk stratification is implicit in precision medicine which involves the transition from an operator-dependent morphology-based to a less-operator dependent, more biomolecular management. The patient's risk stratification based on any combination of "history" and "test results" to decrease colposcopy workload further reduce colposcopic and histologic morphological approaches, while adding genotyping to the risk stratification paradigm means less cytologic morphologic diagnosis. In Italy, there is a strong colposcopic tradition and there is currently no immediate need to reduce the number of colposcopies. Instead, there is a need for more accredited colposcopists to maintain the diagnostic accuracy of colposcopy in the vaccination era.

Palliative care referral criteria and outcomes in cancer and heart failure: a systematic review of literature.

BACKGROUND: Cardiotoxicity resulting in heart failure (HF) is among the most dreaded complications of cancer therapy and can significantly impact morbidity and mortality. Leading professional societies in cardiology and oncology recommend improved access to hospice and palliative care (PC) for patients with cancer and advanced HF. However, there is a paucity of published literature on the use of PC in cardio-oncology, particularly in patients with HF and a concurrent diagnosis of cancer. AIMS: To identify existing criteria for referral to and early integration of PC in the management of cases of patients with cancer and patients with HF, and to identify assessments of outcomes of PC intervention that overlap between patients with cancer and patients with HF. DESIGN: Systematic literature review on PC in patients with HF and in patients with cancer. DATA SOURCES: Databases including Ovid Medline, Ovid Embase, Cochrane Library, and Web of Science from January 2009 to September 2020. RESULTS: Sixteen studies of PC in cancer and 14 studies of PC in HF were identified after screening of the 8647 retrieved citations. Cancer and HF share similarities in their patient-reported symptoms, quality of life, symptom burden, social support needs, readmission rates, and mortality. CONCLUSION: The literature supports the integration of PC into oncology and cardiology practices, which has shown significant benefit to patients, caregivers, and the healthcare system alike. Incorporating PC in cardio-oncology, particularly in the management of HF in patients with cancer, as early as at diagnosis, will enable patients, family members, and healthcare professionals to make informed decisions about various treatments and end-of-life care and provide an opportunity for patients to participate in the decisions about how they will spend their final days.

Advanced Heart Failure: Definition, Epidemiology, and Clinical Course.

Advanced heart failure (HF) is characterized by a progressive worsening of symptoms disabling for daily life, refractory to all therapies, and with high mortality. These patients may be candidates for life-prolonging therapies, such as heart transplantation (HT) or long-term (LT) mechanical circulatory support (MCS) or must just require palliative therapies. The 1-year survival after HT and/or LT-MCS is approaching 80% to 90%, being patient selection and timely referral to advanced HF centers critical for optimal outcomes. There is no single symptom, sign, or test that can identify these patients and different classifications are complementary and helpful for clinical decision-making.

Identification of women at risk for hereditary breast and ovarian cancer in a sample of 1000 Slovenian women: a comparison of guidelines.

BACKGROUND: An important number of breast and ovarian cancer cases is due to a strong genetic predisposition. The main tool for identifying individuals at risk is recognizing a suggestive family history of cancer. We present a prospective study on applying three selected clinical guidelines to a cohort of 1000 Slovenian women to determine the prevalence of at-risk women according to each of the guidelines and analyze the differences amongst the guidelines. METHODS: Personal and family history of cancer was collected for 1000 Slovenian women. Guidelines by three organizations: National Comprehensive Cancer Network (NCCN), American College of Medical Genetics in cooperation with National Society of Genetic Counselors (ACMG/NSGC), and Society of Gynecologic Oncology (SGO) were applied to the cohort. The number of women identified, the characteristics of the high-risk population, and the agreement between the guidelines were explored. RESULTS: NCCN guidelines identify 13.2% of women, ACMG/NSGC guidelines identify 7.1% of women, and SGO guidelines identify 7.0% of women from the Slovenian population, while 6.2% of women are identified by all three guidelines as having high-risk for hereditary breast and ovarian cancer. CONCLUSIONS: We identified 13.7% of women from the Slovenian population as being at an increased risk for breast and ovarian cancer based on their personal and family history of cancer using all of the guidelines. There are important differences between the guidelines. NCCN guidelines are the most inclusive, identifying nearly twice the amount of women as high-risk for hereditary breast and ovarian cancer as compared to the AGMG/NSCG and SGO guidelines in the Slovenian population.

Adherence to the emergency management of severe burns referral criteria in burn patients admitted to a hospital with or without a specialized burn center.

BACKGROUND: The primary aim was to determine to what extent referral and admission of burn patients to a hospital with or without a burn center was in line with the EMSB referral criteria. METHODS: This was a retrospective, multicenter cohort study. Burn patients admitted from 2014 to 2018 to a hospital in the Southwest Netherland trauma region and Network Emergency Care Brabant were included in this study. Outcome measures were the adherence to the EMSB referral criteria. RESULTS: A total of 1790 patients were included, of whom 951 patients were primarily presented to a non-burn center. Of these patients, 666 (70.0%) were managed according to the referral criteria; 263 (27.7%) were appropriately not referred, 403 (42.4%) were appropriately referred. Twenty (2.1%) were overtransferred, and 265 (27.9%) undertransferred. In 1213 patients treated at a burn center 1119 (92.3%) met the referral criteria. Adherence was lowest for electrical (N = 4; 14.3%) and chemical burns (N = 16; 42.1%), and was highest in 'children ≥5% total body surface area (TBSA) burned' (N = 109; 83.2%). CONCLUSION: The overall adherence to the referral criteria of patients presented to a non-burn center was fairly high. However, approximately 25% was not transferred to a burn center while meeting the criteria. Most improvement for individual criteria can be achieved in patients with electrical and chemical burns.

Palliative Care Team Perceptions of Standardized Palliative Care Referral Criteria Implementation in Hospital Settings.

Background: Standardized referral criteria can aid in identifying patients who would benefit from palliative care consultation. Little is known, however, on palliative care team members' perceptions of these criteria. Objective: Describe palliative care programs' reasons for referral criteria implementation and their perception of the benefits or disadvantages of its use. Design: Online survey of National Palliative Care Registry™ participants who use standardized referral criteria. Results: Fifty-three programs participated. Late referrals (64.2%) were the most commonly cited reason for referral criteria implementation. The majority (77.4%) felt that referral criteria lead to positive outcomes, including earlier referrals for palliative care-appropriate patients (71.7%). Increases in staff workload and inappropriate referrals were identified as disadvantages of referral criteria use.* Conclusion: Palliative care program members identified both benefits and disadvantages of referral criteria use, but felt they had mostly productive results. *Correction added on March 18, 2021 after first online publication of December 18, 2020: In the Results section of the abstract, the third sentence was changed from "Increases in clinical volume and inappropriate referrals were identified as disadvantages of referral criteria use." to "Increases in staff workload and inappropriate referrals were identified as disadvantages of referral criteria use."

Criteria for referral of pediatric SARS-CoV-2 infection: a real-life experience in the pandemic era.

A practical guidance on the management of children with COVID-19 to insure homogeneous criteria for referral to a higher-level facility, according to the disease severity, is pivotal in the pandemic era. A panel of experts in pediatric infectious diseases and intensive care at the tertiary-care Meyer Children's University Hospital, Florence, Italy, issued a practical document shared with Tuscany hospitals. The rationale was to target the referral for those children at risk of requiring an intensive support, since the above mentioned hospital has the pediatric intensive care unit. Overall, 378 patients between 0 and 19 years of age were diagnosed with COVID-19 infection in the Tuscany region with 24 (6.3%) hospitalizations. Only three children were centralized to Meyer Children's University Hospital according to reported criteria. Considering that appropriate referral criteria have been associated with reduced mortality in other conditions, our document might be useful to improve outcomes of children with COVID-19.