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Calder AD, Perucca G, Johnson SM, Pandey AR, Moshal K, Kusters MA. Lung infections in immunocompromised children. Pediatr Radiol 2024; 54:530-547. [PMID: 37589764 DOI: 10.1007/s00247-023-05735-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/26/2023] [Accepted: 07/27/2023] [Indexed: 08/18/2023]
Abstract
Pulmonary infection is the leading cause of infectious morbidity and mortality in children with immune defects. We provide a comprehensive review of lung infections in immunocompromised children, with a focus on imaging findings and imaging-based management. We include an overview of the immune defences of the respiratory tract, the aetiologies of immune defects in children, the features of specific infections and important differential diagnoses and describe diagnostic strategies using imaging and non-imaging-based techniques.
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Affiliation(s)
- Alistair D Calder
- Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK.
| | - Giulia Perucca
- Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
| | - Sarah May Johnson
- Paediatric Infectious Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Ashwin R Pandey
- Immunology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Karyn Moshal
- Paediatric Infectious Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Maaike A Kusters
- Immunology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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Pattamapaspong N, Kanthawang T, Bouaziz MC, Ladeb MF, Hammami N, Peh WCG. Imaging of musculoskeletal tuberculosis. Br J Radiol 2024; 97:1-12. [PMID: 38263840 PMCID: PMC11027299 DOI: 10.1093/bjr/tqad019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 09/23/2023] [Accepted: 10/06/2023] [Indexed: 01/25/2024] Open
Abstract
Extra-pulmonary tuberculosis (TB) of the musculoskeletal system usually manifests with non-specific clinical features, mimicking a variety of diseases. Diagnosis and treatment of spinal and extra-spinal musculoskeletal TB are often challenging. Imaging has an important role in detecting this disease, aiding diagnosis, identifying complications, and monitoring disease progression. Radiographs and magnetic resonance imaging are the key imaging modalities utilized. Radiologists should aim to be familiar with the spectrum of imaging features of TB affecting spinal and extra-spinal locations in the musculoskeletal system.
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Affiliation(s)
- Nuttaya Pattamapaspong
- Department of Radiology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Thanat Kanthawang
- Department of Radiology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Mouna Chelli Bouaziz
- Department of Radiology, MT Kassab Institute of Orthopaedics, Tunis, Tunisia
- Faculty of Medicine of Tunis, Tunis-El Manar University, Tunis, Tunisia
| | - Mohamed Fethi Ladeb
- Department of Radiology, MT Kassab Institute of Orthopaedics, Tunis, Tunisia
- Faculty of Medicine of Tunis, Tunis-El Manar University, Tunis, Tunisia
| | - Nadia Hammami
- Department of Neuroradiology, National Institute of Neurology Mongi Ben Hamida, Tunis, Tunisia
| | - Wilfred C G Peh
- Department of Diagnostic Radiology, Khoo Teck Puat Hospital, Singapore 768828, Republic of Singapore
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Naidoo J, Shelmerdine SC, -Charcape CFU, Sodhi AS. Artificial Intelligence in Paediatric Tuberculosis. Pediatr Radiol 2023; 53:1733-1745. [PMID: 36707428 PMCID: PMC9883137 DOI: 10.1007/s00247-023-05606-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/07/2022] [Accepted: 01/13/2023] [Indexed: 01/29/2023]
Abstract
Tuberculosis (TB) continues to be a leading cause of death in children despite global efforts focused on early diagnosis and interventions to limit the spread of the disease. This challenge has been made more complex in the context of the coronavirus pandemic, which has disrupted the "End TB Strategy" and framework set out by the World Health Organization (WHO). Since the inception of artificial intelligence (AI) more than 60 years ago, the interest in AI has risen and more recently we have seen the emergence of multiple real-world applications, many of which relate to medical imaging. Nonetheless, real-world AI applications and clinical studies are limited in the niche area of paediatric imaging. This review article will focus on how AI, or more specifically deep learning, can be applied to TB diagnosis and management in children. We describe how deep learning can be utilised in chest imaging to provide computer-assisted diagnosis to augment workflow and screening efforts. We also review examples of recent AI applications for TB screening in resource constrained environments and we explore some of the challenges and the future directions of AI in paediatric TB.
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Affiliation(s)
- Jaishree Naidoo
- Envisionit Deep AI LTD, Coveham House, Downside Bridge Road, Cobham, KT11 3 EP, UK.
| | - Susan Cheng Shelmerdine
- Department of Clinical Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Great Ormond Street Hospital for Children, UCL Great Ormond Street Institute of Child Health, London, UK
- NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | - Carlos F Ugas -Charcape
- Department of Diagnostic Imaging, Instituto Nacional de Salud del Niño San Borja, Lima, Peru
| | - Arhanjit Singh Sodhi
- Department of Computer Engineering, Thapar Institute of Engineering and Technology, Patiala, Punjab, India
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Laya BF, Concepcion NDP, Garcia-Peña P, Naidoo J, Kritsaneepaiboon S, Lee EY. Pediatric Lower Respiratory Tract Infections: Imaging Guidelines and Recommendations. Radiol Clin North Am 2021; 60:15-40. [PMID: 34836562 DOI: 10.1016/j.rcl.2021.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Lower respiratory tract infection (LRTI) remains a major cause of morbidity and mortality in children. Various organisms cause LRTI, including viruses, bacteria, fungi, and parasites, among others. Infections caused by 2 or more organisms also occur, sometimes enhancing the severity of the infection. Medical imaging helps confirm a diagnosis but also plays a role in the evaluation of acute and chronic sequelae. Medical imaging tests help evaluate underlying pathology in pediatric patients with recurrent or long-standing symptoms as well as the immunocompromised.
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Affiliation(s)
- Bernard F Laya
- Section of Pediatric Radiology, Institute of Radiology, St. Luke's Medical Center-Quezon City, 279 E. Rodriguez Sr. Ave., Quezon City, 1112 Philippines.
| | - Nathan David P Concepcion
- Section of Pediatric Radiology, Institute of Radiology, St. Luke's Medical Center-Quezon City, 279 E. Rodriguez Sr. Ave., Quezon City, 1112 Philippines
| | - Pilar Garcia-Peña
- Autonomous University of Barcelona (AUB), University Hospital Materno-Infantil Vall d'Hebron, Pso. Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Jaishree Naidoo
- Paeds Diagnostic Imaging and Envisionit Deep AI, 2nd Floor, One-on Jameson Building, 1 Jameson Avenue, Melrose Estate, Johannesburg, 2196, South Africa
| | - Supika Kritsaneepaiboon
- Division of Diagnostic Radiology, Department of Radiology, Faculty of Medicine, Prince of Songkla University, Kanjanavanich Road, Hat Yai, 90110, Thailand
| | - Edward Y Lee
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
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[Clinical features of children with immunodeficiency and Mycobacterium tuberculosis infection]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2020; 22. [PMID: 33328001 PMCID: PMC7735922 DOI: 10.7499/j.issn.1008-8830.2007068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To study the clinical features of Mycobacterium tuberculosis infection in children with secondary immunodeficiency disease (SID) versus primary immunodeficiency disease (PID). METHODS A retrospective analysis was performed on the medical data of children with immunodeficiency and Mycobacterium tuberculosis infection (36 children with SID and 52 with PID) and 108 children with Mycobacterium tuberculosis infection but without immunodeficiency (control group). RESULTS The onset age in the PID group was significantly lower than those in the control and SID groups (P < 0.05), and the proportation of males in the PID group was significantly higher than those in the control and SID groups (P < 0.05). Compared with the control group, the SID and PID groups had significantly lower incidence rates of tuberculosis poisoning symptoms (night sweeting, weight loss, fatigue and loss of appetite) and positive rate of PPD test (P < 0.05), as well as a significantly higher incidence rate of the involvement of ≥ 3 pulmonary lobes (P < 0.05). The children with PID tended to have the involvement of multiple organs (P < 0.05). The SID group had a significantly higher incidence rate of miliary shadow on chest CT than the control and PID groups (P < 0.05). The PID group had a significantly lower positive rate of IFN-gamma release assay (IGRA) than the control and SID groups (P < 0.05). Mycobacterium tuberculosis infection manifested as latent tuberculosis infection (36.1%) and active tuberculosis (63.9%) in the SID group. The infection mainly manifested as bacille Calmette-Guérin disease in the PID group (90.4%), among whom 2 children (3.8%) also had tuberculosis. CONCLUSIONS Children with immunodeficiency and Mycobacterium tuberculosis infection have atypical clinical symptoms, with a high incidence rate of disseminated infection and low positive rates of PPD and IGRA tests, which may lead to misdiagnosis and missed diagnosis. Children with immunodeficiency should undergo regular tuberculosis screening for early identification and intervention.
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Mutabazi SA, Jumanne S, Mpondo BC, Mnzava DP. Prevalence of culture positive Tuberculosis and utility of a clinical diagnostic tool for the diagnosis of Tuberculosis among HIV Infected Children attending HIV/AIDS Care and Treatment in Dodoma Municipality, Central Tanzania. Int J Infect Dis 2020; 96:593-599. [PMID: 32505876 DOI: 10.1016/j.ijid.2020.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 05/31/2020] [Accepted: 06/01/2020] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE To evaluate the performance of the modified Keith Edwards TB clinical diagnostic tool among HIV infected children. METHODS Cross sectional study of 252 HIV infected children < 15 years old suspected with TB at four HIV/AIDS Care Clinics in Dodoma, Tanzania from November 2018 - March 2019. The modified Keith Edwards TB clinical diagnostic tool was compared to gastric aspirates, lymphnode aspirates or sputum gene x-pert MTB/RIF and TB culture. Sensitivity, specificity, negative and positive predictive value of the clinical tool were determined. Data was analyzed using SPSS version 25. RESULTS Out of 252 children evaluated, 13.5% (34/252) had TB using the clinical diagnostic tool and 5.2% (13/252) had culture positive TB. The sensitivity of the clinical tool was 76.9%, specificity of 90%. Culture positive TB predictors were lymphadenopathy (AOR 13.74, 95%CI (3.86 - 48.86) p value < 0.001), weight loss (AOR 3.19,95%CI (1.38 - 7.36) p value 0.007), and difficulty breathing (AOR 7.25, 95%CI (1.54 - 34.16) p value 0.012). CONCLUSION The utility of the modified Keith Edwards clinical diagnostic tool for Tuberculosis diagnosis among HIV infected children is limited, calling for further validation. HIV infected children with lymphadenopathy, failure to thrive and difficulty in breathing are at high risk of Tuberculosis.
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Affiliation(s)
- Sauda A Mutabazi
- Department of Paediatrics & Child Health, University of Dodoma Tanzania
| | - Shakilu Jumanne
- Department of Paediatrics & Child Health, University of Dodoma Tanzania.
| | - Bonaventura Ct Mpondo
- Ministry of Health Community Development, Gender, Elderly and Children, National AIDS Control Program, Dodoma, Tanzania
| | - David P Mnzava
- Ministry of Health Community Development, Gender, Elderly and Children, Tanganyika Medical Council, Dodoma, Tanzania
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Giancane G, Swart JF, Castagnola E, Groll AH, Horneff G, Huppertz HI, Lovell DJ, Wolfs T, Herlin T, Dolezalova P, Sanner H, Susic G, Sztajnbok F, Maritsi D, Constantin T, Vargova V, Sawhney S, Rygg M, K Oliveira S, Cattalini M, Bovis F, Bagnasco F, Pistorio A, Martini A, Wulffraat N, Ruperto N. Opportunistic infections in immunosuppressed patients with juvenile idiopathic arthritis: analysis by the Pharmachild Safety Adjudication Committee. Arthritis Res Ther 2020; 22:71. [PMID: 32264969 PMCID: PMC7136994 DOI: 10.1186/s13075-020-02167-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 03/27/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND To derive a list of opportunistic infections (OI) through the analysis of the juvenile idiopathic arthritis (JIA) patients in the Pharmachild registry by an independent Safety Adjudication Committee (SAC). METHODS The SAC (3 pediatric rheumatologists and 2 pediatric infectious disease specialists) elaborated and approved by consensus a provisional list of OI for use in JIA. Through a 5 step-procedure, all the severe and serious infections, classified as per MedDRA dictionary and retrieved in the Pharmachild registry, were evaluated by the SAC by answering six questions and adjudicated with the agreement of 3/5 specialists. A final evidence-based list of OI resulted by matching the adjudicated infections with the provisional list of OI. RESULTS A total of 772 infectious events in 572 eligible patients, of which 335 serious/severe/very severe non-OI and 437 OI (any intensity/severity), according to the provisional list, were retrieved. Six hundred eighty-two of 772 (88.3%) were adjudicated as infections, of them 603/682 (88.4%) as common and 119/682 (17.4%) as OI by the SAC. Matching these 119 opportunistic events with the provisional list, 106 were confirmed by the SAC as OI, and among them infections by herpes viruses were the most frequent (68%), followed by tuberculosis (27.4%). The remaining events were divided in the groups of non-OI and possible/patient and/or pathogen-related OI. CONCLUSIONS We found a significant number of OI in JIA patients on immunosuppressive therapy. The proposed list of OI, created by consensus and validated in the Pharmachild cohort, could facilitate comparison among future pharmacovigilance studies. TRIAL REGISTRATION Clinicaltrials.gov NCT01399281; ENCePP seal: awarded on 25 November 2011.
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Affiliation(s)
- Gabriella Giancane
- IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, PRINTO, Genoa, Italy
| | - Joost F Swart
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, University Utrecht, European Reference Network-RITA, Utrecht, The Netherlands
| | - Elio Castagnola
- Department of Infectious Diseases, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Andreas H Groll
- Infectious Disease Research Program, Department of Pediatric Hematology and Oncology, University Children's Hospital, Münster, Germany
| | - Gerd Horneff
- Asklepios Clinic Sankt Augustin, Department of General Paediatrics, Sankt Augustin, Germany
- Medical Faculty, Department of Paediatric and Adolescents Medicine, University Hospital of Cologne, Cologne, Germany
| | - Hans-Iko Huppertz
- Clinic Bremen-Mitte, Prof.-Hesse Children's Hospital and Pediatric Intensive Care Medicine, Bremen, Germany
| | - Daniel J Lovell
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Tom Wolfs
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, University Utrecht, European Reference Network-RITA, Utrecht, The Netherlands
| | - Troels Herlin
- Pediatric Rheumatology Unit, Aarhus University Hospital, Aarhus, Denmark
| | - Pavla Dolezalova
- 1st Faculty of Medicine, Department of Pediatrics and Adolescent Medicine, Charles University in Prague and General University Hospital, Praha, Czech Republic
| | - Helga Sanner
- Department of Rheumatology, Oslo University Hospital, Oslo, Norway
- Norwegian National Advisory Unit on Rheumatic Diseases in Children and Adolescents, Oslo, Norway
| | - Gordana Susic
- Institute of Rheumatology of Belgrade, Division of Pediatric Rheumatology, Belgrade, Serbia
| | - Flavio Sztajnbok
- Hospital Universitario Pedro Ernesto, Nucleo de Estudos da Saúde do Adolescente, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Despoina Maritsi
- 2nd Department of Pediatrics Athens Medical School, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Tamas Constantin
- Unit of Pediatric Rheumatology-Immunology, Second Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Veronika Vargova
- Faculty of Medicine, Department of Paediatrics and Adolescent Medicine, Pavol Jozef Šafárik University in Košice, Kosice, Slovakia
| | - Sujata Sawhney
- Sir Ganga Ram Hospital Marg, Centre for Child Health, Sir Ganga Ram Hospital, New Delhi, India
| | - Marite Rygg
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
- Department of Pediatrics, St. Olavs University Hospital of Trondheim, Trondheim, Norway
| | - Sheila K Oliveira
- Instituto de Puericultura e Pediatria Martagao Gesteira (IPPMG), Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marco Cattalini
- Clinica Pediatrica dell'Università di Brescia, Spedali Civili, Unità di Immunologia e Reumatologia Pediatrica, Brescia, Italy
| | - Francesca Bovis
- IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, PRINTO, Genoa, Italy
| | - Francesca Bagnasco
- IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, PRINTO, Genoa, Italy
| | - Angela Pistorio
- IRCCS Istituto Giannina Gaslini, Servizio di Epidemiologia e Biostatistica, Genoa, Italy
| | - Alberto Martini
- Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili (DiNOGMI), Università degli Studi di Genova, Genoa, Italy
| | - Nico Wulffraat
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, University Utrecht, European Reference Network-RITA, Utrecht, The Netherlands
| | - Nicolino Ruperto
- IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, PRINTO, Genoa, Italy.
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Shugaeva SN, Savilov ED. Prognostic Model for Progradient Tuberculosis Course in HIV-Infected Children. Sovrem Tekhnologii Med 2020; 12:74-78. [PMID: 34513056 PMCID: PMC8353684 DOI: 10.17691/stm2020.12.2.09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Indexed: 11/14/2022] Open
Abstract
The aim of the study was to define independent predictors and create a prognostic model for the progradient course of tuberculosis in HIV-infected children. Materials and Methods The prospective observational study of tuberculosis cases of HIV-infected children under 15 years of age has been carried out over 2000-2014 using a continuous sampling method (n=65). Two observation groups were formed: the main group comprising children with a progradient (progressive) type of tuberculosis (n=37) and the comparison group of children with a regradient (regressive) type of the disease (n=28). The logistic regression method was used to create a prognostic model. The quality of model approximation was assessed using maximum likelihood function. Indicators of model goodness of fit are the coefficient of concordance (a permissible level of frequency disagreement is less than 20%) and Hosmer-Lemeshow test. Results As a result of a paired comparative analysis based on 17 medico-biological, epidemiological and social signs, 11 statistically different parameters have been distinguished. On their basis, a functional prognostic model has been created including six independent predictors: flaws in children observation in the general medical network (b=23.962), absence of Bacillus Calmette-Guérin vaccination (b=20.404), fatal course of tuberculosis in the human source of infection (b=2.762), tuberculosis identification in children under 3 years of age (b=2.620), absence or low adherence to therapy of the latent tuberculosis infection before tuberculosis detection (b=1.859), marked or severe immunodeficiency (b=1.693). The degrees of the risk factors for the progradient tuberculosis course have been established at the following probability values (decile): at 0.3-0.4 the risk is minimal; at 0.5-1.0 the risk is high; at values of 0-0.2 there is no risk of the disease. Programs for quantitative and qualitative assessment of the risk of progradient tuberculosis course in children with HIV infection have been designed to facilitate the model use. Conclusion The presented prognostic model is based on the analysis of the obligatory data in the diagnostic search making its use convenient at any stage of rendering medical aid to HIV-infected children.
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Affiliation(s)
- S N Shugaeva
- Head of the Department of Phthisiopulmonology, Irkutsk State Medical University, 1 Krasnogo Vosstaniya St., Irkutsk, 664003, Russia; Leading Researcher, Irkutsk State Medical Academy of Postgraduate Education - Branch of the Russian Medical Academy of Continuing Professional Education, 100 Yubileyny Microdistrict, Irkutsk, 664049, Russia
| | - E D Savilov
- Professor, Head of the Department of Epidemiology and Microbiology, Irkutsk State Medical Academy of Postgraduate Education - Branch of the Russian Medical Academy of Continuing Professional Education, 100 Yubileyny Microdistrict, Irkutsk, 664049, Russia; Chief Researcher, Scientific Center of Family Health Problems and Human Reproduction, 16 Timiryazeva St., Irkutsk, 664003, Russia
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Laya BF. Revisiting and redefining the standards in tuberculosis imaging. Pediatr Radiol 2017; 47:1235-1236. [PMID: 29052775 DOI: 10.1007/s00247-017-3925-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 06/07/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Bernard F Laya
- St. Luke's Medical Center-Global City, 32nd Street Bonifacio Global City, 1634, Taguig City, Philippines.
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