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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. Pediatrics 2024; 154:e2024066855. [PMID: 38932719 DOI: 10.1542/peds.2024-066855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/28/2024] [Indexed: 06/28/2024] Open
Abstract
Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging, are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. J Am Coll Radiol 2024; 21:e37-e69. [PMID: 38944445 DOI: 10.1016/j.jacr.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024]
Abstract
Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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Oz Alcalay L, Fanous E, Goldberg L, Livni G, Pasternak Y. Risk Factors for Invasive Interventions in Hospitalized Children With Suppurative Cervical Lymphadenitis. Clin Pediatr (Phila) 2024:99228231222702. [PMID: 38174715 DOI: 10.1177/00099228231222702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Suppurative cervical lymphadenitis sometimes resolves with oral antibiotic treatment; however, many children are hospitalized for intravenous treatment due to lack of improvement. When there is no substantial improvement, the possibility of a liquefaction process is considered, and as a result, source control such as needle aspiration or open surgical drainage is recommended. We examined, among pediatric patients hospitalized with suppurative cervical lymphadenitis, clinical and laboratory predictors for invasive intervention that may lead to early imaging and intervention, hasten recovery, and shorten length of hospitalization. We compared laboratory and clinical characteristics of pediatric patients hospitalized with suppurative cervical lymphadenitis during 2010-2017, according to 3 treatments: needle aspiration (N = 54), open surgical drainage (N = 37), and conservative adequate antibiotic treatment only (N = 292). Physical indicators such as local erythema and fluctuation were found as predictors for invasive interventions in hospitalized pediatric patients diagnosed with suppurative cervical lymphadenitis. No significant associations were found between invasive interventions and laboratory parameters assessed in this study. Children who underwent interventions displayed a prolonged average length of hospitalization and received extended antibiotic treatment prior to hospital admission. In hospitalized pediatric patients diagnosed with suppurative cervical lymphadenitis, physical examination findings are the main predictive factors for invasive interventions. Consequently, when such straightforward clinical findings are observed in the context of insufficient improvement during antibiotic treatment, they should prompt consideration of invasive intervention.
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Affiliation(s)
- Lital Oz Alcalay
- Department of Pediatrics A, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eliana Fanous
- Department of Pediatrics A, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Lotem Goldberg
- Department of Pediatrics B, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Gilat Livni
- Department of Pediatrics A, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Infectious Disease Unit, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Yehonatan Pasternak
- Department of Pediatrics A, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Hosokawa T, Yoshizawa S, Deie K, Ohashi K, Kawashima H. Point-of-Care Ultrasound for Mimicker Lesions of Incarcerated Inguinal Hernia. Case Rep Pediatr 2023; 2023:5593369. [PMID: 37711640 PMCID: PMC10499529 DOI: 10.1155/2023/5593369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 08/29/2023] [Accepted: 09/01/2023] [Indexed: 09/16/2023] Open
Abstract
Inguinal hernia is the most common surgical disease in pediatric patients, and urgent intervention such as manual reduction is needed for incarcerated inguinal hernia. Torsion of undescended testes, inguinal herniated ovarian torsion, and purulent lymphadenitis are mimickers of this condition. If these mimicker lesions are misdiagnosed as incarcerated inguinal hernia, manual reduction usually fails, and edematous and erythematous changes may occur in these mimicker lesions due to manual reduction. For physicians in the emergency department, prompt decisions and familiarity with the sonographic appearance of different contents within an inguinal hernia are important to accurately diagnose these mimickers. In this case series, we present sonographic images of a typical case of incarcerated inguinal hernia (an 11-month-old male with right incarcerated inguinal hernia) and three cases of mimicker lesions (a 7-month-old female with herniated ovarian torsion, a 7-year-old boy with undescended testicular torsion, and a 2-month-old male with purulent lymphadenitis). The incidence of incarcerated inguinal hernia is reported to be higher in males (80%), on the right side (60%), and in infants and toddlers. This information is important for diagnosing mimicker lesions. In addition, to prevent manual reduction in mimicker diseases, point-of-care ultrasound before manual reduction in suspected cases of incarcerated inguinal hernia is important.
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Affiliation(s)
- Takahiro Hosokawa
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Shinsuke Yoshizawa
- Department of Urology, Saitama Children's Medical Center, Saitama, Japan
| | - Kyoichi Deie
- Department of Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Kensuke Ohashi
- Department of Urology, Saitama Children's Medical Center, Saitama, Japan
| | - Hiroshi Kawashima
- Department of Surgery, Saitama Children's Medical Center, Saitama, Japan
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Ramazani F, Yunker WK, Liu CC. Sensitivity and Specificity of US and CT as Diagnostic Tools for Pediatric Lateral Neck Abscesses. Otolaryngol Head Neck Surg 2023; 168:1529-1534. [PMID: 36939468 DOI: 10.1002/ohn.209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 09/04/2022] [Accepted: 11/02/2022] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Ultrasound (US) and computed tomography (CT) are commonly used in the diagnosis of pediatric neck abscesses. The objective of this study is to determine the sensitivity and specificity of US and CT in the diagnosis of pediatric lateral neck abscesses, with a secondary objective of evaluating the association of specific clinical features with a positive US or CT scan. STUDY DESIGN Retrospective review of pediatric patients admitted to a tertiary care center from January 1, 2011, to December 31, 2020, with neck abscesses. SETTING Tertiary care center. METHODS The sensitivity and specificity of US and CT were calculated by comparing imaging performed within 24 h of incision and drainage (I&D). Multiple regression was used to evaluate the association of clinical features with a true positive US or CT. RESULTS There were 171 patients included in this study, with a median age of 1.5 years (interquartile range [IQR]: 1-5 years). I&D was done in 156 patients (91.2%), while 15 (8.8%) were treated with antibiotics. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of US were 69.5%, 80%, 96.6%, and 24.2%. The sensitivity, specificity, PPV, and NPV of neck CT were 95.5%, 80%, 95.5%, and 57.1%. Length of symptoms, skin erythema, and fluctuance were not significantly associated with a positive US (F(3, 82) = 0.24, p = .9, R2 = 0.01) or CT scan (F(3, 30) = 0.84, p = .5, R2 = 0.08). CONCLUSION Neck US has a low sensitivity for diagnosing pediatric neck abscesses, when compared to CT, but remains a useful initial investigation given its high PPV. Clinicians should have a low threshold for pursuing CT if there is a high suspicion of abscess formation. LEVEL OF EVIDENCE Level 4.
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Affiliation(s)
- Fatemeh Ramazani
- Department of Surgery, Section of Otolaryngology-Head and Neck Surgery, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Warren K Yunker
- Department of Surgery, Section of Otolaryngology-Head and Neck Surgery, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Che Carrie Liu
- Department of Otolaryngology-Head and Neck Surgery, University of Arizona College of Medicine, Tuscon, Arizona, USA
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The effect of point-of-care ultrasound on length of stay in the emergency department in children with neck swelling. Am J Emerg Med 2021; 48:295-300. [PMID: 34052608 DOI: 10.1016/j.ajem.2021.05.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 05/01/2021] [Accepted: 05/02/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Ultrasound is the imaging modality of choice in children presenting to the emergency department (ED) with soft tissue neck swelling. Point of care ultrasound (POCUS) has good accuracy when compared to comprehensive radiology department ultrasound (RADUS). POCUS could potentially improve ED length of stay (LOS) by improving efficiency. We aimed to evaluate the LOS of pediatric patients seen in ED with soft tissue neck swelling who received POCUS compared to RADUS. We determined unscheduled 30-day return visit rates in both groups as a balancing measure. METHODS We performed a retrospective review of the electronic medical record for our cross-sectional study of discharged patients ≤21 years of age who had a neck ultrasound performed by a credentialed POCUS physician or by the radiology department between July 2014 and January 2020. We included patients who had both POCUS and RADUS in the POCUS group. We compared median ED LOS in both groups using the Mann Whitney U test and proportion of unscheduled return visits to the ED in both groups using odds ratio and 95% CI. RESULTS There were 925 patients: 76 with only POCUS, 6 with POCUS and RADUS, and 843 with only RADUS performed. Median LOS in the POCUS group was 68.5 min (IQR 38.3120.3) versus 154.0 min (IQR 111.0, 211.0) in the RADUS group (p < 0.001). Return visit overall was 7.6%: 13.2% in the POCUS group versus 7.1% in the RADUS group (p = 0.07). CONCLUSION Pediatric patients evaluated in the ED for soft tissue neck swelling had a shorter LOS with POCUS than with RADUS without a statistically significant increase in 30-day return visits. We suggest a "POCUS First" approach to the care of these patients.
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Desai S, Shah SS, Hall M, Richardson TE, Thomson JE. Imaging Strategies and Outcomes in Children Hospitalized with Cervical Lymphadenitis. J Hosp Med 2020; 15:197-203. [PMID: 31891560 PMCID: PMC7153489 DOI: 10.12788/jhm.3333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES This study aimed to describe variation in imaging practices and examine the association between early imaging and outcomes in children hospitalized with cervical lymphadenitis. METHODS This multicenter cross-sectional study included children between two months and 18 years hospitalized with cervical lymphadenitis between 2013 and 2017. Children with complex chronic conditions, transferred from another institution, and with prior hospitalizations for lymphadenitis were excluded. To examine hospital-level variation, we calculated the proportion of children at each hospital who received any imaging study, early imaging (conducted on day 0 of hospitalization), multiple imaging studies, and CT imaging. Generalized linear or logistic mixed effects models examined the association between early imaging and outcomes (ie, multiple imaging studies, surgical drainage, 30-day readmission, and length of stay) while accounting for patient demographics, markers of illness duration and severity, and clustering by hospital. RESULTS Among 10,014 children with cervical lymphadenitis, 61% received early imaging. There was hospital-level variation in imaging practices. Compared with children who did not receive early imaging, children who received early imaging presented increased odds of having multiple imaging studies (adjusted odds ratio [aOR] 3.0; 95% CI: 2.6-3.6), surgical drainage (aOR 1.3, 95%CI: 1.1-1.4), and 30-day readmission for lymphadenitis (aOR 1.5, 95%CI: 1.2-1.9), as well as longer lengths of stay (adjusted rate ratio 1.2, 95%CI: 1.1-1.2). CONCLUSIONS Children receiving early imaging had more resource utilization and intervention than those without early imaging. Our findings may represent a cascade effect, in which routinely conducted early imaging prompts clinicians to pursue additional testing and interventions in this population.
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Affiliation(s)
- Sanyukta Desai
- Division of Hospital Medicine, Department of Pediatrics, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, Washington
- Corresponding Author: Sanyukta Desai, MD; E-mail: ; Telephone: 206-987-7370
| | - Samir S Shah
- Divisions of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Divisions of Infectious Diseases, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Matt Hall
- Children’s Hospital Association, Lenexa, Kansas
| | | | - Joanna E Thomson
- Divisions of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Long M, Reddy DN, Akiki S, Barrowman NJ, Zemek R. Paediatric acute lymphadenitis: Emergency department management and clinical course. Paediatr Child Health 2019; 25:534-542. [PMID: 33354264 DOI: 10.1093/pch/pxz125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 07/19/2019] [Indexed: 11/13/2022] Open
Abstract
Objectives To describe clinical characteristics and management of acute lymphadenitis and to identify risk factors for complications. Methods Health record review of children ≤17 years with acute lymphadenitis (≤2 weeks) in a tertiary paediatric emergency department (2009-2014); 10% of charts were reviewed by a blinded second reviewer. Multivariate logistic regression identified factors associated with intravenous antibiotic treatment, unplanned return visits warranting intervention, and surgical drainage. Results Of 1,023 health records, 567 participants with acute lymphadenitis were analyzed. The median age = 4 years (interquartile range [IQR]: 2 to 8 years), and median duration of symptoms = 1.0 day (IQR: 0.5 to 3.0 days). Cervical lymphadenitis was most common. Antibiotics were prescribed in 73.5% of initial visits; 86.9% of participants were discharged home. 29.0% received intravenous antibiotics, 19.3% had unplanned emergency department return visits, and 7.4% underwent surgical drainage. On multivariate analysis, factors associated with intravenous antibiotic use included history of fever (odds ratio [OR]=2.07, 95% confidence interval [CI]: 1.11 to 3.92), size (OR=1.74 per cm, 95% CI: 1.44 to 2.14), age (OR=0.84 per year, 95% CI: 0.76 to 0.92), and prior antibiotic use (OR=4.45, 95% CI: 2.03 to 9.88). The factors associated with unplanned return visit warranting intervention was size (OR=1.30 per cm, 95% CI: 1.06 to 1.59) and age (OR=0.89, 95% CI: 0.80 to 0.97). Factors associated with surgical drainage were age (OR=0.68 per year, 95% CI: 0.53 to 0.83) and size (OR=1.80 per cm, 95% CI: 1.41 to 2.36). Conclusions The vast majority of children with acute lymphadenitis were managed with outpatient oral antibiotics and did not require return emergency department visits or surgical drainage. Larger lymph node size and younger age were associated with increased intravenous antibiotic initiation, unplanned return visits warranting intervention and surgical drainage.
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Affiliation(s)
- Michelle Long
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario.,University of Ottawa, Ottawa, Ontario
| | - Deepti N Reddy
- University of Ottawa, Ottawa, Ontario.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario
| | - Salwa Akiki
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario
| | - Nicholas J Barrowman
- University of Ottawa, Ottawa, Ontario.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario
| | - Roger Zemek
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario.,University of Ottawa, Ottawa, Ontario.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario
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Grazioli P, Bazzana T, Berlucchi M, Nassif N, Tonni D, Redaelli de Zinis LO. Minimally invasive approach to suppurated cervical lymphadenitis in children: Our experience on 60 patients. Clin Otolaryngol 2018; 43:1177-1179. [PMID: 29687954 DOI: 10.1111/coa.13117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2018] [Indexed: 11/30/2022]
Affiliation(s)
- P Grazioli
- Pediatric Otolaryngology Head Neck Surgery, Children Hospital "ASST Spedali Civili", Brescia, Italy
| | - T Bazzana
- Pediatric Otolaryngology Head Neck Surgery, Children Hospital "ASST Spedali Civili", Brescia, Italy
| | - M Berlucchi
- Pediatric Otolaryngology Head Neck Surgery, Children Hospital "ASST Spedali Civili", Brescia, Italy
| | - N Nassif
- Pediatric Otolaryngology Head Neck Surgery, Children Hospital "ASST Spedali Civili", Brescia, Italy
| | - D Tonni
- Pediatric Otolaryngology Head Neck Surgery, Children Hospital "ASST Spedali Civili", Brescia, Italy
| | - L O Redaelli de Zinis
- Pediatric Otolaryngology Head Neck Surgery, Children Hospital "ASST Spedali Civili", Brescia, Italy.,Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Section of Head and Neck Surgery, University of Brescia, Brescia, Italy
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