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Hagelberg J, Pape B, Heikkinen J, Nurminen J, Mattila K, Hirvonen J. Diagnostic accuracy of contrast-enhanced CT for neck abscesses: A systematic review and meta-analysis of positive predictive value. PLoS One 2022; 17:e0276544. [PMID: 36288374 PMCID: PMC9604924 DOI: 10.1371/journal.pone.0276544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 10/08/2022] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES To review the diagnostic accuracy of contrast-enhanced computed tomography (CT) in differentiating abscesses from cellulitis in patients with neck infections, using surgical findings as the reference standard. MATERIALS AND METHODS Previous studies in the last 32 years were searched from PubMed and Embase. Because of partial verification bias (only positive abscess findings are usually verified surgically), sensitivity and specificity estimates are unreliable, and we focused on positive predictive value (PPV). For all studies, PPV was calculated as the proportion of true positives out of all positives on imaging. To estimate pooled PPV, we used both the median with an interquartile range and a model-based estimate. For narrative purposes, we reviewed the utility of common morphological CT criteria for abscesses, such as central hypodensity, the size of the collection, bulging, rim enhancement, and presence of air, as well as sensitivity and specificity values reported by the original reports. RESULTS 23 studies were found reporting 1453 patients, 14 studies in children (771 patients), two in adults (137 patients), and seven including all ages (545 patients). PPV ranged from 0.67 to 0.97 in individual studies, had a median of 0.84 (0.79-0.87), and a model-based pooled estimate of 0.83 (95% confidence interval 0.80-0.85). Most morphological CT criteria had considerable overlap between abscesses and cellulitis. CONCLUSIONS The pooled estimate of PPV is 0.83 for diagnosing neck abscesses with CT. False positives may be due to limited soft tissue contrast resolution. Overall, none of the morphological criteria seem to be highly accurate for differentiation between abscess and cellulitis.
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Affiliation(s)
- Jon Hagelberg
- Department of Radiology, Faculty of Medicine and Health Technology and Tampere University Hospital, Tampere University, Tampere, Finland
| | - Bernd Pape
- Turku Clinical Research Center, Turku University Hospital, Turku, Finland
- School of Technology and Innovations, University of Vaasa, Vaasa, Finland
| | - Jaakko Heikkinen
- Department of Radiology, University of Turku and Turku University Hospital, Turku, Finland
| | - Janne Nurminen
- Department of Radiology, University of Turku and Turku University Hospital, Turku, Finland
| | - Kimmo Mattila
- Department of Radiology, University of Turku and Turku University Hospital, Turku, Finland
| | - Jussi Hirvonen
- Department of Radiology, Faculty of Medicine and Health Technology and Tampere University Hospital, Tampere University, Tampere, Finland
- Department of Radiology, University of Turku and Turku University Hospital, Turku, Finland
- * E-mail:
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Retropharyngeal, Parapharyngeal and Peritonsillar Abscesses. CHILDREN 2022; 9:children9050618. [PMID: 35626793 PMCID: PMC9139861 DOI: 10.3390/children9050618] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/14/2022] [Accepted: 04/22/2022] [Indexed: 11/16/2022]
Abstract
Deep neck infections (DNIs) include all the infections sited in the potential spaces and fascial planes of the neck within the limits of the deep layer of the cervical fascia. Parapharyngeal and retropharyngeal infections leading to parapharyngeal abscess (PPA) and retropharyngeal abscess (RPA) are the most common. DNIs remain an important health problem, especially in children. The aim of this narrative review is to describe the management of peritonsillar, retropharyngeal and parapharyngeal abscesses in pediatric age. Despite relatively uncommon, pediatric DNIs deserve particular attention as they can have a very severe course and lead to hospitalization, admission to the intensive care unit and, although very rarely, death. They generally follow a mild upper respiratory infection and can initially present with signs and symptoms that could be underestimated. A definite diagnosis can be made using imaging techniques. Pus collection from the site of infection, when possible, is strongly recommended for definition of diseases etiology. Blood tests that measure the inflammatory response of the patient may contribute to monitor disease evolution. The therapeutic approach should be targeted toward the individual patient. Regardless of the surgical treatment, antibiotics are critical for pediatric DNI prognosis. The diagnostic-therapeutic procedure to be followed in the individual patient is not universally shared because it has not been established which is the most valid radiological approach and which are the criteria to be followed for the differentiation of cases to be treated only with antibiotics and those in which surgery is mandatory. Further studies are needed to ensure the best possible care for all children with DNIs, especially in this era of increased antimicrobial resistance.
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Heilbronn C, Heyming TW, Knudsen-Robbins C, Schomberg J, Simon D, Bacon K, Huoh K. Features associated with surgically significant abscesses on computed tomography evaluation of the neck in pediatric patients. Int J Pediatr Otorhinolaryngol 2021; 150:110893. [PMID: 34438187 DOI: 10.1016/j.ijporl.2021.110893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/27/2021] [Accepted: 08/19/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Neck-related chief complaints are common in the pediatric Emergency Department (ED), and although the incidence of pathology such as retropharyngeal abscesses is rare, the ability to rule out abscesses requiring surgical/procedural intervention is essential. However, there are no clear clinical guidelines regarding work-up and diagnosis in this population, possibly contributing to an excess use of potentially harmful and costly computed tomography (CT) imaging. OBJECTIVE In this study we sought to identify historical, physical exam, and laboratory findings associated with surgically significant neck abscesses to better delineate CT neck imaging criteria. METHODS We conducted a retrospective chart review of all patients ≤18 years presenting to a pediatric ED between 2013 and 2017 who underwent CT neck imaging. Surgically significant abscesses (SSAs) were defined as abscesses ≥2 cm, retropharyngeal abscesses (RPA), parapharyngeal abscesses (PPA), or peritonsillar abscesses (PTA). Historical factors, physical exam findings, laboratory results, demographics, and CT results were analyzed using univariate statistical analysis and regression models. RESULTS A total of 718 patients received neck CTs and 153 SSAs were identified. In children younger than 6 years, factors associated with statistically significant increased odds of an SSA were reported throat pain (OR 1.18; 95% CI 1.05, 1.33), fussiness (OR 1.18; 1.01, 1.39), lethargy (OR 1.43; 1.07, 1.91), tonsillar enlargement (OR 1.17; 1.02, 1.34), C-reactive protein (CRP) > 10 (OR 1.22; 1.07, 1.40), and an ED visit within the preceding week (OR 1.18; 1.04, 1.33). In children older than 6 years, the factors associated with statistically significant increased odds of an SSA included current antibiotic use (OR 1.12; 1.02, 1.22) and a CRP >10 (OR 1.14; 1.03, 1.26). CONCLUSION Some historical, physical exam, and laboratory findings are associated with SSAs, and while not definitive in isolation, may be beneficial additions to routine SSA assessment, as a supplement to clinical judgement regarding CT and observation decisions. This may potentially allow for the identification of patients requiring CT versus those who may not, and thus the opportunity to safely reduce the use of CT imaging in select patients.
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Affiliation(s)
- Cameron Heilbronn
- Children's Hospital of Orange County, Department of Otolaryngology, Orange, CA, USA
| | - Theodore W Heyming
- Children's Hospital of Orange County, Department of Emergency Medicine, Orange, CA, USA; Department of Emergency Medicine, University of California, Irvine, USA.
| | | | - John Schomberg
- Children's Hospital of Orange County, Research Institute, Orange, CA, USA
| | - Dina Simon
- Children's Hospital of Orange County, Research Institute, Orange, CA, USA
| | - Kellie Bacon
- Children's Hospital of Orange County, Research Institute, Orange, CA, USA
| | - Kevin Huoh
- Children's Hospital of Orange County, Department of Otolaryngology, Orange, CA, USA
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Velhonoja J, Lääveri M, Soukka T, Hirvonen J, Kinnunen I, Irjala H. Early surgical intervention enhances recovery of severe pediatric deep neck infection patients. Int J Pediatr Otorhinolaryngol 2021; 144:110694. [PMID: 33799100 DOI: 10.1016/j.ijporl.2021.110694] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 03/24/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Pediatric deep neck space infection (DNI) is a relatively rare but potentially life-threatening condition and requires prompt and accurate management. This study retrospectively reviews our experience in a tertiary referral hospital from 2004 to 2019. METHODS Systematic data collection from medical records using ICD10 codes between 2004 and 2019. INCLUSION CRITERIA age ≤16 years, DNI requiring hospitalization and/or surgery. EXCLUSION: peritonsillar abscess without complications. RESULTS We identified 42 patients, 21 boys and 21 girls, with a median age of 4.9 years. Most of the patients had severe symptoms, the most common of which were neck swelling (n = 39; 92.9%), neck pain (n = 39; 92.9%) and fever (n = 32; 76.2%). Twenty-two (52.4%) had torticollis, and the mean duration of symptoms before hospitalization was 4.95 days. Diagnosis was confirmed by MRI (n = 24), contrast-enhanced CT (n = 11) or ultrasonography (n = 6), except in one case. Twenty-three (54.8%) required an open neck incision, ten (23.8%) patients had intraoral surgery and nine were treated conservatively. Twelve (28.6%) patients were admitted to the pediatric ICU. Median hospitalization duration was six days. The infection most commonly had tonsillopharyngeal etiology (n = 18) and a retropharyngeal location (n = 17). Staphylococcus Aureus (n = 7) and Streptococcus pyogenes (n = 7) were the most frequent pathogens. We compared the early surgical intervention group (<2 days of intravenous antibiotics; n = 18; 42.9%) to the late surgery group (n = 15; 35.7%) and the conservatively treated groups (n = 9; 21.4%). The overall length of stay (LOS) was lower in the shorter preoperative medication group (mean 4.4 vs. 7.2; p = 0.009). The size of the abscess did not differ between the groups (mean 28 mm; 30 mm; 21 mm; p = 0.075) and the neck incision rate was similar in the operated groups. CONCLUSION Early surgical intervention is associated with decreased LOS among severe pediatric DNI patients.
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Affiliation(s)
- Jarno Velhonoja
- Department of Otorhinolaryngology and Head and Neck Surgery, Turku University Hospital and University of Turku, Kiinanmyllynkatu 4-8, 20520, Turku, Finland.
| | - Meira Lääveri
- Department of Oral and Maxillofacial Surgery, Turku University Hospital and University of Turku, Lemminkäisenkatu 2, 20520, Turku, Finland.
| | - Tero Soukka
- Department of Oral and Maxillofacial Surgery, Turku University Hospital and University of Turku, Lemminkäisenkatu 2, 20520, Turku, Finland.
| | - Jussi Hirvonen
- Department of Radiology, Turku University Hospital and University of Turku, Kiinanmyllynkatu 4-8, 20520, Turku, Finland.
| | - Ilpo Kinnunen
- Department of Otorhinolaryngology and Head and Neck Surgery, Turku University Hospital and University of Turku, Kiinanmyllynkatu 4-8, 20520, Turku, Finland.
| | - Heikki Irjala
- Department of Otorhinolaryngology and Head and Neck Surgery, Turku University Hospital and University of Turku, Kiinanmyllynkatu 4-8, 20520, Turku, Finland.
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Lim S, Lee NY, Han SB, Jeong DC, Kang JH. Deep Neck Inflammation: Probable Kawasaki Disease in Korean Children. Clin Exp Otorhinolaryngol 2019; 13:77-82. [PMID: 31599139 PMCID: PMC7010501 DOI: 10.21053/ceo.2019.00948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 08/23/2019] [Indexed: 11/27/2022] Open
Abstract
Objectives Deep neck infections (DNIs) can cause life-threatening complications, and prompt diagnosis and management are necessary. Kawasaki disease (KD) may be accompanied by deep neck inflammation; making it difficult to distinguish from DNIs. This study was performed to evaluate clinical features and outcomes of children with parapharyngeal and retropharyngeal inflammation. Methods Medical records of the children diagnosed with parapharyngeal and retropharyngeal cellulitis or abscess using cervical computed tomography (CT) between 2013 and 2017 were retrospectively reviewed. Results A total of 47 children were diagnosed with parapharyngeal and retropharyngeal inflammation. Eleven (23.4%) of them were eventually diagnosed with KD, and 36 (76.6%) were diagnosed with DNIs. There were no significantly different clinical and laboratory characteristics on admission between children diagnosed with KD and DNIs; however, significantly more children with KD were febrile for ≥3 days after admission compared to those with DNIs (P=0.009). Deep neck abscesses on CT were observed in 16 children with DNIs (44.4%) and in no child with KD (P=0.009). Among the 36 children with DNIs, 30 (83.3%) were cured with antibiotic therapy only. Conclusion A quarter of children presenting with deep neck inflammation were diagnosed with KD. KD should be considered in children showing deep neck inflammation unresponsive to empirical antibiotic therapy after 3 days, especially in those presenting with deep neck cellulitis rather than deep neck abscess.
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Affiliation(s)
- Sooyeon Lim
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Na Young Lee
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seung Beom Han
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea.,The Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dae Chul Jeong
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea.,The Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jin Han Kang
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea.,The Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Hah YM, Jung AR, Lee YC, Eun YG. Risk factors for transcervical incision and drainage of pediatric deep neck infections. J Pediatr Surg 2018; 53:666-670. [PMID: 28688792 DOI: 10.1016/j.jpedsurg.2017.06.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 05/29/2017] [Accepted: 06/21/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The aim of this study was to identify risk factors for transcervical approaches in the treatment of pediatric deep neck infections (DNIs). METHODS We performed a retrospective analysis of data from patients who were diagnosed with DNIs. All medical records were reviewed for demographic characteristics, presenting signs and symptoms, duration of symptoms, size of abscess, laboratory results, duration of intravenous (IV) antibiotic administration, duration of hospitalization, medical treatment, and type of surgical drainage (oral or transcervical approach). We divided 126 patients into three groups according to the approach used to treat the DNI: non-surgical, intraoral surgical and external transcervical surgical. RESULTS The average ages of the non-surgical, intraoral, and transcervical groups were 10.46±5.27, 12.75±4.82 and 5.54±5.15years, respectively. The transcervical approach was used to treat younger patients (p<0.001). Abscess size was significantly larger for the transcervical group compared to the other groups (5.72±8.93, 13.51±14.74, 18.36±16.05mm, non-surgical, intraoral, and transcervical group, respectively, p=0.009). The average duration of IV antibiotic administration for the transcervical group was 9.77±3.27days, which was significantly higher than those for the other groups (5.49±3.28 for non-surgical and 6.13±2.85 for intraoral, p<0.001). Multivariate analysis revealed that submandibular abscesses (Exp (B)=5.254, p=0.012) were the only significant risk factor for the transcervical approach in surgical treatment of DNIs. CONCLUSION Submandibular space abscesses were the only significant risk factor for the transcervical approach in the treatment of pediatric DNI patients. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Young-Min Hah
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Ah Ra Jung
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Young Chan Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Kyung Hee University, Seoul, Republic of Korea.
| | - Young-Gyu Eun
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Kyung Hee University, Seoul, Republic of Korea.
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Côrte FC, Firmino-Machado J, Moura CP, Spratley J, Santos M. Acute pediatric neck infections: Outcomes in a seven-year series. Int J Pediatr Otorhinolaryngol 2017; 99:128-134. [PMID: 28688554 DOI: 10.1016/j.ijporl.2017.05.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 04/18/2017] [Accepted: 05/25/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVES The aim of this study was to analyse the epidemiology, clinical presentation, diagnostic clues, as biochemical parameters and imaging studies, of children with acute neck infections (ANI) to identify possible independent prognostic factors leading to complications and prolonged hospitalization. METHODS Records of children admitted to a tertiary university hospital from January 2008 to December 2014 with a diagnosis of ANIs were reviewed retrospectively. Diseases were categorized according to the site of infection and patients were divided into two groups: children (aged<10 years) and adolescents (aged 10-18 years). RESULTS A total of 102 patients belonged to the children's group and 57 were adolescents. Forty-nine patients (27.2%) received antibiotics prior to presentation. The most frequent ANI was peritonsillar abscess (n = 72). Four peritonsillar abscesses progressed to parapharyngeal and retropharyngeal abscesses (n = 2 respectively). An association between age and type of abscess was found, with most of the retropharyngeal abscesses occurring in children (p = 0.05), and the submandibular abscesses in adolescents (p < 0.001). The most frequent symptoms/signs were fever (63.9%) and odynophagia (50.6%). Upon admission, all patients received intravenous antibiotics and 86.8% underwent drainage of the abscess. Cultures were harvested in 87 abscesses and the most frequent pathogen isolated was Streptococcus pyogenes. Signs of airway obstruction occurred in two patients with submandibular abscess, one with peritonsillar and one with parapharyngeal abscess. There were no cases of death or severe sequelae. Recurrent ANIs were observed in eight patients including two infected branchial cysts. Children, presence of multiple abscesses and palpable cervical mass on admission, absence of odynophagia and pharyngeal bulging, surgery with general anaesthesia and surgery after 24 h, were associated with prolonged hospitalization. Presence of toothache and neck pain on admission were identified as predictors of complications. CONCLUSIONS The present study found, that often, the diagnosis and treatment of neck abscesses in paediatric patients is not straightforward, but can achieve a favourable outcome. The primary location of the ANI appears to vary in different paediatric age groups. Younger age, presence of multiple abscesses or a palpable cervical mass on admission, were associated with prolonged hospitalization. Presence of toothache and neck pain on admission was identified as possible predictors of complications.
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Affiliation(s)
- Filipa Camacho Côrte
- Department of Otorhinolaryngology, Hospital de São João EPE, Porto, Portugal; University of Porto Medical School, Porto, Portugal.
| | | | - Carla Pinto Moura
- Department of Otorhinolaryngology, Hospital de São João EPE, Porto, Portugal; University of Porto Medical School, Porto, Portugal; Institute for Research and Innovation in Health, University of Porto, Porto, Portugal
| | - Jorge Spratley
- Department of Otorhinolaryngology, Hospital de São João EPE, Porto, Portugal; University of Porto Medical School, Porto, Portugal
| | - Margarida Santos
- Department of Otorhinolaryngology, Hospital de São João EPE, Porto, Portugal
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Ubaidulhaq M, Shahid N, Ang JY. Pillow Feather-Associated Unusual Neck Complication in a Young Child. Glob Pediatr Health 2016; 3:2333794X16646697. [PMID: 27336019 PMCID: PMC4905150 DOI: 10.1177/2333794x16646697] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 03/29/2016] [Accepted: 03/30/2016] [Indexed: 11/17/2022] Open
Affiliation(s)
| | | | - Jocelyn Y Ang
- Children's Hospital of Michigan, Detroit, MI, USA; Wayne State University, Detroit, MI, USA
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Martin C, Gabrillargues J, Louvrier C, Saroul N, Mom T, Gilain L. Contribution of CT scan and CT-guided aspiration in the management of retropharyngeal abscess in children based on a series of 18 cases. Eur Ann Otorhinolaryngol Head Neck Dis 2014; 131:277-82. [DOI: 10.1016/j.anorl.2013.04.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2012] [Revised: 03/16/2013] [Accepted: 04/03/2013] [Indexed: 11/26/2022]
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Mutlu M, Dereci S, Aslan Y. Deep neck abscess in neonatal period: case report and review of literature. Int J Pediatr Otorhinolaryngol 2014; 78:577-82. [PMID: 24512784 DOI: 10.1016/j.ijporl.2014.01.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 01/08/2014] [Accepted: 01/11/2014] [Indexed: 01/30/2023]
Abstract
Deep neck abscess is very rare in neonatal period. We reported a deep neck abscess caused by methicillin-sensitive Staphylococcus aureus infection (MSSA) in a neonate. A 10-day male infant was admitted to our neonatal unit with the complaints of fever, irritability, and refused to food intake. Ultrasonography and magnetic resonance imaging revealed as an abscess in the neck. Needle aspiration from abscess revealed pus. Antibiotics and drainage were applied. We also reviewed the neonatal deep neck abscess reported in English literature and clinical presentation, risk factors, causing microorganisms, treatment, complication and outcome of deep neck abscesses were discussed.
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Affiliation(s)
- Mehmet Mutlu
- Department of Neonatology, Karadeniz Technical University, Faculty of Medicine, Trabzon, Turkey.
| | - Selim Dereci
- Department of Pediatrics, Recep Tayyip Erdoğan University, Faculty of Medicine, Rize, Turkey
| | - Yakup Aslan
- Department of Neonatology, Karadeniz Technical University, Faculty of Medicine, Trabzon, Turkey
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Chang L, Chi H, Chiu NC, Huang FY, Lee KS. Deep Neck Infections in Different Age Groups of Children. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2010; 43:47-52. [DOI: 10.1016/s1684-1182(10)60007-2] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2008] [Revised: 02/10/2009] [Accepted: 02/23/2009] [Indexed: 11/25/2022]
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