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Domínguez-Rodríguez S, Liz-López H, Panizo-LLedot A, Ballesteros Á, Dagan R, Greenberg D, Gutiérrez L, Rojo P, Otheo E, Galán JC, Villanueva S, García S, Mosquera P, Tagarro A, Moraleda C, Camacho D. Testing the performance, adequacy, and applicability of an artificial intelligence model for pediatric pneumonia diagnosis. Comput Methods Programs Biomed 2023; 242:107765. [PMID: 37704545 DOI: 10.1016/j.cmpb.2023.107765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 07/07/2023] [Accepted: 08/13/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Community-acquired Pneumonia (CAP) is a common childhood infectious disease. Deep learning models show promise in X-ray interpretation and diagnosis, but their validation should be extended due to limitations in the current validation workflow. To extend the standard validation workflow we propose doing a pilot test with the next characteristics. First, the assumption of perfect ground truth (100% sensitive and specific) is unrealistic, as high intra and inter-observer variability have been reported. To address this, we propose using Bayesian latent class models (BLCA) to estimate accuracy during the pilot. Additionally, assessing only the performance of a model without considering its applicability and acceptance by physicians is insufficient if we hope to integrate AI systems into day-to-day clinical practice. Therefore, we propose employing explainable artificial intelligence (XAI) methods during the pilot test to involve physicians and evaluate how well a Deep Learning model is accepted and how helpful it is for routine decisions as well as analyze its limitations by assessing the etiology. This study aims to apply the proposed pilot to test a deep Convolutional Neural Network (CNN)-based model for identifying consolidation in pediatric chest-X-ray (CXR) images already validated using the standard workflow. METHODS For the standard validation workflow, a total of 5856 public CXRs and 950 private CXRs were used to train and validate the performance of the CNN model. The performance of the model was estimated assuming a perfect ground truth. For the pilot test proposed in this article, a total of 190 pediatric chest-X-ray (CXRs) images were used to test the CNN model support decision tool (SDT). The performance of the model on the pilot test was estimated using extensions of the two-test Bayesian Latent-Class model (BLCA). The sensitivity, specificity, and accuracy of the model were also assessed. The clinical characteristics of the patients were compared according to the model performance. The adequacy and applicability of the SDT was tested using XAI techniques. The adequacy of the SDT was assessed by asking two senior physicians the agreement rate with the SDT. The applicability was tested by asking three medical residents before and after using the SDT and the agreement between experts was calculated using the kappa index. RESULTS The CRXs of the pilot test were labeled by the panel of experts into consolidation (124/176, 70.4%) and no-consolidation/other infiltrates (52/176, 29.5%). A total of 31/176 (17.6%) discrepancies were found between the model and the panel of experts with a kappa index of 0.6. The sensitivity and specificity reached a median of 90.9 (95% Credible Interval (CrI), 81.2-99.9) and 77.7 (95% CrI, 63.3-98.1), respectively. The senior physicians reported a high agreement rate (70%) with the system in identifying logical consolidation patterns. The three medical residents reached a higher agreement using SDT than alone with experts (0.66±0.1 vs. 0.75±0.2). CONCLUSIONS Through the pilot test, we have successfully verified that the deep learning model was underestimated when a perfect ground truth was considered. Furthermore, by conducting adequacy and applicability tests, we can ensure that the model is able to identify logical patterns within the CXRs and that augmenting clinicians with automated preliminary read assistants could accelerate their workflows and enhance accuracy in identifying consolidation in pediatric CXR images.
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Affiliation(s)
- Sara Domínguez-Rodríguez
- Pediatric Research and Clinical Trials Unit (UPIC). Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Fundación para la Investigación Biomédica del Hospital 12 de Octubre, Madrid, Spain
| | - Helena Liz-López
- Computer Systems Engineering Department, Universidad Politécnica de Madrid, Spain
| | - Angel Panizo-LLedot
- Computer Systems Engineering Department, Universidad Politécnica de Madrid, Spain.
| | - Álvaro Ballesteros
- Pediatric Research and Clinical Trials Unit (UPIC). Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Fundación para la Investigación Biomédica del Hospital 12 de Octubre, Madrid, Spain
| | - Ron Dagan
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - David Greenberg
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel; Soroka University Medical Center, Beer-Sheva, Israel
| | - Lourdes Gutiérrez
- Pediatric Research and Clinical Trials Unit (UPIC). Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Fundación para la Investigación Biomédica del Hospital 12 de Octubre, Madrid, Spain
| | - Pablo Rojo
- Pediatric Research and Clinical Trials Unit (UPIC). Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Fundación para la Investigación Biomédica del Hospital 12 de Octubre, Madrid, Spain; Pediatric Infectious Diseases Unit. Department of Pediatrics, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Enrique Otheo
- Hospital Universitario Ramón y Cajal. Pediatrics Department, Madrid, Spain
| | - Juan Carlos Galán
- Hospital Universitario Ramón y Cajal, Microbiology Department, Madrid, Spain
| | - Sara Villanueva
- Pediatric Infectious Diseases Unit. Department of Pediatrics, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Sonsoles García
- Pediatric Infectious Diseases Unit. Department of Pediatrics, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Pablo Mosquera
- Pediatric Infectious Diseases Unit. Department of Pediatrics, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Alfredo Tagarro
- Pediatric Research and Clinical Trials Unit (UPIC). Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Fundación para la Investigación Biomédica del Hospital 12 de Octubre, Madrid, Spain; Fundación para la Investigación e Innovación Biomédica del Hospital Universitario Infanta Sofía y Hospital Universitario del Henares. Madrid, Spain; Pediatrics Research Group. Universidad Europea de Madrid. Pediatrics, Madrid, Spain
| | - Cinta Moraleda
- Pediatric Research and Clinical Trials Unit (UPIC). Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Fundación para la Investigación Biomédica del Hospital 12 de Octubre, Madrid, Spain; Pediatric Infectious Diseases Unit. Department of Pediatrics, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - David Camacho
- Computer Systems Engineering Department, Universidad Politécnica de Madrid, Spain
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2
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Moraleda C, Domínguez-Rodríguez S, Mesa JM, García-Sánchez P, de la Serna M, Alonso-Cadenas JA, Bermejo A, Sabrido G, Martínez-Campos L, González-Posada AF, Illán-Ramos M, Cobos-Carrascosa E, Ballesteros Á, Galán JC, Llorente F, Aguilera-Alonso D, Jiménez AB, Catalán P, Dahdouh E, Navarro I, Fernández-Garoz B, Mendoza P, Pérez-Jorge C, Cabezas-Fernández T, Blázquez-Gamero D, Rivas G, Gonzalez-Donapetry P, Sáez E, Fernández-Pinero J, Lucas-Fernández J, Pérez-Ramírez E, Merino P, Miragaya S, Lorente J, Iglesias I, Tagarro A. Oral saliva swab reverse transcription PCR for Covid-19 in the paediatric population. Arch Dis Child 2022; 107:1051-1058. [PMID: 35688603 PMCID: PMC9240444 DOI: 10.1136/archdischild-2021-323712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 05/12/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To evaluate the performance of oral saliva swab (OSS) reverse transcription PCR (RT-PCR) compared with RT-PCR and antigen rapid diagnostic test (Ag-RDT) on nasopharyngeal swabs (NPS) for SARS-CoV-2 in children. DESIGN Cross-sectional multicentre diagnostic study. SETTING Study nested in a prospective, observational cohort (EPICO-AEP) performed between February and March 2021 including 10 hospitals in Spain. PATIENTS Children from 0 to 18 years with symptoms compatible with Covid-19 of ≤5 days of duration were included. Two NPS samples (Ag-RDT and RT-PCR) and one OSS sample for RT-PCR were collected. MAIN OUTCOME Performance of Ag-RDT and RT-PCR on NPS and RT-PCR on OSS sample for SARS-CoV-2. RESULTS 1174 children were included, aged 3.8 years (IQR 1.7-9.0); 73/1174 (6.2%) patients tested positive by at least one of the techniques. Sensitivity and specificity of OSS RT-PCR were 72.1% (95% CI 59.7 to 81.9) and 99.6% (95% CI 99 to 99.9), respectively, versus 61.8% (95% CI 49.1 to 73) and 99.9% (95% CI 99.4 to 100) for the Ag-RDT. Kappa index was 0.79 (95% CI 0.72 to 0.88) for OSS RT-PCR and 0.74 (95% CI 0.65 to 0.84) for Ag-RDT versus NPS RT-PCR. CONCLUSIONS RT-PCR on the OSS sample is an accurate option for SARS-CoV-2 testing in children. A less intrusive technique for younger patients, who usually are tested frequently, might increase the number of patients tested.
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Affiliation(s)
- Cinta Moraleda
- Pediatric Infectious Diseases Unit. Department of Pediatrics, Hospital Universitario 12 de Octubre. Pediatric Research and Clinical Trials Unit (UPIC). RITIP (Translational Research Network in Pediatric Infectious Diseases), Madrid, Spain
- Instituto de Investigación 12 de Octubre (imas12), Fundación para la Investigación Biomédica del Hospital 12 de Octubre, Madrid, Spain
| | - Sara Domínguez-Rodríguez
- Instituto de Investigación 12 de Octubre (imas12), Fundación para la Investigación Biomédica del Hospital 12 de Octubre, Madrid, Spain
| | - Juan Miguel Mesa
- Paediatrics Department. Pediatrics Research Group, Hospital Universitario Infanta Sofia, San Sebastian de los Reyes, Madrid, Spain
| | - Paula García-Sánchez
- Emergency Pediatric Department. Instituto Investigación Hospital La Paz (IDIPaz), Hospital Universitario La Paz, Madrid, Spain
| | - María de la Serna
- Paediatrics Department. Pediatrics Research Group, Hospital Universitario Infanta Sofia, San Sebastian de los Reyes, Madrid, Spain
| | - José Antonio Alonso-Cadenas
- Emergency Pediatric Department. Instituto Investigación La Princesa, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Amanda Bermejo
- Pediatric Department, Hospital Universitario de Móstoles, Móstoles, Madrid, Spain
| | - Gema Sabrido
- Pediatric Department, Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, Spain
| | - Leticia Martínez-Campos
- Pediatric Infectious Diseases, Materno Infantil. Hospital Universitario Torrecárdenas, Almeria, Spain
| | | | - Marta Illán-Ramos
- Pediatrics Department, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - Elena Cobos-Carrascosa
- Instituto de Investigación 12 de Octubre (imas12), Fundación para la Investigación Biomédica del Hospital 12 de Octubre, Madrid, Spain
| | - Álvaro Ballesteros
- Instituto de Investigación 12 de Octubre (imas12), Fundación para la Investigación Biomédica del Hospital 12 de Octubre, Madrid, Spain
| | - Juan Carlos Galán
- Microbiology Department, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS). Centro de Investigación Biomédica en Red en Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Francisco Llorente
- Centro de Investigacion en Sanidad Animal INIA-CSIC, Valdeolmos, Madrid, Spain
| | - David Aguilera-Alonso
- Pediatric Infectious Diseases Unit. Department of Pediatrics, Hospital Universitario Gregorio Marañón. Unidad de Investigación Maternoinfantil Fundación Familia Alonso (UDIMIFFA), Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM). CIBER en Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
| | - Ana Belén Jiménez
- Pediatrics Department, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Pilar Catalán
- Servicio de Microbiologia Clinica y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Elias Dahdouh
- Clinical Microbiology and Parasitology Department, Hospital Universitario La Paz. IdiPAZ, Madrid, Spain
| | - Ignacio Navarro
- Paediatrics Department. Pediatrics Research Group, Hospital Universitario Infanta Sofia, San Sebastian de los Reyes, Madrid, Spain
| | | | - Pablo Mendoza
- Microbiology Department, Hospital Universitario de Móstoles, Mostoles, Madrid, Spain
| | - Concepción Pérez-Jorge
- Microbiology Department, Hospital Universitario Rey Juan Carlos, Mostoles, Madrid, Spain
| | | | - Daniel Blázquez-Gamero
- Pediatric Infectious Diseases Unit. Department of Pediatrics, Hospital Universitario 12 de Octubre. Pediatric Research and Clinical Trials Unit (UPIC). RITIP (Translational Research Network in Pediatric Infectious Diseases), Madrid, Spain
- Instituto de Investigación 12 de Octubre (imas12), Fundación para la Investigación Biomédica del Hospital 12 de Octubre, Madrid, Spain
- Universidad Complutense, Madrid, Spain
| | - Gonzalo Rivas
- Microbiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - Elena Sáez
- Microbiology Department, UR Salud. Hospital Universitario Infanta Sofía. Paediatrics Research Group, San Sebastian de los Reyes, Madrid, Spain
| | | | - Jesús Lucas-Fernández
- Microbiology Department, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS). Centro de Investigación Biomédica en Red en Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Elisa Pérez-Ramírez
- Centro de Investigacion en Sanidad Animal INIA-CSIC, Valdeolmos, Madrid, Spain
| | - Paloma Merino
- Microbiology Department, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - Sandra Miragaya
- Clinic Analysis Department, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Jorge Lorente
- Emergency Pediatric Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Irene Iglesias
- Centro de Investigacion en Sanidad Animal INIA-CSIC, Valdeolmos, Madrid, Spain
| | - Alfredo Tagarro
- Instituto de Investigación 12 de Octubre (imas12), Fundación para la Investigación Biomédica del Hospital 12 de Octubre, Madrid, Spain
- Paediatrics Department. Pediatrics Research Group, Hospital Universitario Infanta Sofia, San Sebastian de los Reyes, Madrid, Spain
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3
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del Valle R, Ballesteros Á, Calvo C, Sainz T, Mendez A, Grasa C, Molina PR, Mellado MJ, Sanz‐Santaeufemia FJ, Herrero B, Calleja L, Soriano‐Arandes A, Melendo S, Rincón‐López E, Hernánz A, Epalza C, García‐Baeza C, Rupérez‐García E, Berzosa A, Ocaña A, Villarroya‐Villalba A, Barrios A, Otheo E, Galán JC, Rodríguez MJ, Mesa JM, Domínguez‐Rodríguez S, Moraleda C, Tagarro A. Comparison of pneumonia features in children caused by SARS-CoV-2 and other viral respiratory pathogens. Pediatr Pulmonol 2022; 57:2374-2382. [PMID: 35754093 PMCID: PMC9349806 DOI: 10.1002/ppul.26042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 05/01/2022] [Accepted: 06/23/2022] [Indexed: 01/08/2023]
Abstract
BACKGROUND Pneumonia is a frequent manifestation of coronavirus disease 2019 (COVID-19) in hospitalized children. METHODS The study involved 80 hospitals in the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Spanish Pediatric National Cohort. Participants were children <18 years, hospitalized with SARS-CoV-2 community-acquired pneumonia (CAP). We compared the clinical and radiological characteristics of SARS-CoV-2-associated CAP with CAP due to other viral etiologies from ValsDance (retrospective) cohort. RESULTS In total, 151 children with SARS-CoV-2-associated CAP and 138 with other viral CAP were included. Main clinical features of SARS-CoV-2-associated CAP were cough, fever, or dyspnea. Lymphopenia was found in 43% patients and 15% required admission to the pediatric intensive care unit (PICU). Chest X-ray revealed condensation (42%) and other infiltrates (58%). Compared with CAP from other viral pathogens, COVID-19 patients were older, with lower C-reactive protein (CRP) levels, less wheezing, and greater need of mechanical ventilation (MV). There were no differences in the use of continuous positive airway pressure (CPAP) or HVF, or PICU admission between groups. CONCLUSION SARS-CoV-2-associated CAP in children presents differently to other virus-associated CAP: children are older and rarely have wheezing or high CRP levels; they need less oxygen but more CPAP or MV. However, several features overlap and differentiating the etiology may be difficult. The overall prognosis is good.
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Affiliation(s)
- Rut del Valle
- Pediatrics Department, Pediatrics Research Group, Hospital Universitario Infanta SofíaUniversidad Europea de MadridMadridSpain
| | - Álvaro Ballesteros
- Pediatric Research and Clinical Trials Unit (UPIC), Pediatrics Department, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Fundación de Investigación Biomédica Hospital 12 de OctubreRITIP (Translational Research Network in Paediatric Infectious Diseases)MadridSpain
| | - Cristina Calvo
- Pediatrics, Infectious and Tropical Diseases Department, Hospital Universitario La Paz, Instituto Investigación Hospital La Paz (IDIPaz)RITIP (Translational Research Network in Paediatric Infectious Diseases)MadridSpain
| | - Talía Sainz
- Pediatrics, Infectious and Tropical Diseases Department, Hospital Universitario La Paz, Instituto Investigación Hospital La Paz (IDIPaz)RITIP (Translational Research Network in Paediatric Infectious Diseases)MadridSpain
- Research Center, Centro de Investigación en Red en Enfermedades Infecciosas (CIBERINFEC)Instituto de Salud Carlos III, Madrid, SpainMadridSpain
| | - Ana Mendez
- Pediatrics, Infectious and Tropical Diseases Department, Hospital Universitario La Paz, Instituto Investigación Hospital La Paz (IDIPaz)RITIP (Translational Research Network in Paediatric Infectious Diseases)MadridSpain
| | - Carlos Grasa
- Pediatrics, Infectious and Tropical Diseases Department, Hospital Universitario La Paz, Instituto Investigación Hospital La Paz (IDIPaz)RITIP (Translational Research Network in Paediatric Infectious Diseases)MadridSpain
| | - Paula R. Molina
- Pediatrics, Infectious and Tropical Diseases Department, Hospital Universitario La Paz, Instituto Investigación Hospital La Paz (IDIPaz)RITIP (Translational Research Network in Paediatric Infectious Diseases)MadridSpain
| | - María J. Mellado
- Pediatrics, Infectious and Tropical Diseases Department, Hospital Universitario La Paz, Instituto Investigación Hospital La Paz (IDIPaz)RITIP (Translational Research Network in Paediatric Infectious Diseases)MadridSpain
| | | | - Blanca Herrero
- Pediatrics DepartmentHospital Universitario Niño JesúsMadridSpain
| | - Lourdes Calleja
- Pediatrics DepartmentHospital Universitario Niño JesúsMadridSpain
| | - Antoni Soriano‐Arandes
- Infectious Diseases and Pediatric Immunology Unit, Department of PediatricsHospital Universitario Vall d'HebronBarcelonaSpain
| | - Susana Melendo
- Infectious Diseases and Pediatric Immunology Unit, Department of PediatricsHospital Universitario Vall d'HebronBarcelonaSpain
| | - Elena Rincón‐López
- Pediatric Infectious Diseases Unit, Department of PediatricsHospital Universitario Gregorio MarañónMadridSpain
| | - Alicia Hernánz
- Pediatric Infectious Diseases Unit, Department of PediatricsHospital Universitario Gregorio MarañónMadridSpain
- Research CenterGregorio Marañón Research Institute (IiSGM)MadridSpain
| | - Cristina Epalza
- Pediatric Research and Clinical Trials Unit (UPIC), Pediatrics Department, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Fundación de Investigación Biomédica Hospital 12 de OctubreRITIP (Translational Research Network in Paediatric Infectious Diseases)MadridSpain
- Pediatric Infectious Diseases Unit, Department of PediatricsHospital Universitario 12 de OctubreMadridSpain
| | - Carmen García‐Baeza
- Pediatric Infectious Diseases Unit, Department of PediatricsHospital Universitario 12 de OctubreMadridSpain
| | | | - Arantxa Berzosa
- Pediatrics DepartmentHospital Universitario Clínico San CarlosMadridSpain
| | - Angustias Ocaña
- Pediatric Intensive Care Unit DepartmentHospital La MoralejaMadridSpain
| | - Alvaro Villarroya‐Villalba
- Pediatric Infectious Diseases Unit, Pediatrics DepartmentHospital Universitari i Politècnic La FeValenciaSpain
| | - Ana Barrios
- Pediatrics Department, Pediatrics Research Group, Hospital Universitario Infanta SofíaUniversidad Europea de MadridMadridSpain
| | - Enrique Otheo
- Pediatrics Department, Hospital Universitario Ramón y CajalUniversidad de Alcalá MadridMadridSpain
| | - Juan C. Galán
- Microbiology Department, Hospital Universitario Ramón y CajalInstituto Ramón y Cajal para la Investigación Sanitaria (IRYCIS)MadridSpain
- Centro de Investigación Biomédica en Red en Epidemiología y Salud Pública (CIBERESP)MadridSpain
| | - Mario José Rodríguez
- Microbiology Department, Hospital Universitario Ramón y CajalInstituto Ramón y Cajal para la Investigación Sanitaria (IRYCIS)MadridSpain
- Centro de Investigación Biomédica en Red en Epidemiología y Salud Pública (CIBERESP)MadridSpain
| | - Juan M. Mesa
- Pediatrics Department, Pediatrics Research Group, Hospital Universitario Infanta SofíaUniversidad Europea de MadridMadridSpain
| | - Sara Domínguez‐Rodríguez
- Pediatric Research and Clinical Trials Unit (UPIC), Pediatrics Department, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Fundación de Investigación Biomédica Hospital 12 de OctubreRITIP (Translational Research Network in Paediatric Infectious Diseases)MadridSpain
| | - Cinta Moraleda
- Pediatric Research and Clinical Trials Unit (UPIC), Pediatrics Department, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Fundación de Investigación Biomédica Hospital 12 de OctubreRITIP (Translational Research Network in Paediatric Infectious Diseases)MadridSpain
| | - Alfredo Tagarro
- Pediatrics Department, Pediatrics Research Group, Hospital Universitario Infanta SofíaUniversidad Europea de MadridMadridSpain
- Pediatric Research and Clinical Trials Unit (UPIC), Pediatrics Department, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Fundación de Investigación Biomédica Hospital 12 de OctubreRITIP (Translational Research Network in Paediatric Infectious Diseases)MadridSpain
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4
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Cobos‐Carrascosa E, Ballesteros Á, Aguilera‐Alonso D, Mesa JM, García‐Sánchez P, Navarro I, Alonso‐Cadenas JA, Bermejo A, Sabrido G, Martinez‐Campos L, González‐Posada AF, Illán‐Ramos M, Lorente J, Jiménez AB, Del Valle R, Domínguez‐Rodríguez S, Tagarro A, Moraleda C. Manifestations and clinical phenotypes are not specific enough to predict SARS-CoV-2 infection in symptomatic children. Acta Paediatr 2022; 111:1974-1977. [PMID: 35657111 PMCID: PMC9347920 DOI: 10.1111/apa.16441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 05/19/2022] [Accepted: 06/01/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Elena Cobos‐Carrascosa
- Fundation for Biomedical Research Hospital 12 de Octubre Instituto de Investigación 12 de Octubre (imas12) Madrid Spain
| | - Álvaro Ballesteros
- Fundation for Biomedical Research Hospital 12 de Octubre Instituto de Investigación 12 de Octubre (imas12) Madrid Spain
| | - David Aguilera‐Alonso
- Fundation for Biomedical Research Hospital 12 de Octubre Instituto de Investigación 12 de Octubre (imas12) Madrid Spain
- Pediatric Infectious Diseases Unit, Department of Pediatrics, Hospital General Universitario Gregorio Marañón, Unidad de Investigación Materno‐Infantil Fundación Familia Alonso (UDIMIFFA) Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM) Madrid Spain
- CIBER en Enfermedades Infecciosas (CIBERINFEC) Instituto de Salud Carlos III Madrid Spain
| | - Juan Miguel Mesa
- Pediatric Department Hospital Universitario Infanta Sofía, Pediatrics Research Group Madrid Spain
| | | | - Ignacio Navarro
- Pediatric Department Hospital Universitario Infanta Sofía, Pediatrics Research Group Madrid Spain
- Fundation for Biomedical Research Hospital Infanta Sofía and Hospital del Henares Madrid Spain
| | | | - Amanda Bermejo
- Pediatric Department Hospital Universitario de Móstoles Madrid Spain
| | - Gema Sabrido
- Pediatric Department Hospital Universitario Rey Juan Carlos Madrid Spain
| | | | | | - Marta Illán‐Ramos
- Pediatric Department Hospital Universitario Clínico San Carlos Madrid Spain
| | - Jorge Lorente
- Pediatric Infectious Diseases Unit, Emergency Pediatric Department Hospital Universitario Gregorio Marañón Madrid Spain
| | - Ana Belén Jiménez
- Pediatric Department Hospital Universitario Fundacion Jimenez Diaz Madrid Spain
| | - Rut Del Valle
- Pediatric Department Hospital Universitario Infanta Sofía, Pediatrics Research Group Madrid Spain
- Fundation for Biomedical Research Hospital Infanta Sofía and Hospital del Henares Madrid Spain
- Universidad Europea Madrid Spain
| | - Sara Domínguez‐Rodríguez
- Fundation for Biomedical Research Hospital 12 de Octubre Instituto de Investigación 12 de Octubre (imas12) Madrid Spain
| | - Alfredo Tagarro
- Fundation for Biomedical Research Hospital 12 de Octubre Instituto de Investigación 12 de Octubre (imas12) Madrid Spain
- Pediatric Department Hospital Universitario Infanta Sofía, Pediatrics Research Group Madrid Spain
- Fundation for Biomedical Research Hospital Infanta Sofía and Hospital del Henares Madrid Spain
- Universidad Europea Madrid Spain
| | - Cinta Moraleda
- Fundation for Biomedical Research Hospital 12 de Octubre Instituto de Investigación 12 de Octubre (imas12) Madrid Spain
- Pediatric Infectious Diseases Unit, Department of Pediatrics Hospital Universitario 12 de Octubre, Pediatric Research and Clinical Trials Unit (UPIC), RITIP (Translational Research Network in Pediatric Infectious Diseases) Madrid Spain
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5
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Aguilera-Alonso D, Epalza C, Sanz-Santaeufemia FJ, Grasa C, Villanueva-Medina S, Melendo Pérez S, Cervantes Hernández E, Urretavizcaya-Martínez M, Pino R, Gómez M, Orive J, González Zárate A, Vidal Lana P, González Montero R, Ruiz González S, Calvo C, Iglesias-Bouzas MI, Caro-Teller JM, Domínguez-Rodríguez S, Ballesteros Á, Mesa J, Cobos-Carrascosa E, Tagarro A, Moraleda C. Antibiotic Prescribing in Children Hospitalized With COVID-19 and Multisystem Inflammatory Syndrome in Spain: Prevalence, Trends, and Associated Factors. J Pediatric Infect Dis Soc 2022; 11:225-228. [PMID: 35188190 PMCID: PMC8903467 DOI: 10.1093/jpids/piac003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 01/12/2022] [Indexed: 11/29/2022]
Abstract
The SARS-CoV-2 pandemic has caused an increase in antibiotic use in different settings. We describe the antibiotic prescribing prevalence, associated factors and trends, as well as concomitant bacterial infections in children hospitalized with COVID-19 or multisystemic inflammatory syndrome related to SARS-CoV-2 in Spain.
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Affiliation(s)
- David Aguilera-Alonso
- Pediatric Infectious Diseases Unit, Department of Pediatrics, Hospital General Universitario Gregorio Marañón, Madrid, Spain,Unidad de Investigación Maternoinfantil Fundación Familia Alonso (UDIMIFFA), Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain,CIBER en Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Cristina Epalza
- Pediatric Infectious Diseases Unit, Department of Pediatrics, Hospital Universitario 12 de Octubre, Madrid, Spain,Pediatric Research and Clinical Trials Unit (UPIC), Instituto de Investigación Sanitaria Hospital 12 de Octubre (IMAS12), Madrid, Spain,Fundación para la Investigación Biomédica del Hospital 12 de Octubre, RITIP (Traslational Research Network in Pediatric Infectious Diseases), Madrid, Spain,Corresponding Author: Cristina Epalza, MD, Hospital Universitario 12 de Octubre, Servicio de Pediatría, Avenida de Córdoba s/n, 28041 Madrid, Madrid, Spain. E-mail:
| | | | - Carlos Grasa
- CIBER en Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain,Pediatrics, Infectious and Tropical Diseases Department, Hospital Universitario La Paz, Instituto Investigación Hospital La Paz (IDIPaz), RITIP (Traslational Research Network in Pediatric Infectious Diseases), Madrid, Spain
| | - Sara Villanueva-Medina
- Pediatric Infectious Diseases Unit, Department of Pediatrics, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Susana Melendo Pérez
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall dʹHebron, Vall dʹHebron Research Institute, Barcelona, Spain
| | | | | | - Rosa Pino
- Pediatrics Department, Hospital Sant Joan de Déu (HSJD), Barcelona, Spain
| | - Marisa Navarro Gómez
- Pediatric Infectious Diseases Unit, Department of Pediatrics, Hospital General Universitario Gregorio Marañón, Madrid, Spain,Unidad de Investigación Maternoinfantil Fundación Familia Alonso (UDIMIFFA), Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain,CIBER en Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Javier Pilar Orive
- Pediatric Critical Care Service, Hospital Universitario Cruces, Barakaldo, Spain,Pediatric Critical Care Group, BioCruces Health Research Institute, Barakaldo, Spain
| | - Ana González Zárate
- Department of Pediatrics, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain,Universidad Europea, Madrid, Spain
| | - Paula Vidal Lana
- Department of Pediatrics, Hospital Lozano Blesa, Zaragoza, Spain
| | | | - Sara Ruiz González
- Department of Pediatrics, Hospital Universitario Severo Ochoa, Madrid, Spain
| | - Cristina Calvo
- CIBER en Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain,Pediatrics, Infectious and Tropical Diseases Department, Hospital Universitario La Paz, Instituto Investigación Hospital La Paz (IDIPaz), RITIP (Traslational Research Network in Pediatric Infectious Diseases), Madrid, Spain
| | | | | | - Sara Domínguez-Rodríguez
- Pediatric Research and Clinical Trials Unit (UPIC), Instituto de Investigación Sanitaria Hospital 12 de Octubre (IMAS12), Madrid, Spain,Fundación para la Investigación Biomédica del Hospital 12 de Octubre, RITIP (Traslational Research Network in Pediatric Infectious Diseases), Madrid, Spain
| | - Álvaro Ballesteros
- Pediatric Research and Clinical Trials Unit (UPIC), Instituto de Investigación Sanitaria Hospital 12 de Octubre (IMAS12), Madrid, Spain,Fundación para la Investigación Biomédica del Hospital 12 de Octubre, RITIP (Traslational Research Network in Pediatric Infectious Diseases), Madrid, Spain
| | - Juan Mesa
- Pediatric Research and Clinical Trials Unit (UPIC), Instituto de Investigación Sanitaria Hospital 12 de Octubre (IMAS12), Madrid, Spain,Fundación para la Investigación Biomédica del Hospital 12 de Octubre, RITIP (Traslational Research Network in Pediatric Infectious Diseases), Madrid, Spain,Department of Pediatrics, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain,Universidad Europea, Madrid, Spain
| | - Elena Cobos-Carrascosa
- Pediatric Research and Clinical Trials Unit (UPIC), Instituto de Investigación Sanitaria Hospital 12 de Octubre (IMAS12), Madrid, Spain,Fundación para la Investigación Biomédica del Hospital 12 de Octubre, RITIP (Traslational Research Network in Pediatric Infectious Diseases), Madrid, Spain
| | - Alfredo Tagarro
- Pediatric Research and Clinical Trials Unit (UPIC), Instituto de Investigación Sanitaria Hospital 12 de Octubre (IMAS12), Madrid, Spain,Fundación para la Investigación Biomédica del Hospital 12 de Octubre, RITIP (Traslational Research Network in Pediatric Infectious Diseases), Madrid, Spain,Department of Pediatrics, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain,Universidad Europea, Madrid, Spain
| | - Cinta Moraleda
- Pediatric Infectious Diseases Unit, Department of Pediatrics, Hospital Universitario 12 de Octubre, Madrid, Spain,Pediatric Research and Clinical Trials Unit (UPIC), Instituto de Investigación Sanitaria Hospital 12 de Octubre (IMAS12), Madrid, Spain,Fundación para la Investigación Biomédica del Hospital 12 de Octubre, RITIP (Traslational Research Network in Pediatric Infectious Diseases), Madrid, Spain
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Tagarro A, Cobos-Carrascosa E, Villaverde S, Sanz-Santaeufemia FJ, Grasa C, Soriano-Arandes A, Hernanz A, Navarro ML, Pino R, Epalza C, Batista R, Rizo J, Iglesias-Bouzas MI, Rodríguez-Molino P, Villanueva-Medina S, Carrasco-Colom J, Alonso-Cadenas JA, Mellado MJ, Herrero B, Melendo S, De La Torre M, Calleja L, Calvo C, Urretavizcaya-Martínez M, Astigarraga I, Menasalvas A, Penin M, Neth O, Berzosa A, De Ceano-Vivas M, Vidal P, Romero I, González R, García ML, Mesa JM, Ballesteros Á, Bernardino M, Moraleda C. Clinical spectrum of COVID-19 and risk factors associated with severity in Spanish children. Eur J Pediatr 2022; 181:1105-1115. [PMID: 34738173 PMCID: PMC8568563 DOI: 10.1007/s00431-021-04306-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 10/06/2021] [Accepted: 10/28/2021] [Indexed: 12/13/2022]
Abstract
We aimed to identify the spectrum of disease in children with COVID-19, and the risk factors for admission in paediatric intensive care units (PICUs). We conducted a multicentre, prospective study of children with SARS-CoV-2 infection in 76 Spanish hospitals. We included children with COVID-19 or multi-inflammatory syndrome (MIS-C) younger than 18 years old, attended during the first year of the pandemic. We enrolled 1200 children. A total of 666 (55.5%) were hospitalised, and 123 (18.4%) required admission to PICU. Most frequent major clinical syndromes in the cohort were mild syndrome (including upper respiratory tract infection and flu-like syndrome, skin or mucosae problems and asymptomatic), 44.8%; bronchopulmonary syndrome (including pneumonia, bronchitis and asthma flare), 18.5%; fever without a source, 16.2%; MIS-C, 10.6%; and gastrointestinal syndrome, 10%. In hospitalised children, the proportions were 28.5%, 25.7%, 16.5%, 19.1% and 10.2%, respectively. Risk factors associated with PICU admission were age in months (OR: 1.007; 95% CI 1.004 to 1.01), MIS-C (OR: 14.4, 95% CI 8.9 to 23.8), chronic cardiac disease (OR: 4.8, 95% CI 1.8 to 13), asthma or recurrent wheezing (OR: 2.5, 95% CI 1.2 to 5.2) and after excluding MIS-C patients, moderate/severe liver disease (OR: 8.6, 95% CI 1.6 to 47.6). However, asthmatic children were admitted into the PICU due to MIS-C or pneumonia, not due to asthma flare.Conclusion: Hospitalised children with COVID-19 usually present as one of five major clinical phenotypes of decreasing severity. Risk factors for PICU include MIS-C, elevation of inflammation biomarkers, asthma, moderate or severe liver disease and cardiac disease. What is Known: • All studies suggest that children are less susceptible to serious SARS-CoV-2 infection when compared to adults. Most studies describe symptoms at presentation. However, it remains unclear how these symptoms group together into clinically identifiable syndromes and the severity associated with them. What is New: • We have gathered the primary diagnoses into five major syndromes of decreasing severity: MIS-C, bronchopulmonary syndrome, gastrointestinal syndrome, fever without a source and mild syndrome. Classification of the children in one of the syndromes is unique and helps to assess the risk of critical illness and to define the spectrum of the disease instead of just describing symptoms and signs.
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Affiliation(s)
- Alfredo Tagarro
- Paediatrics Department, Paediatrics Research Group, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, Madrid, Spain. .,Fundación de Investigación Biomédica Hospital 12 de Octubre, Instituto de Investigación 12 de Octubre (imas12), RITIP (Translational Research Network in Paediatric Infectious Diseases), Madrid, Spain. .,Pediatrics Department, Hospital Universitario Infanta Sofía, Madrid, Spain.
| | - Elena Cobos-Carrascosa
- grid.144756.50000 0001 1945 5329Fundación de Investigación Biomédica Hospital 12 de Octubre, Instituto de Investigación 12 de Octubre (imas12), RITIP (Translational Research Network in Paediatric Infectious Diseases), Madrid, Spain
| | - Serena Villaverde
- grid.144756.50000 0001 1945 5329Fundación de Investigación Biomédica Hospital 12 de Octubre, Instituto de Investigación 12 de Octubre (imas12), RITIP (Translational Research Network in Paediatric Infectious Diseases), Madrid, Spain
| | | | - Carlos Grasa
- grid.81821.320000 0000 8970 9163Paediatrics, Infectious and Tropical Diseases Department, Hospital Universitario La Paz, RITIP (Translational Research Network in Paediatric Infectious Diseases), Instituto Investigación Hospital La Paz (IDIPaz), Madrid, Spain
| | - Antoni Soriano-Arandes
- grid.411083.f0000 0001 0675 8654Infectious Diseases and Paediatric Immunology Unit, Department of Paediatrics, Hospital Universitario Vall d’Hebron, Barcelona, Spain
| | - Alicia Hernanz
- grid.410526.40000 0001 0277 7938Paediatric Infectious Diseases Unit, Department of Paediatrics, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - María Luisa Navarro
- grid.410526.40000 0001 0277 7938Paediatric Infectious Diseases Unit, Department of Paediatrics, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Rosa Pino
- grid.411160.30000 0001 0663 8628Paediatric Infectious Diseases Unit, Department of Paediatrics, Hospital Universitario Sant Joan de Deu Barcelona, Barcelona, Spain
| | - Cristina Epalza
- grid.144756.50000 0001 1945 5329Fundación de Investigación Biomédica Hospital 12 de Octubre, Instituto de Investigación 12 de Octubre (imas12), RITIP (Translational Research Network in Paediatric Infectious Diseases), Madrid, Spain ,grid.144756.50000 0001 1945 5329Paediatric Infectious Diseases Unit, Department of Paediatrics, Paediatric Research and Clinical Trials Unit (UPIC), Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Rosa Batista
- Paediatrics Department, Paediatrics Research Group, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, Madrid, Spain
| | - Jana Rizo
- Paediatrics Department, Paediatrics Research Group, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, Madrid, Spain
| | - María-Isabel Iglesias-Bouzas
- grid.411107.20000 0004 1767 5442Paediatric Intensive Care Unit, Hospital Universitario Niño Jesús, Madrid, Spain
| | - Paula Rodríguez-Molino
- grid.81821.320000 0000 8970 9163Paediatrics, Infectious and Tropical Diseases Department, Hospital Universitario La Paz, RITIP (Translational Research Network in Paediatric Infectious Diseases), Instituto Investigación Hospital La Paz (IDIPaz), Madrid, Spain
| | - Sara Villanueva-Medina
- grid.144756.50000 0001 1945 5329Paediatric Infectious Diseases Unit, Department of Paediatrics, Paediatric Research and Clinical Trials Unit (UPIC), Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Jaime Carrasco-Colom
- grid.144756.50000 0001 1945 5329Paediatric Infectious Diseases Unit, Department of Paediatrics, Paediatric Research and Clinical Trials Unit (UPIC), Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - María-José Mellado
- grid.81821.320000 0000 8970 9163Paediatrics, Infectious and Tropical Diseases Department, Hospital Universitario La Paz, RITIP (Translational Research Network in Paediatric Infectious Diseases), Instituto Investigación Hospital La Paz (IDIPaz), Madrid, Spain
| | - Blanca Herrero
- grid.411107.20000 0004 1767 5442Paediatrics Department, Hospital Universitario Niño Jesús, Madrid, Spain
| | - Susana Melendo
- grid.411083.f0000 0001 0675 8654Infectious Diseases and Paediatric Immunology Unit, Department of Paediatrics, Hospital Universitario Vall d’Hebron, Barcelona, Spain
| | - Mercedes De La Torre
- grid.411107.20000 0004 1767 5442Paediatrics Department, Hospital Universitario Niño Jesús, Madrid, Spain
| | - Lourdes Calleja
- grid.411107.20000 0004 1767 5442Paediatrics Department, Hospital Universitario Niño Jesús, Madrid, Spain
| | - Cristina Calvo
- grid.81821.320000 0000 8970 9163Paediatrics, Infectious and Tropical Diseases Department, Hospital Universitario La Paz, RITIP (Translational Research Network in Paediatric Infectious Diseases), Instituto Investigación Hospital La Paz (IDIPaz), Madrid, Spain
| | | | - Itziar Astigarraga
- Department of Pediatrics, Hospital Universitario Cruces, Biocruces Bizkaia Health Research Institute, University of the Basque Country UPV/EHU, OsakidetzaBarakaldo, Spain
| | - Ana Menasalvas
- grid.411372.20000 0001 0534 3000Paediatrics Department, Hospital Universitario Virgen de La Arrixaca, Murcia, Spain
| | - María Penin
- grid.411336.20000 0004 1765 5855Paediatrics Department, Hospital Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Olaf Neth
- grid.411109.c0000 0000 9542 1158Paediatrics Department, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Arantxa Berzosa
- grid.411068.a0000 0001 0671 5785Paediatrics Department, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - María De Ceano-Vivas
- grid.81821.320000 0000 8970 9163Emergency Pediatrics Department, Hospital Universitario La Paz, Instituto Investigación Hospital La Paz (IDIPaz), Madrid, Spain
| | - Paula Vidal
- grid.411050.10000 0004 1767 4212Paediatrics Department, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Isabel Romero
- Paediatrics Department, Hospitales HM, Madrid, Spain
| | - Raúl González
- Paediatrics Department, Hospital Universitario Sant Joan, Comunidad Valenciana, AlacantAlicante, Spain
| | - María Luz García
- grid.411361.00000 0001 0635 4617Paediatrics Department, Hospital Universitario Severo Ochoa, Leganés, Madrid, Spain
| | - Juan-Miguel Mesa
- Paediatrics Department, Paediatrics Research Group, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, Madrid, Spain
| | - Álvaro Ballesteros
- grid.144756.50000 0001 1945 5329Fundación de Investigación Biomédica Hospital 12 de Octubre, Instituto de Investigación 12 de Octubre (imas12), RITIP (Translational Research Network in Paediatric Infectious Diseases), Madrid, Spain
| | - María Bernardino
- Paediatrics Department, Paediatrics Research Group, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, Madrid, Spain
| | - Cinta Moraleda
- grid.144756.50000 0001 1945 5329Fundación de Investigación Biomédica Hospital 12 de Octubre, Instituto de Investigación 12 de Octubre (imas12), RITIP (Translational Research Network in Paediatric Infectious Diseases), Madrid, Spain ,grid.144756.50000 0001 1945 5329Paediatric Infectious Diseases Unit, Department of Paediatrics, Paediatric Research and Clinical Trials Unit (UPIC), Hospital Universitario 12 de Octubre, Madrid, Spain
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Amezcua‑Valmala N, Vázquez D, Ballesteros Á, Bella M, Casanova C, Colmenares F. Paramètres socio-spatiaux, réseaux sociaux et budget d'activité chez un groupe de mâles chimpanzés : stabilité dans le temps et effet de la réduction spatiale. primatologie 2015. [DOI: 10.4000/primatologie.2031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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