| Radiological
Appearances of Recent Cases of Atypical Pneumonia in Hong Kong |
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[ ENGLISH | RUSSIAN
| 中文 ]
Prepared
by Drs. Anil T. Ahuja & Jeffrey K. T. Wong.
Maintained by Drs. James F. Griffith & Gregory E.
Antonio.
This webpage
was first set up on the 21st March, 2003.
Page Hits:
/ Updated on
13th July
2004
A message
to our visitors
A year has passed since the end of the SARS outbreak in Hong Kong and it appears that we (the world community in general) have been spared of a massive recurrence of this infection this year. Nonetheless, research on this disease is on-going and we would like to congratulate all who have contributed to furthering our knowledge of this disease.
The convalescent period of this disease has not been uneventful. Complications of the disease such as Lung fibrosis resulting in limitations to respiratory function, post-traumatic stress disorder like psychological trauma, side-effects of corticosteroid therapy (adrenal insufficiency and osteonecrosis) continue to surface. We have included some of the relevant images and references with this update.
With the help of many co-workers from Hong Kong and other countries, we are pleased to announce that we have compiled a book documenting our collective knowledge and experience on SARS. This book is titled "Imaging in SARS", published by Cambridge University Press (http://www.cambridge.org/uk/catalogue/catalogue.asp?isbn=1841102199). Despite its title, this book contains extensive information on the epidemiology, clinical diagnosis and treatment, emergency medicine, intensive care medicine and infection control related to SARS.
On another front, a different viral infection has re-surfaced this past winter, the Avian Influenza. We have created a webpage similar to this SARS webpage for sharing images of that infection with all. The address of the Avian Influenza webpage is: http://www.diir.cuhk.edu.hk/web/specials/avian_flu/avian_flu.htm
If you come across something interesting in your management of SARS or Avian Influenza patients and would like to share this with the rest of the medical community, we would be more than happy to post it on our website. Acknowledgement and copyright will obviously be granted to the contributor and institution.
Again we like to thank our support staff for the great work they have done and the personal sacrifices they have made to get both webpages up and running. We would also like to thank the numerous visitors who have given us very valuable feed back to help us improve our website.
With our sincere thanks,
The Department of Imaging and Interventional Radiology,
The Chinese University of Hong Kong.
INTRODUCTION
The beginning of 2004 saw the confirmation of the
first community acquired case of SARS since the end of the 2003
epidemic. We now know much more about this novo disease and the
United States Centers of Disease Control and prevention has issued
an updated case definition in December 2003. Radiology continues
to be an integral part of the diagnosis and management of patients
with SARS.
The following are the radiological and CT features
of this disease based on our experience (336 patients imaged during
after the epidemic) at the Department of Diagnostic Radiology
and Organ Imaging, Chinese University of Hong Kong, Prince of
Wales Hospital, Hong Kong.
These are presented here to facilitate early diagnosis
and management should it be encountered in other centres.
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FOLLOW-UP IMAGING
FINDINGS IN SARS
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| (a) T1W coronal |
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| (b) T2W fat-saturated
coronal |
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| (c) PD sagittal |
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Patient
Two
32 year old male previous treated for SARS Co-V infection.
MRI of the right hip shows abnormal subchondral areas bound by geographic
borders in the femoral head: (a) T1W coronal (b) T2W fat-saturated coronal
(c) PD sagittal. The appearances are consistent with avascular necrosis.
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ACUTE IMAGING
FINDINGS IN SARS
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Radiographs:
In the early stage of the disease, a peripheral
/ pleural-based opacity may be the only abnormality. This may
range from ground-glass to consolidation in appearance. A particular
area to review is the paraspinal region behind the heart. In our
experience, this is frequently where lung lesions are detected
on HRCT in suspected SARS patients with normal radiographs.
In the more advanced cases, there is widespread
opacification which may be ground-glass or consolidative affecting
large areas. This tends to affect the lower zones first and is
not uncommonly bilateral. Calcification, cavitation, pleural effusion
or lymphadenopathy are not features of this disease.
HRCT:
Solitary or multiple patchy area(s) of
- Ground-glass opacification with or without thickening of the
intra-lobular interstitium or interlobular interstitium.
- Consolidation
- A combination of 1 & 2
These tend to occupy a sub-pleural position rather
than axial. Again, calcification, cavitation, pleural effusion
or lymphadenopathy are not features of this disease
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| CXR
WITH CORRESPONDING HRCT |
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| Patient
Three |
Patient
Four |
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| 24 year
old symptomatic female. Frontal view shows vague paraspinal
opacity in the left lower zone |
Click here
to view corresponding HRCT |
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| 29 year
old symptomatic female with normal radiographic appearance |
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Click here
to view corresponding HRCT |
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| Patient
One |
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27 year
old symptomatic female with subtle left lower zone opacity
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Click here
to view corresponding HRCT |
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| PROGRESS
CXR |
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| Case
1: A 31-year-old health-care worker presented with 2-day history of fever,
chills and myalgia. |
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| Figure 1 -
CXR at the time of diagnosis showed ill-defined air space opacification
in right lower zone |
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| Figure 2 -
CXR after 3 days showed partial resoulation of consolidatve changes
in right lower zone. There is a new finding of ill-defined air space
opacification in left lower zone |
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| Figure 3 -
CXR after another 4 days showed progressive resolution of the changes
in both lower zones |
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| Case
2: A 34-year-old presented with 3-day history of fever, chills and malaise. |
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| Figure 1 -
CXR (7 days after admission) showed ill-defined air space opacification
in periphery of right lower zone |
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| Figure 2 -
CXR (2 days later) showed progression of air space opacification
in right lower zone and a new finding of similar changes in left
mid and lower zones after initial treatment |
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| Figure 3 -
CXR (after another 4 days) showed marked resolution of the consolidative
changes in both lungs after treatment |
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| Case
3: A 34-year-old health care worker presented with fever, chills and myalgia
for 2 days. |
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| Figure 1 -
CXR showed ill-defined air-space opacity in periphery of left upper
and mid zones |
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| Figure 2 -
CXR (after 5 days) showed progressive air-space opacities in both
lungs |
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| Figure 3 -
CXR (after another 7 days) showed resolution of radiographic changes
after successful treatment |
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| IMAGES
FROM OTHER CENTERS |
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Boca
Raton, Florida, USA
Courtesy of Dr. Michael E. Katz M D |
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| 52-year-old
symptomatic female from Virginia |
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15 MARCH 2003
(On presentation to A&E) |
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| 19 MARCH 2003 |
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| 20 MARCH 2003 |
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Changi
General Hospital, Singapore
Courtesy of Dr Augustine Tee |
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| 24-year-old
Filipino nursing aid from nursing home with one week history of fever,
dry cough and myalgia. |
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| Day 1 - CXR
showed subtle left lower zone airspace infiltrates. |
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| Day 5 - CXR
showed left lower zone consolidation became more obvious. |
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| Day 7 - Patient
became hypoxic & required subsequent intubation. CXR showed bilateral
widespread airspace infiltrates. |
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NEW! Li
Shin Hospital, Taiwan
Courtesy of Dr Lu Yeh-Chiu |
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| 16
years old male c/o swinging but persisted fever above 38 degree Celius
for a few days with dry cough CXR taken on the 10th day in our OPD department.
No fever at that time. |
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| CXR PA : bronchitis
? |
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| Repeated CXR
PA another 10 days later. |
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| Repeated CXR
PA on the 20th day. |
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Please
send us your images to share with the rest of the medical community.
E-mail address: gregantonio@cuhk.edu.hk
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| IMAGE
GALLERY |
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| CHEST
RADIOGRAPHS |
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Fig 1: (day
3 after onset of symptoms)
Ill-defined air-space opacification in right lower zone |
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Fig 2: (day
4 after onset of symptoms)
Confluent air-space opacification in left lower zone |
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Fig 3: (day
5 after onset of symptoms)
Air-space
opacification in the periphery of middle lobe abutting the superior
aspect of the horizontal fissure |
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Fig 4: (day
3 after onset of symptoms)
Ill-defined opacity in left lower zone |
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Fig 5: (day
4 after onset of symptoms)
Bilateral lower zones air-space opacities in para-cardiac areas |
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Fig 6: (day
2 after onset of symptoms)
Middle lobe air-space opacity obscuring part of right heart border
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Fig 7: (day
4 after onset of symptoms)
Peripheral segmental air-space opacification in right upper lobe |
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Fig 8: (day
5 after onset of symptoms)
Patchy peripheral opacities involving both lower lobes |
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Fig 9: (day
6 after onset of symptoms)
Multi-focal ill-defined air-space opacities in both lower and right
upper zones |
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Fig 10: (day
5 after onset of symptoms)
Patchy air-space opacification in both mid and lower zones |
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Fig 11: (day
4 after onset of symptoms)
Peripheral patchy opacification in right upper and left lower zones |
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Fig 12: (day
7 after onset of symptoms)
Multi-focal diffuse air-space opacities in both lungs |
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Fig 13: (day
5 after onset of symptoms)
Multi-focal confluent areas of air-space opacities in both lungs |
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Fig 14: (day
6 after onset of symptoms)
Diffuse and widespread consolidative changes in both lungs (patient
is intubated) |
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Note:
ARDS (Adult Respiratory Distress Syndrome) may be a feature in severe
disease |
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| PAEDIATRICS |
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| 2-year-old
boy presented with febrile convulsion and cough. CXR on admission
showed air-space opacities in left mid and lower zones. |
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| 6-year-old
girl presented with fever, running nose and cough. CXR on admission
showed focal air-space consolidation in left upper zone. |
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| 5-year-old
girl presented with fever for 4 days. CXR showed air-space opacity
in left lower zone. |
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| CT |
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Fig 1: (day
3 after onset of symptoms)
Peripheral ill-defined consolidation in the lateral basal segment
of left lower lobe |
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Fig 2: (day
2 after onset of symptoms)
Peripheral ground-glass opacification in middle lobe |
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Fig 3: (day
2 after onset of symptoms)
Patchy ground-glass opacification in periphery of both lower lobes
(R>L) |
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Fig 4: (day
3 after onset of symptoms)
Ill-defined consolidation with air-bronchogram in apical segment
of right lower lobe |
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Fig 5: (day
5 after onset of symptoms)
Multi-focal peripheral consolidation in posterior basal segments
of both lower lobes and an area of ground-glass opacification in
left lingular segment |
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Fig 6: (day
5 after onset of symptoms)
Patchy, multi-focal, ground-glass opacification and consolidation
in both upper lobes |
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Fig 7: (day
4 after onset of symptoms)
Multiple confluent areas of consolidation in the middle lower and
both lower lobes |
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| IMAGING
PROTOCOL |
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Our
current imaging protocol is
- If SARS is clinically suspected, a chest radiograph should
be performed.
- If the chest radiograph is abnormal, then no further imaging
investigation is required other than serial radiographs
for follow up.
- If the chest radiograph is normal, a HRCT is performed. This
may show changes one to two days before they become radiographically
apparent.
- All patients currently admitted with this syndrome have
abnormal chest imaging findings.
- Please note that as the disease is contagious appropriate
personal precautions need to be taken as well as appropriate
cleansing of radiographic or CT equipment.
N.B. Initially we performed both conventional and high resolution
CT of the thorax on all patients. With increasing experience, it
became apparent that pleural effusion or lymphadenopathy was not
a feature of this disease. CT examination is now limited to HRCT
only.
STRICT
INFECTION CONTROL IS A MUST.
PLEASE REFER TO OUR GUIDELINES REGARDING MANAGEMENT
AND INFECTION CONTROL IN A RADIOLOGY DEPARTMENT DURING THE SARS
OUTBREAK.
All staff in the radiology department must
be absolutely familiar with and adhere to infection control guidelines.
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Suggested
algorithm for imaging investigation of SARS:
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* HRCT should be used with
caution as it may result in overdiagnosis. It should be used only
if:
- there is a history of contact OR
- the clinical signs, such as a continuing fever, leucopenia
etc., are strongly suggestive of SARS, AND
- the initial chest radiograph is normal
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MANAGEMENT
AND INFECTION CONTROL IN A RADIOLOGY DEPARTMENT DURING THE SARS
OUTBREAK
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IMAGING
OF SARS PATIENTS AT DISCHARGE
As
SARS is a new disease, there is no previously established imaging
policy at the time of discharge for reference. We have adopted
the following protocol for imaging SARS patients on discharge.
This may evolve with greater experience. Our current protocol
for imaging SARS patients on discharge is:
- For patients with positive initial CXR and displaying resolution
of radiographic changes on treatment, we perform a CXR on discharge
(and subsequently monitor their clinical progress).
- For patients with normal chest radiographs and lung changes
were detected only on HRCT, we perform a HRCT on discharge (and
subsequently monitor their clinical progress).
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| DROID
SARS ACTIVITIES |
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Indexed
Publications on SARS: |
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| 1. |
Lee N, Hui D, Wu A, Chan P, Cameron P, Joynt GM,
Ahuja A, Yung MY, Leung CB, To KF, Lui SF, Szeto CC, Chung
SSC and Sung JJY. A Major Outbreak of Severe Acute Respiratory
Syndrome in Hong Kong. N Engl J Med. 2003 May 15;348(20):1986-94.
Epub 2003 Apr 07. |
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Wong KT, Antonio GE, Hui DSC, Lee N, Yuen EHY,
Wu A, Leung CB, Rainer TH, Cameron P, Chung SSC, Sung JJY,
Ahuja AT. Radiographic Appearances and Pattern of Progression
of Severe Acute Respiratory Syndrome (SARS): A Study of 138
Patients.Radiology 2003; 228:401-406. |
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Wong KT, Antonio GE, Hui DSC, Lee N, Yuen EHY,
Wu A, Leung CB, Rainer TH, Cameron P, Chung SSC, Sung JJY,
Ahuja AT. Radiological Appearances of Severe Acute Respiratory
Syndrome. Journal of the Hong Kong College of Radiologists
2003;6:4-6. |
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Wong KT, Antonio GE, Hui DSC, Lee N, Yuen EHY,
Wu A, Leung CB, Rainer TH, Cameron P, Chung SSC, Sung JJY,
Ahuja AT. Thin-Section CT of Severe Acute Respiratory Syndrome:
Evaluation of 73 Patients Exposed to or with the Disease.
Radiology 2003;228:395-400. |
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Ahuja AT. Letter to Editor, Severe Acute Respiratory
Syndrome in Hong Kong. Clin Radiol. 2003 Jun;58(6):496. |
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| 6. |
Antonio GE, Wong KT, Hui DSC Lee N, Yuen EHY,
Wu A, Leung CB, Rainer TH, Cameron P, Chung SSC, Sung JJY,
Ahuja AT. Pictorial Essay: Imaging of Severe Acute Respiratory
Syndrome in Hong Kong. AJR Am J Roentgenol 2003;181:11-7. |
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| 7. |
Antonio GE, Wong KT, Hui DSC Lee N, Yuen EHY,
Wu A, Leung CB, Rainer TH, Cameron P, Chung SSC, Sung JJY,
Ahuja AT. Thin-section Computed Tomography in Severe Acute
Respiratory Syndrome (SARS) Patients Following Hospital Discharge:
Radiology. 2003 Sep;228(3):810-5. Epub 2003 Jun 12. |
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| 8. |
King AD, Ching ASC, Chan PL, Cheng AYH, Wong PK,
Ho SSY, Griffith JF, Lyon DJ, Fung KSC, Choi P, Li CK, Cheng
AFB, Ahuja AT. Severe Acute Respiratory Syndrome: Avoiding
the Spread of Infection in a Radiology Department. AJR Am
J Roentgenol. 2003 Jul;181(1):25-7. |
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| 9. |
Ho SSY, Chan PL, Wong, PK Antonio GE, Wong KT,
Lyon DJ, Fung KSC, Li CK, Cheng AFB, Ahuja AT. Eye of the
Storm: The Roles of a Radiology Department in the Outbreak
of Severe Acute Respiratory Syndrome. AJR Am J Roentgenol.
2003 Jul;181(1):19-24. |
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| 10. |
Griffith JF, Antonio GE, Ahuja AT. SARS and the
Modern Day Pony Express (the World Wide Web). American Journal
of Roentgenology 2003;180:1736. |
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| 11. |
Hon KLE, Leung CW, Cheng WTF, Chan PKS, Chu WCW,
Kwan YW, Li AM, Fong NC, Ng PC, Chiu MC, Li CK, Tam JS, Fok
TF. Clinical presentations and outcome of severe acute respiratory
syndrome in childern. Lancet. 2003 May 17;361(9370):1701-3. |
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| 12. |
Antonio GE, Wong KT, Chu WC, et al. Imaging in
severe acute respiratory syndrome (SARS). Clin Radiol. 2003
Nov;58(11):825-32. |
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| 13. |
Gomersall CD, Joynt GM, Lam P, et al. Short-term
outcome of critically ill patients with severe acute respiratory
syndrome. Intensive Care Med. 2004 Mar;30(3):381-7. Epub 2004
Jan 23. |
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| 14. |
Hui DSC, Wong KT, Antonio GE et al. Severe Acute
Respiratory Syndrome (SARS): Correlation of Clinical Outcome
and Radiological Features. Radiology in press. |
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| 15. |
Joynt GM, Antonio GE, Lam P, et al. Late-stage
adult respiratory distress syndrome caused by severe acute
respiratory syndrome: abnormal findings at thin-section CT.
Radiology. 2004 Feb;230(2):339-46 |
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| 16. |
Griffith JF, Antonio GE, Kumta SM, et al. Osteonecrosis
of the hip and knee in SARS patients treated with steroids.
Radiology in press. |
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Conference
Lectures/ Presentations on SARS: |
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| 1. |
Hong Kong College of Radiologists, Hong Kong Academy
of Medicine and Hong Kong Hospital Authority. SARS Imaging
Symposium. Hong Kong, China. 7th June 2003
Pneumonia, atypical pneumonia and pneumonia-like conditions
"Pneumonia
in children including SARS"
Dr. Winnie Chu |
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Hong Kong College of Radiologists, Hong Kong Academy
of Medicine and Hong Kong Hospital Authority. SARS Imaging
Symposium. Hong Kong, China. 7th June 2003
Pneumonia, atypical pneumonia and pneumonia-like conditions
"Application
& Imaging Features of SARS on HRCT"
Dr. KT Wong |
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| 3. |
World Health Organization, SARS Clinical Management
Workshop, Hong Kong, China, 13th June 2003.
"Imaging in SARS: The Hong Kong Experience"
Dr. Ahuja |
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| 4. |
The Second Chinese Medical Association Medical
Forum, Beijing, China. 9th September 2003.
"Imaging of Severe Acute Respiratory Syndrome (SARS)"
Dr. Antonio |
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| 5. |
Radiological Society of North America Scientific
Assembly and Annual Meeting. 1st December 2003.
"Computed Tomography of Severe Acute respiratory Syndrome:
Initial Experience"
Dr. Antonio |
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| 6. |
16th European Congress of Radiology, 8 March,
2004
"Steroid-induced AVN in patients treated for SARS: Early
observations." (abstract B-702)
Dr. Antonio |
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| 7. |
16th European Congress of Radiology, 9 March,
2004
"Radiographic appearances and pattern of progression
of Severe Acute Respiratory Syndrome (SARS)." (abstract
B-862).
Dr. Antonio |
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| 8. |
Hong Kong SARS Forum and Hospital Authority Convention
2004. 8 May 2004.
"Magnetic Resonance Screening for Skeletal Abnormalities
in post-SARS patients"
Dr. Antonio |
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Scientific
Exhibits on SARS: |
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| 1. |
SARS Imaging - What do we need to know?
Shetty S, Burney K, Hopkins R, Antonio GE, Ahuja AT
Annual Meeting of The Royal College of Radiologists UK September
2003 |
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| 2. |
Severe Acute Respiratory Syndrome (SARS): Correlation
of Clinical Outcome and Radiological Features.
Wong KT, Hui DSC, Antonio GE, Wu A, Wong V, Lau W, Wu, JC,
Tam LS, Yu LM, Joynt, GM, Chung SSC, Ahuja AT.
Hong Kong College of Radiologists 11th Annual Scientific Meeting,
Hong Kong, 18th -19th October 2003. |
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| 3. |
Computerised tomography (CT) in severe acute
respiratory syndrome 9SARS): late-stage acute respiratory
disease syndrome (ARDS) and follow-up findings.
Joynt G, Antonio G, Wong K, Lam P, Gomersall C, Li T.
24th International Symposium on Intensive Care and Emergency
Medicine
Brussels, Belgium, 30 March - 2 April 2004 |
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| 4. |
Texture Classification of SARS Infected Region
in Radiographic Image
Xiaoou Tang, Dacheng Tao, Gregory E Antonio
Institute of Electrical and Electronics Engineers, 11th International
Conference on Image Processing, Singapore October 2004 |
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| 1. |
Imaging in SARS
Editors: Anil T Ahuja and Clara GC Ooi
2004 Greenwich Medical Media Limited, London, UK.
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| 1. |
SARS. Editor: Joseph JY Sung
Imaging in Severe Acute Respiratory Syndrome (SARS)
KT Wong, Gregory E Antonio, Anil T Ahuja, |
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| 2. |
Imaging in SARS. Editors: Anil T Ahuja and Clara
GC Ooi
2004 Greenwich Medical Media Limited, London, UK.
Chapter 5
The Role of Chest Radiographs in the Diagnosis of SARS
KT Wong, Gregory E Antonio, Anil T Ahuja |
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| 3. |
Imaging in SARS. Editors: Anil T Ahuja and Clara
GC Ooi
2004 Greenwich Medical Media Limited, London, UK.
Chapter 6
Chest radiography: Clinical correlation and its role in the
management of Severe Acute Respiratory Syndrome (SARS)
David SC Hui, KT Wong, Gregory E Antonio, Anil T Ahuja, Joseph
JY Sung |
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| 4. |
Imaging in SARS. Editors: Anil T Ahuja and Clara
GC Ooi
2004 Greenwich Medical Media Limited, London, UK.
Chapter 7
The Role of High-resolution Computed Tomography (HRCT) in
Diagnosis of SARS
Gregory E Antonio, KT Wong, Anil T Ahuja |
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| 5. |
Imaging in SARS. Editors: Anil T Ahuja and Clara
GC Ooi
2004 Greenwich Medical Media Limited, London, UK.
Chapter 8
The Role of Imaging in the Follow up of SARS
Gregory E Antonio, KT Wong, Anil T Ahuja |
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| 6. |
Imaging in SARS. Editors: Anil T Ahuja and Clara
GC Ooi
2004 Greenwich Medical Media Limited, London, UK.
Chapter 9
Treatment of Severe Acute Respiratory Syndrome
Joseph JY Sung, Alan Wu |
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| 7. |
Imaging in SARS. Editors: Anil T Ahuja and Clara GC Ooi
2004 Greenwich Medical Media Limited, London, UK.
Chapter 10
SARS in the Intensive Care Unit
Gavin M Joynt, Gregory E Antonio, Charles D Gomersall. |
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| 8. |
Imaging in SARS. Editors: Anil T Ahuja
and Clara GC Ooi
2004 Greenwich Medical Media Limited, London, UK.
Chapter 11
Imaging of Pneumonia in Children
Winnie CW Chu |
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| 9. |
Imaging in SARS. Editors: Anil T Ahuja and Clara
GC Ooi
2004 Greenwich Medical Media Limited, London, UK.
Chapter 12
Imaging and Clinical Management of Paediatric SARS
Winnie CW Chu, Ellis KL Hon, Frankie WT Cheng, TF Fok |
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| 10. |
Imaging in SARS. Editors: Anil T Ahuja and Clara
GC Ooi
2004 Greenwich Medical Media Limited, London, UK.
Chapter 14
Radiographers' Perspective in the Outbreak of SARS
Stella SY Ho |
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| 11. |
Imaging in SARS. Editors: Anil T Ahuja and Clara
GC Ooi
2004 Greenwich Medical Media Limited, London, UK.
Chapter 15
Implementation of Measures to Prevent the Spread of SARS in
a Radiology Department
Anne D King and Alex SC Ching |
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| 12. |
Imaging in SARS. Editors: Anil T Ahuja and Clara
GC Ooi
2004 Greenwich Medical Media Limited, London, UK.
Chapter 16
Post-mortem of SARS
Gregory E Antonio, James F Griffith, Anil T Ahuja |
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| 13. |
Imaging in SARS. Editors: Anil T Ahuja and Clara
GC Ooi
2004 Greenwich Medical Media Limited, London, UK.
Chapter 17
The Future of Severe Acute Respiratory Syndrome
Anil T Ahuja, Gregory E Antonio |
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| ARTICLES
ON SARS |
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TO TOP |
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| USEFUL
LINKS |
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| BACK
TO TOP |
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| FREQUENTLY
ASKED QUESTIONS |
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