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Biomedical subjects

L Bastian

Publications and source records attributed to L Bastian.

At least 55 records · Page 3Linked to original sources
PubMed1999

[Practical aspects of early enteral feeding].

"Gut injury" and a corresponding impaired gut barrier function are thought to have a high impact on the development of multiple organ failure (MOF) in the critically ill. Mucosal lesions and increased intestinal permeability can provoke translocation of bacteria and endotoxins and initiate local and/or systemic immune-inflammatory response, bearing the risk of development of multiple organ failure. Enteral nutrition using the physiological pathway provides the intestinal mucosa with nutrients, which is thought to reduce bacterial translocation and septic complications. Considerable gastric reflux and delayed bowel motility are the principal problems of enteral nutrition. Therefore, in the early postoperative period at least a nasoduodenal or--jejunal feeding tube or feeding jejunostomy is required. The commonly used enteral formulas are well tolerated. So-called "immunonutrition" includes special formulas supplemented with immunemodulating substances like arginine, omega-3-fatty acids, ribonucleic acids and glutamine. Some beneficial effects of immune-enhancing diets have recently been reported for immune response, infectious complication rate, systemic inflammatory response syndrome (SIRS), multiple organ failure (MOF), antibiotic usage and length of hospital stay, especially in patients after trauma or surgery. However, the definite role is still unknown and indications have still to be defined. Enteral feeding should start with small volumes, the amount being gradually increased according to a patient's individual tolerance. Common problems are gastric reflux, diarrhoea and distension, but usage of a suitable formula, a gradual increase or reduction in the amount of enteral feeding and, additionally, parenteral nutrition can help to overcome such complications. Clinical examination of the enterally fed patient should be performed carefully. Standard nutritional monitoring of electrolytes, glucose, triglycerides, cholinesterase, albumin, differential blood count, urine-glucose and nitrogen retention to assess the catabolic state should be performed routinely. Although only little data from randomised trials are available, enteral nutrition has advantages and is cheaper than total parenteral nutrition. In the critically ill, the goal of enteral feeding is not coverage of total caloric requirements, but continuous administration of at least a small amount in order to prevent gut mucosa atrophy. Nutrition is an important aspect in critical care medicine, and enteral feeding should be attempted at least partially.

Critical Care↗
PubMed1998

[Complex injuries of the spine].

3 different types of complex spinal trauma are defined: Type I means a multilevel contiguous or non contiguous unstable injury, type II is described as a spinal injury with concomitant thoracic or abdominal lesion, type III stands for the coincidence of spinal injury and polytrauma. Overlapping of different types occurs. Type I: The incidence amounts according a german multicenter study to about 2.5%. Multilevel injuries need to be stabilized for a long distance from posterior. With a thorough analysis the segments to be fused are determined. Type II: The leading thoracic injury is a lung contusion which occurs in up to 50% of the cases. A CT scan of the thorax during the first diagnostic screening is recommended. Early reduction and stabilization from posterior should be aimed at. During the first two weeks anterior procedures are contraindicated. Abdominal injuries are to be found in 3-4% of all spinal injuries. All organs could be affected. A typical constallation is the "seat-belt syndrome" with lesions of the upper abdominal organs and a flexiondistraction injury of the upper lumbar spine. The main problem is to make the diagnosis of both components initially. Most of the patients may be treated in one operation by first taking care of the abdominal injury and than stabilizing the spine. The prognosis of this combination is favorable. Type III: In 17-18% of all polytraumatized patients lesions of the spine are to be diagnosed. From these only one third need surgical care. From 680 patients with operatively treated fractures of the thoracolumbar junction 6.2% were polytraumatized according to the multicenter study mentioned above. The risk of missing a spinal injury in polytrauma totals approximately 20%. Surgical stabilization should be performed in the primary phase (day-1-surgery). Additional injuries, potentially time consuming operations with a high blood loss sometimes necessitate a different approach. Non stabilized spinal injuries apparently do not have the same negative effect on the whole organism as long bone fractures. In the early phase of treatment on the C-spine only anterior procedures and on the thoracolumbar spine only posterior techniques should be applied.

Adolescent↗
PubMed1998

[Clinical effects of supplemental enteral nutrition solution in severe polytrauma].

Previous studies in critically ill patients have shown the beneficial effects of early enteral nutrition supplemented with arginine, omega-3 fatty acids and nucleotides (Impact) on immunological response, infection rate and length of stay in hospital. No specific data exist for patients with severe multiple injury, who represent a high risk group for systemic inflammatory response syndrome (SIRS), septic complications and multiple organ failure (MOF). In this prospective, randomized, double-blind controlled clinical study on patients after severe trauma (ISS ca. 40) the primary study endpoints were incidence of SIRS and MOF [definitions according to Am Soc Crit Care Med (5) and Goris (23), Sauaia (43)]. Thirty-two patients enrolled in the study, and 29 were eligible for analysis: test (Impact) (n = 16), control (n = 13). Both groups were comparable according to age, body mass index and severity of trauma (PTS-test: 38.8 +/- 12.5, PTS-control: 40.8 +/- 15.5, ISS-test: 39.6 +/- 11.4, ISS-control: 40.5 +/- 9.2). Patients were randomized to receive either Impact (test) or an isonitrogenous isocaloric diet (control). Feeding was started on the 2nd day after trauma via endoscopically placed nasoduodenal or jejunal feeding tubes. The experimental diet was safe and well tolerated. During the 1st week the enteral feeding amount was about 2000 ml without significant difference. Test-fed patients developed SIRS significantly less frequently between day 1 and day 28 (8 vs 13.3; P < 0.05) and especially between day 8 and day 14 (3 vs 6.2; P < 0.001). In the control group the Goris score was significantly worse (P < 0.05) on days 3, 4, 6, 7, 10, 11, 16 and 17 and the Sauaia score on days 8, 9, 10 and 11 (P < 0.05; P < 0.01). Mortality rate did not significantly differ (test 2/16, control 4/13), nor did length of ICU or hospital stay. With regard to the acute-phase response, C-reactive protein was significantly lower on day 4 in the test group (test: 131 +/- 67 mg/l, control: 221 +/- 110 mg/l) as was fibrinogen on day 12 (6.6 +/- 1.4 vs 7.5 +/- 1.4 g/l) and day 14 (7.1 +/- 1.3 vs 7.8 +/- 0.8 g/l). No significant difference could be observed for CD4/CD8 ratio, CD45 isotope on activated T-cells and lymphocytic interleukin (II)-2-receptor- and II-6 level. However, HLA-DR antigen presentation on peripheral monocytes was significantly elevated on day 7 in the test group (P < 0.05). According to the results, arginine, omega-3 fatty acids and nucleotides-enriched diet during early enteral feeding leads to reduction of SIRS after severe multiple injury. There is evidence for improvement of post-traumatic immunological response which helps to overcome the immunological depression after trauma.

Adolescent↗
PubMed1998

Influence of arginine, omega-3 fatty acids and nucleotide-supplemented enteral support on systemic inflammatory response syndrome and multiple organ failure in patients after severe trauma.

This study investigated the influence of an enteral diet supplemented with arginine, omega-3 fatty acids, and nucleotides (Impact, Sandoz Nutrition, Berne, Switzerland) on the incidence of systemic inflammatory response syndrome (SIRS) and multiple organ failure (MOF) in patients after severe trauma. Thirty-two patients with an injury-severity score > 20 were included in this prospective, randomized, double-blind, controlled study. Primary endpoints were the incidence of SIRS and MOF. Secondary endpoints were parameters of acute phase and immune response as well as infection rate, mortality, and hospital stay. For statistical analysis 29 patients (test group n = 16, control n = 13) were eligible. In the test group, significantly fewer SIRS days per patient were found during 28 d. The difference was highly significant between d 8-14 (P < 0.001). MOF score was significantly lower in the test group on d 3 and d 8-11 (P < 0.05). Acute phase parameters showed lower C-reactive protein serum levels (significant on D day 4) and fibrinogen plasma levels (significant on d 12 and 14; P < 0.05). HLA-DR expression on monocytes showed significantly higher fluorescence activity on d 7. No significant difference was found for T-lymphocyte CD4/CD8 ratio, interleukin-2 receptor expression, infection rate, mortality (2/16 vs. 4/13), and hospital stay. The results of the study provide further support for beneficial effects of arginine, omega-3-fatty acids and nucleotide-supplemented enteral diet in critically ill patients.

Acute-Phase Reaction↗
PubMed1998

[The intestine as the central organ in the development of multiple organ failure after severe trauma--pathophysiology and therapeutic approaches].

Multiple organ failure is with an incidence of 10-25% and a mortality of 50-70% the most severe complication after severe trauma. Intestinal ischemia and a corresponding impaired gut barrier function is thought to have a high impact on the development of multiple organ failure after severe trauma. Under normal conditions the intestinal wall is a sufficient barrier against bacteria and their products. Gut ischemia is followed by mucosal lesions, the intestinal permeability is increased. Translocating bacteria and bacterial products (endotoxin, peptidoglykan) can lead to a local and/or systemic immun-inflammatory response, which is made responsible for the development of multiple organ failure. Tonometry as a possibility of monitoring intestinal ischemia as well as a tool to estimate the prognosis of multiple trauma patients is still discussed controversially. Dopexamin, which directly influences intestinal ischemia (goal directed therapy) might be a successful treatment option, however until now no clinical study about beneficial effects of dopexamine in severely injured patients is available. Selective gut decontamination showed no clinical benefits in multiple trauma patients. Early enteral nutrition especially with immunomodulating ingredients ("immunonutrition") decreases posttraumatic complications as well as the incidence of MOF. However a reduction of mortality could not be described in severely injured patients so far.

Bacterial Translocation↗
PubMed1998

[Reduction and positioning of cervical spine injuries].

Prerequisites for successful reduction of cervical spine injuries are an exact analysis and classification of every lesion. In locked dislocations disc protrusion should be excluded prior to reduction by MRI or CT-scan. For manual reduction and closed manipulation by the trauma surgeon we use a halo-ring which is applied in local anaesthesia and fluoroscopic control. The anatomic position is maintained by a halo-fixator until surgery. Skeletal traction is used mainly for locked dislocations and late malalignements. Traction is provided by a halo-ring and weights up to 20 kg. Repeated clinical and neurological examinations are necessary to rule out overdistraction of the spine or neurologic deterioration. The weight may be reduced after reduction to 2 kg. For intraoperative positioning and reduction of cervical spine injuries we designed a special device which is connected to the halo ring and allows to fix the head and spine in any desired position. It may be used in prone or supine position of the patient. Operative reductions are rarely necessary on the cervical spine. Typical indication are fractures of posterior elements of the spine preventing closed reduction. Reduction manoeuvers depend on the kind of injury and are mainly composed of traction and a reversal of the trauma mechanism. The most severe complication is a neurologic deterioration. Reports in literature about 13 patients having sustained such a fate are showing the following: In most cases disc material dislocated in the spinal canal during reduction could be made responsible for the catastrophic course. Especially at risk are patients with open reduction from a posterior approach.

Cervical Vertebrae↗
PubMed1998

[Ventral interbody spondylodesis in injuries of the cervical spine. Indications, surgical technique and results].

Lower cervical spine injuries with instability of the anterior and/or posterior column can be treated by anterior interbody fusion and plate fixation. Plates available for anterior instrumentation of the lower cervical spine can be divided into locking or non-locking systems with uni- or bicortical screw purchase. Our biomechanical comparative testing of different screw fixation systems demonstrates improved stability with the use of bicortical purchase. Clinical studies, however, have proven high fusion rates without loss of correction and a low implant related morbidity with the use of unicortical as well of bicortical plate systems. Correct reduction and intraoperative positioning of the unstable cervical spine is crucial to avoid implant related complications. Also, limitations of anterior instrumentation for the treatment of specific lesions of the lower cervical spine have to be considered, e.g. in complex lesions with axial instability or in fracture dislocations with ankylosing spondylitis. Changes or alterations of adjacent segments can be reduced by the use of plates with correct lengths, contact of uninjured adjacent discs with implants should be avoided. A comparative analysis of two patient collectives--89 patients (1972-1983) and 102 patients (1987-1994), all of them treated with bicortical plate fixation--revealed different results in terms of implant failure, operative reduction and loss of correction. All but one surgical fusions had healed radiologically. Implant related complications during the first 3 months after the initial operation were lower in the latter group, only 3 out of 102 patients (3%) with implant loosening versus 7 our of 89 patients (8%) with implant breakage or loosening required surgical revision. In all cases technical errors could be detected. Clinical follow-ups with personal examination was performed in 144 patients: 57 of 72 survivors of series I (79%) after an average time of 11 years 9 months and 87 out of 94 survivors of series II (85%). The radiologic examination revealed 2 patients with screw breakage in series I, one patient with an asymptomatic implant loosening in series II. Only one case was observed with a loss of correction after loosened and early removed hardware. In all other patients there was no difference of radiologic angles between postoperative X-ray and follow-up. 16 patients, 12 of series I, 4 of series II, were fused in a kyphotic position after insufficient preoperative reduction. Radiologic alterations of adjacent segments, i.e. spondylophyts or "spontaneous" fusions, were observed in more than 50% of all patients of both series. However, complaints or persistent pain did not correlate with radiologic findings. Also in both series there was a high percentage of patients with mild, residual neck pain in spite of a very good radiologic result. Only in a very few cases the complaints had to be treated by drugs.

Adolescent↗
PubMed1998

[Is modification of systemic inflammatory response syndrome and multiple organ failure by parenteral feeding possible?].

In this prospective, randomized, double-blind controlled clinical study, 29 patients after severe trauma (ISS about 40) were randomized to receive either IMPACT (Test) or an isonitrogenous isocaloric diet (Control). The primary study endopoints were the incidence of SIRS and MOF (definitions according to Bone, Goris and Sauaia). Test-fed patients developed significantly less SIRS between days 1 and 28 (8 vs 13.3, P < 0.05) and especially between days 8 and 14 (3 vs 6.2, P < 0.001). In the control group the Goris score was significantly worse (P < 0.05) on days 3, 4, 6, 7, 10, 11, 16, 17 and the Sauaia score on days 8, 9, 10, 11 (P < 0.05, P < 0.01). According to the results, an arginine, omega-3-fatty acids and nucleotide-enriched diet during early enteral feeding leads to reduction of SIRS and MOF scores after severe multiple injury.

Critical Care↗
PubMed1997

[Fractures of the thoracolumbar spine. Late results of dorsal instrumentation and its consequences].

Between January 1989 and July 1992, 76 patients with thoracolumbar fractures were operatively treated at the Department of Trauma Surgery, Hannover Medical School. After a mean of more than 3 years, 56 of 62 patients (90%) still alive who had their implants removed were examined. According to the ASIF classification 33 patients sustained type A fractures, 13 type B and 10 type C. Three patients with incomplete paraplegia returned to normal; in one case of complete paraplegia no change occurred. In 40 cases the dorsal instrumentation was combined with transpedicular cancellous bone grafting. The mean operative time totaled 3 h. In this series, two complications (3.6%) were observed: one iatrogenic vertebral arch fracture without consequences and one deep infection. Compared to the preoperative status, our follow-up examinations demonstrated permanent physical and social sequelae; the percentage of individuals able to do physical labor was reduced by half (22 to 11 patients) whereas the share of unemployed or retired patients doubled (4 to 8 patients). At the time of follow-up examination only 21 of 42 patients continued in sports. The assessment of complaints and functional outcome with the "Hannover Spinal Trauma Score" reflected a significant difference (P < 0.001) between the status before injury (96.6/100 points) and at the time of follow-up (71.4/100 points). The radiographic assessment in the lateral plane (Cobb technique) demonstrated a significant (P < 0.001) mean restoration from an initial angle of -15.6 degrees (kyphosis) to +0.4 degree (lordosis). Serial postoperative radiographic follow-up showed progressive loss of correction; at follow-up examination we found a mean of 10.1 degrees (P < 0.001). Compared to the preoperative deformity a mean improvement of 6.1 degrees to an average of -9.7 degrees at follow-up examination was noted. The addition of transpedicular cancellous bone grafting did not decrease the loss of correction. CT scans after implant removal were performed in 9 cases: only 3 of 9 patients showed evidence of intervertebral fusion. No correlation could be found between ASIF classification and radiographic outcome. However, the preoperative wedge angle of the vertebral body correlated significantly with the postoperative loss of reduction. Due to disappointing results after dorsal stabilization with transpedicular cancellous bone grafting we recommend a combined procedure with dorsal stabilization and ventral fusion in cases of complete or incomplete burst injury of the vertebral body.

Adolescent↗
PubMed1997

[New developments in surgery of the injured spine].

There are many new options, and those procedures that are interesting from the aspect of traumatology have been selected: (1) A special positioning aid for the treatment of injuries to the cervical spine. The appliance has proved extremely useful for reduction and immobilization of fractures and dislocations and also allows reliable positioning of the head in all desired surgical positions when ventral and/or dorsal approaches are used. (2) A new titanium H-plate, which can be fixed either with the usual 3.5-mm-thick screws or with unconventional 4.5-mm-thick screws in the case of lesions to the lower cervical spine. (3) A new technique for less invasive atlanto-axial screw fixation, with a cannula system extending to the axis from small incisions at the level of the upper thoracic spine, by way of which the C-1 joint block can be drilled, milled and screwed. (4) Jeanneret's CerviFix rod system. This system has progressed beyond the drawbacks of plating as performed so far for internal fixation of the dorsal cervical spine, in which screws could be inserted only at predetermined intervals and angles. Movable grips, lateral stabilizers and extension pieces mean that the system is very well able to fulfil the demands of a variable and stable implant. (5) Transthoracic endoscopic spinal surgery, which is excellently suited to fusion of a traumatized segment to supplement reduction and instrumentation from a dorsal approach. (6) A reduced-invasion method at the thoracolumbar transition, with no insertion of implants from a ventral approach and blocking through a small left lateral thoracotomy with autogeneic shavings from the iliac crest.

Endoscopes↗
PubMed1997

[Bacillus cereus pneumonia after thoracic trauma. Case report and review of the literature].

We report on the case of a pneumonia caused by Bacillus cereus in a patient who sustained severe thoracic trauma, fractures of ribs 3-12, left lung contusion and haematopneumothorax. Bronchoscopic alveolar lavage (BAL) performed on ICU day four helped identifying the underlying cause of pneumonia. Inspite of early diagnosis and antibiotic treatment with clindamycin, cefotaxim and tobramycin, which rapidly eliminated the bacteria from the patient's lungs, the patient eventually died from the severe underlying injuries. However, this case emphasises that early performed BAL and rapid microbiological staining techniques can help diagnose pneumonia in critically ill patients. We also review the literature on pulmonary infections caused by Bacillus cereus.

Adult↗
PubMed1996

[Feasibility and complications in early enteral nutrition of severely injured polytrauma patients via duodenal tubes].

Early enteral nutrition is widely accepted for its support of organ structure and function ("gut injury hypothesis") and reduction of infectious complications and hypermetabolism in critically ill postoperative or postinjury patients. Nineteen severely injured patients (Injury Severity Score 40.3 +/- 11.6) were studied for the feasibility of early enteral nutrition via a duodenal feeding tube. Despite maxillary fractures, rhinoliquorrhea and blunt abdominal trauma the enteral feeding was mostly started immediately after trauma. Intermittent diarrhea or constipation resolved after reduction of the feeding rate within 1 or 2 days. Total enteral nutrition could not be realized in all cases; a central venous line was always additionally necessary. However, the goal was not complete enteral nutrition but a continuous enteral supply to maintain the integrity of the gut. The study has shown that early enteral nutrition via a duodenal feeding tube is also feasible in severely injured patients. The expenditure to overcome the technical and organizational problems seems to be justified. Enterally fed patients may have a better outcome that those in whom only parenteral is employed.

Adolescent↗
PubMed1996

Why the Urgency for Earlier Diagnosis of HIV Infection in Women?

As our perspective of AIDS changes from a disease that affects homosexual men and intravenous drug abusers to one that spreads increasingly through heterosexual contact, greater numbers of women are being diagnosed with HIV infection. Because clinicians still may perceive AIDS to be primarily a "male" disease and may maintain a low level of suspicion of it in their female patients, HIV infection is believed to be underdiagnosed and go unrecognized for longer periods in women than in men. Early reports in the 1980s that showed a worse prognosis and shorter median survival for women than for men are now explained by factors such as later presentation and diagnosis, disparity in access to care, and reluctance of clinicians to prescribe zidovudine to pregnant patients. Recent studies show that, with early identification of infection and subsequent treatment and prophylactic therapy, there are no differences in disease progression or survival in women compared with men. Moreover, from a public health standpoint, earlier diagnosis can decrease incidence of both sexual and vertical transmission. Women may choose to undergo tubal ligation to prevent future vertical transmission; additionally, zidovudine now is used in pregnant women and has been demonstrated to decrease transmission rates from 25% to 8%

Journal Article↗
PubMed1995

[Various therapy concepts in severe fractures of the tibial pilon (type C injuries). A comparative study].

Between 1982 and 1992, 79 pylon fractures were treated with internal fixation as the primary treatment at the trauma department of the Hannover Medical School. In a retrospective study 71 patients were evaluated, and 51 of them were re-examined clinically and radiographically an average of 68 months after injury. The purpose of this study was to compare these different forms of surgical management concerning their long-term results: 1. Minimal invasive internal fixation for reconstruction of the joint with external transfixation of the ankle joint and/or plaster cast until bony healing occurred. 2. Primary internal fixation with plating of tibia and fibula following the AO techniques. 3. Internal fixation with a plate applied in a second step after initial reconstruction of the joint with minimal internal fixation and short-term external transfixation. Evaluation was based on the infection rate, the development of posttraumatic arthritis and the range of motion in the ankle joint as objective criteria. Subjective criteria were pain, swelling, and restrictions of working or leisure activities. Although only closed fractures were treated primarily by internal fixation with plating no significant differences between the three groups were found in the classification of fractures and soft tissue damage. All but 4 fractures were type-C lesions according to the AO classification, and 19 patients sustained open injuries. The infection rate for minimal invasive internal fixation was significantly lower with a two-step procedure (group 3) than with the one-step procedure according to a suitable statistic test (P < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1993

Differences between men and women with HIV-related Pneumocystis carinii pneumonia: experience from 3,070 cases in New York City in 1987.

Although women make up the fastest growing group of persons with AIDS, studies of human immunodeficiency virus (HIV)-infected persons reported to date have included predominantly or exclusively men. We evaluated sex differences in sociodemographic characteristics, hospital characteristics, in-hospital resource use, and short-term mortality rates for 2,526 men and 544 women admitted for their first-episode of HIV-related Pneumocystis carinii pneumonia (PCP) in New York City in 1987. Compared with men, women were significantly less likely to be white (81% vs. 54%, p < or = 0.001) or have private health insurance (80% vs. 58%, p < or = 0.001), and more likely to be admitted through an emergency room (79% vs. 71%, p < or = 0.001) and receive care at hospitals that had less experience treating PCP (p < or = 0.001). Women were more likely than men to die in the hospital [33% vs. 24%; crude odds ratio = 1.56, confidence interval (CI) = 1.28-1.91, p < or = 0.001]. In a logistic regression model, the risk of death in the hospital was associated with age 60-65 years [adjusted odds ratio (AOR) = 4.19, CI = 2.13-8.21], not having private health insurance (AOR = 1.37, CI = 1.08-1.75), admission through the emergency room (AOR = 1.54, CI = 1.21-1.96), and receiving care at hospitals with less experience treating PCP (AOR = 1.63, CI = 1.15-2.30), but women were not significantly more likely to die in the hospital than men (AOR = 1.18, CI = 0.93-1.50). Poorer access to medical care as well as higher use of hospitals with less experience treating AIDS may account for the difference in mortality rates observed in women with HIV-related PCP.

AIDS-Related Opportunistic Infections↗
PubMed1989

The importance of screening for medullary thyroid carcinoma in families of patients with MEN 2.

Family screening for medullary thyroid cancer (MTC) is important for detecting members of multiple endocrine neoplasia type 2 (MEN 2) families who may be gene carriers but show no clinical evidence of the disease. Most members of our MEN 2 families are screened yearly by measuring basal and pentagastrin-stimulated calcitonin (CT) levels. A 15-year-old first-degree relative of an affected member of the D-kindred showed a normal basal and an elevated stimulated CT level. Clinical examination, ultrasonography, and scintigraphy were normal. Thyroidectomy and bilateral neck dissection revealed a multicentric MTC with no lymph node involvement. In the O-kindred we detected elevated basal and/or stimulated CT levels in three asymptomatic first-degree relatives. At surgery we found a small multicentric MTC in one family member, C-cell hyperplasia in another member, and bilateral lymph node metastases in one member who had been previously thyroidectomized. Basal and stimulated CT estimations in MEN 2 family members provide an effective method for detecting MTC in early, treatable stages.

Adolescent↗