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S Maurea

Publications and source records attributed to S Maurea.

53 records · Page 3Linked to original sources
PubMed1994

Diagnostic evaluation of thyroid involvement by histiocytosis X.

UNLABELLED: We report the successful diagnosis of thyroid involvement by histiocytosis X due to accurate evaluation of nuclear medicine results. METHODS: A total thyroidectomy specimen from our patient was initially suggestive of medullary thyroid carcinoma. However, histologic reevaluation was performed on the basis of nuclear medicine findings which were incompatible with the original histologic diagnosis. RESULTS: Immunohistochemical and light microscopy studies were performed to obtain the correct diagnosis. Diffuse thyroid involvement by histiocytosis X was demonstrated. CONCLUSION: Thyroid scintigraphy was helpful in successfully diagnosing thyroid involvement by histiocytosis X. Because tracer uptake is related to increased cellularity and metabolism, none of these tracers reported here is specific for defining histiocytosis X.

3-Iodobenzylguanidine↗
PubMed1993

Regional systolic function, myocardial blood flow and glucose uptake at rest in hypertrophic cardiomyopathy.

Decreased 18fluorodeoxyglucose (FDG) uptake and blood flow at rest in the ventricular septum, as compared with the lateral wall, have been reported in mildly symptomatic patients with hypertrophic cardiomyopathy (HC). To assess whether regional metabolic heterogeneity in patients with HC is related to heterogeneous regional systolic function, 10 symptomatic patients (mean age 36 +/- 17 years) with HC and no coronary artery disease underwent positron emission tomography with oxygen-15-water and FDG, and nuclear magnetic resonance imaging at rest to assess regional anatomy and systolic function. Regional absolute blood flow was similar between the ventricular septum and lateral wall. In contrast, FDG activity was significantly greater in the lateral wall than in the septum (1,023 +/- 588 vs 767 +/- 388 nCi/ml, respectively; p < 0.01). However, regional systolic wall thickening was also significantly greater in the lateral wall than in the septum (5.3 +/- 4.3 vs 2.4 +/- 4.0 mm, respectively; p < 0.001). Patients were then divided into group A (n = 5) with similar regional wall thickening in the septum and lateral wall, and group B (n = 5) with greater thickening in the lateral wall than in the septum. In both groups, regional blood flow was similar between the septum and lateral wall. However, the regional septal-to-lateral FDG activity ratio was 0.97 +/- 0.31 in group A, and 0.74 +/- 0.25 in group B (p < 0.01); the ratio in group A did not differ from that in 5 normal subjects (1.02 +/- 0.58).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1993

Iodine-131 metaiodobenzylguanidine scintigraphy for localization of lesions in children with neuroblastoma: comparison with computed tomography and ultrasonography.

Iodine-131 metaiodobenzylguanidine (MIBG) scintigraphy, computed tomography (CT) and ultrasonography (US) were used to localize tumour lesions in 28 children with histologically proven neuroblastoma. Overall, a total of 73 lesions were detected on imaging studies. MIBG scintigraphy, CT and US localized 63 (86%), 49 (67%) and 36 (49%) of these lesions, respectively. The findings of the three imaging techniques were concordant in respect of only 31 (42%) of the lesions. The best agreement among MIBG scintigraphy, CT and US was observed for abdominal lesions (the techniques were concordant for 22 of 23 lesions, i.e. 96%). MIBG scintigraphy detected nine out of ten (90%) liver metastases, but agreement with CT and US was observed in only six instances (60%). The imaging findings were concordant in respect of only two (33%) out of six lymph node metastases; the MIBG scan was normal in the other four cases. Imaging agreement was observed for a lesion located in the pelvis. MIBG and CT findings were concordant in four lesions located in the chest, but US was not performed. MIBG scintigraphy depicted the majority (96%) of the skeletal lesions (23/24); CT showed five of these, but, again, US was not performed. The imaging findings were not concordant as regards the remaining five lesions located in different anatomical sites. The results indicated that MIBG imaging is more sensitive that CT and US in localizing the majority of neuroblastoma lesions. Since the metastatic spread of neuroblastoma is unpredictable, we recommend MIBG scintigraphy as the initial imaging modality for staging of these patients.(ABSTRACT TRUNCATED AT 250 WORDS)

3-Iodobenzylguanidine↗
PubMed1993

Resting technetium-99m methoxyisobutylisonitrile cardiac imaging in chronic coronary artery disease: comparison with rest-redistribution thallium-201 scintigraphy.

We studied 19 patients with angiographically proven coronary artery disease and left ventricular dysfunction (ejection fraction 33% +/- 8%) by resting technetium-99m methoxyisobutylisonitrile (99mTc-MIBI) and rest-redistribution thallium-201 cardiac imaging. Thallium and 99mTc-MIBI studies were visually analysed. Of 285 segments, 203 (71%) had normal thallium uptake, 48 (17%) showed reversible thallium defects and 34 (12%) showed irreversible thallium defects. Of these 34 irreversible thallium defects, 19 (56%) were moderate and 15 (44%) were severe. Of the corresponding 285 segments, 200 (70%) had normal 99mTc-MIBI uptake, while 37 (13%) showed moderate and 48 (17%) showed severe reduction of 99mTc-MIBI uptake. Myocardial segmental agreement for regional uptake score between initial thallium and resting 99mTc-MIBI images was 90% (kappa = 0.78). Segmental agreement between delayed thallium and resting 99mTc-MIBI images was 77% (kappa = 0.44). In particular, in 26 (9%) segments 99mTc-MIBI uptake was severely reduced while delayed thallium uptake was normal or only moderately reduced. These data suggest that although rest-redistribution thallium and resting 99mTc-MIBI cardiac imaging provide concordant results in the majority of myocardial segments, some segments with severely reduced resting 99mTc-MIBI uptake may contain viable but hypoperfused myocardium. Thus, conclusions on myocardial viability based on 99mTc-MIBI uptake should be made with caution in chronic coronary artery disease.

Adult↗
PubMed1993

Rest-injected thallium-201 redistribution and resting technetium-99m methoxyisobutylisonitrile uptake in coronary artery disease: relation to the severity of coronary artery stenosis.

To compare rest-injected thallium-201 (Tl) redistribution and resting technetium-99m methoxyisobutylisonitrile (99mTc-MIBI) myocardial uptake in chronic coronary artery disease (CAD), 15 patients with angiographically proven CAD and left ventricular (LV) dysfunction (ejection fraction 34% +/- 9%) were studied. All patients underwent rest-redistribution Tl and resting 99mTc-MIBI cardiac imaging. Gated 99mTc-MIBI images were also acquired to assess regional LV wall motion (WM). Myocardial segments (n = 225) were divided into three groups on the basis of the degree of coronary artery stenosis: group 1 (total occlusion, n = 82), group 2 (50%-99% of stenosis, n = 84) and group 3 (< 50% of stenosis, n = 59). WM was significantly worse in groups 1 and 2 compared to group 3 (P < 0.001), but no difference was observed between groups 1 and 2. Tl and 99mTc-MIBI uptake were significantly lower in groups 1 and 2 compared to group 3 (P < 0.001), and in group 1 compared to group 2 (P < 0.001). When Tl and 99mTc-MIBI uptake were directly compared. Tl uptake was higher than 99mTc-MIBI uptake in group 1 (P < 0.001), while no significant difference was observed in groups 2 and 3. Thus, both rest-injected Tl redistribution and resting 99mTc-MIBI uptake reflected the severity of coronary artery stenosis in CAD. However, in myocardial segments with total coronary occlusion Tl uptake was significantly higher than 99mTc-MIBI uptake.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1993

Repeatability of haemodynamic responses to cardiac stimulations by ambulatory monitoring of left ventricular function.

Ambulatory monitoring (VEST) of left ventricular (LV) function has been shown to be accurate and repeatable. The aim of this study was to assess VEST repeatability in the evaluation of haemodynamic responses to different cardiac stimulations. Twelve patients (all men, mean age 59 +/- 8 years) underwent two separate VEST studies 5-day apart. In both studies, LV function was continuously monitored at rest and during different cardiac stimulations: 1) changing position from supine to upright (tilt); 2) sustained isometric exercise (handgrip); and 3) sublingual administration of 5 mg of nitroglycerin (NTG). Changes from baseline to peak response (delta) in the heart rate, ejection fraction, end-diastolic volume, end-systolic volume, stroke volume and cardiac output were evaluated. Reproducibility was assessed by computing, the coefficient of repeatability. In addition, the differences between the delta values obtained with the two VEST studies were plotted against their mean. This plot allowed us to detect whether there was any relationship between the error in the measurements and the best estimate of the "true value". No statistically significant differences between the two VEST studies were found in the haemodynamic changes in heart rate, ejection fraction, end-diastolic volume, end-systolic volume, stroke volume and cardiac output induced by handgrip, tilt and NTG. For each parameter the mean difference was not significantly different from zero and no significant relationship between the error and the "true value" was observed. Our results demonstrate that VEST has a good repeatability in measuring cardiac haemodynamic responses to different types of stimulations.

Exercise↗
PubMed1993

[Role of magnetic resonance in the study of benign and malignant pheochromocytomas. Quantitative analysis of the intensity of the resonance signal].

In order to assess the clinical role of Magnetic Resonance (MR) imaging in patients with benign or malignant pheochromocytomas, the MR signal intensity ratios of benign and malignant tumors were evaluated. Eighteen patients (9 men and 9 women, mean age: 37 +/- 8 years) with benign (n = 10) or malignant (n = 8) pheochromocytomas were studied. A total of 27 lesions (12 benign and 15 malignant) were analyzed. In all patients, histology confirmed the disease. MR studies were performed using a 1.5-T superconducting magnet system. Sequences were used to obtain T1-weighted (TR/TE 300/12 ms) and T2-weighted (TR/TE 2000/80 ms) images. On both T1- and T2-weighted MR images, the mean absolute signal intensity values of tumor lesions, of liver, muscle and fat tissues, and of image background were measured to obtain the corresponding signal intensity ratios for each lesion. Our results exhibited no statistically significant differences in both T1 and T2 MR signal intensity ratios between benign and malignant lesions. In conclusion, our results suggest that MR imaging cannot differentiate benign from malignant lesions in patients with pheochromocytoma.

Adrenal Gland Neoplasms↗
PubMed1993

Iodine-131-metaiodobenzylguanidine scintigraphy in preoperative and postoperative evaluation of paragangliomas: comparison with CT and MRI.

Iodine-131-metaiodobenzylguanidine (MIBG) scintigraphy, transmission computed tomography and magnetic resonance imaging were used to evaluate 36 patients with clinically suspected functioning paragangliomas. The patients were divided into two groups. In Group 1 (n = 21), studied before surgery, patients mainly had benign adrenal disease. In Group 2 (n = 15), studied after surgery, patients frequently had malignant or extra-adrenal tumors. In Group 1, transmission computed tomography and magnetic resonance imaging were more sensitive (100% for both) than MIBG scintigraphy (82%), which, however, was the most specific (100%). In Group 2, MIBG scintigraphy and magnetic resonance imaging were more sensitive (83% for both) than transmission computed tomography (75%), but MIBG was again the most specific (100%). Thus, all three were complementary modalities for localizing paragangliomas both preoperatively and postoperatively. MIBG imaging is indicated for both groups but it is especially recommended for postsurgical patients with recurrence because the disease is often malignant or extra-adrenal.

3-Iodobenzylguanidine↗
PubMed1993

Reverse redistribution in resting thallium-201 myocardial scintigraphy in patients with coronary artery disease: relation to coronary anatomy and ventricular function.

We studied 25 male patients, with coronary artery disease, mean age 56 +/- 8 yr. All underwent 201Tl rest-redistribution and resting 99mTc methoxyisobutyl isonitrile (MIBI) cardiac imaging. Regional 201Tl and MIBI uptake were quantitatively analyzed. Regional left ventricular wall motion (WM) was visually assessed on MIBI gated images using a three-point scale (0 = normal, 1 = hypokinetic, 2 = a/dyskinetic). Two patterns of reverse redistribution (RR) were identified: RR-A when 201Tl uptake was normal on rest images and abnormal on redistribution images, and RR-B when 201Tl uptake was abnormal on rest images and a significant decrease in uptake was observed on redistribution images. Of the total 375 myocardial segments analyzed, 229 were classified as normal (Nl), 40 as reversible defect (RD), 74 as irreversible defect (ID); 26 showed RR-A while 6 myocardial segments had RR-B. Myocardial segments with RR-A differed from NI in the degree of coronary artery stenosis (81% +/- 33% versus 57% +/- 39%, respectively, p < 0.05), in WM score (1.1 +/- 0.7 versus 0.5 +/- 0.6, respectively, p < 0.01), and in MIBI uptake (81% +/- 10% versus 92% +/- 9%, respectively, p < 0.0001). Moreover, the percent of myocardial segments supplied by a totally occluded coronary artery was significantly higher (p < 0.05) in myocardial segments with RR-A (46%) than in NI (22%). Segments with RR-B did not show any significant difference either from RD and ID. These results suggest that myocardial segments with RR-A on resting 201Tl images have impaired function and are supplied by severely stenosed coronary arteries and should not be considered normal.

Adult↗
PubMed1992

Metabolic evidence of viable myocardium in regions with reduced wall thickness and absent wall thickening in patients with chronic ischemic left ventricular dysfunction.

Reduced end-diastolic wall thickness with absent systolic wall thickening has been reported to represent nonviable myocardium in patients with chronic coronary artery disease. To assess whether reduced regional end-diastolic wall thickness and absent wall thickening accurately identify nonviable myocardium, 25 patients with ischemic left ventricular dysfunction (ejection fraction at rest 27 +/- 10%) underwent positron emission tomography with oxygen-15-labeled water and 18fluorodeoxyglucose to assess metabolic activity and spin-echo gated nuclear magnetic resonance imaging to measure regional end-diastolic wall thickness and wall thickening. The presence of metabolic activity was defined as 18fluorodeoxyglucose uptake (corrected for partial volume) greater than 50% of that in normal regions. Of 355 myocardial regions evaluated, 266 were hypokinetic or normokinetic at rest and 89 were akinetic (that is, absent wall thickening). 18Fluorodeoxyglucose uptake was observed in 97% of the hypokinetic and normokinetic regions and in 74% of the akinetic regions. End-diastolic wall thickness was greater in akinetic regions with than in those without 18fluorodeoxyglucose uptake (11 +/- 4 vs. 7 +/- 3 mm, p less than 0.01). The highest values for sensitivity and specificity of end-diastolic wall thickness in predicting the absence of metabolic activity in akinetic regions were 74% and 79%, respectively, and corresponded to an end-diastolic threshold of 8 mm. However, the positive predictive accuracy was only 55% and did not improve for other end-diastolic wall thickness values. In all myocardial regions, there was only a weak correlation between 18fluorodeoxyglucose activity and either end-diastolic wall thickness (r = 0.17) or wall thickening (r = 0.32). Thus, metabolic activity is present in many regions with reduced end-diastolic wall thickness and absent wall thickening. These data indicate that assessment of regional anatomy and function may be inaccurate in distinguishing asynergic but viable myocardium from nonviable myocardium.

Adult↗
PubMed1992

Regional left ventricular wall thickening. Relation to regional uptake of 18fluorodeoxyglucose and 201Tl in patients with chronic coronary artery disease and left ventricular dysfunction.

BACKGROUND: In previous studies comparing regional 201Tl (201Tl) and 18fluorodeoxyglucose (FDG) activity in patients with chronic coronary artery disease and left ventricular dysfunction, we hypothesized that regions with mild-to-moderate reduction in FDG activity and regions with mild-to-moderate irreversible 201Tl defects after 3- to 4-hour redistribution represent viable myocardium. In the present study, regional FDG and 201Tl activities were compared with regional systolic wall thickening by gated magnetic resonance imaging (MRI) to confirm the presence of viable myocardium in these territories. METHODS AND RESULTS: Twenty-five patients with chronic stable coronary artery disease and left ventricular dysfunction (ejection fraction, 28 +/- 10) underwent exercise 201Tl tomographic imaging (SPECT), using a reinjection protocol, positron emission tomography (PET) with FDG and H2(15)O, and gated MRI. Matched SPECT, PET, and MRI tomograms were analyzed. From the PET data, 105 regions had matched reduction in FDG and blood flow, of which 69 regions had moderately reduced FDG uptake (50-79% uptake relative to a normal reference region) and 36 had severely reduced FDG uptake (less than 50% of normal activity). Regions with moderately reduced as compared with severely reduced FDG activity had greater end-diastolic wall thickness (9.4 +/- 2.6 versus 8.0 +/- 3.7 mm; p less than 0.05) and regional systolic wall thickening (1.7 +/- 2.7 versus -0.7 +/- 2.1 mm; p less than 0.01). From the SPECT data, 169 irreversible 201Tl defects after 3-4 hour redistribution were identified, of which 70 were mild (greater than 65 to less than 85% of maximal 201Tl activity), 52 were moderate (50-65% of maximal activity), and 47 were severe (less than 50% of maximal activity). Regional systolic wall thickening was greater in regions with normal 201Tl uptake (3.3 +/- 2.3 mm) as compared with all other regions. Regions showing only mild or moderate irreversible defects at redistribution, however, showed wall thickening (2.4 +/- 2.4 and 2.2 +/- 2.5 mm, respectively), which was similar to that observed in regions with reversible 201Tl defects (2.1 +/- 2.2 mm). Only regions with severe irreversible defects at redistribution showed absence of thickening (-0.1 +/- 2.9 mm, p less than 0.01 versus all other groups). After 201Tl reinjection, 12 of 47 (26%) regions with severe irreversible defects showed enhanced 201Tl uptake. The impairment in regional systolic wall thickening was not significantly different between 201Tl defects with and without enhanced 201Tl uptake after reinjection. FDG activity, however, was present in all 12 regions (100%) with enhanced 201Tl uptake after reinjection as compared with only five of 35 (14%) that were unchanged after reinjection (p less than 0.01). CONCLUSIONS: Therefore, preserved wall thickness and systolic wall thickening in regions with moderate reduction in blood flow and FDG activity, and in irreversible 201Tl defects that are only mild-to-moderate, provide additional evidence that such regions represent viable myocardium. Moreover, the finding of metabolic activity and 201Tl uptake in regions with reduced blood flow and absent wall thickening provides clinical evidence of hibernating myocardium in humans.

Adult↗
PubMed1991

[131I-meta-iodobenzylguanidine scintigraphy in patients with a suspected pheochromocytoma. A comparison with CT and biohumoral parameters].

The results of 131I metaiodobenzylguanidine (MIBG) and Computed Tomography (CT) scans in a group of patients with clinically suspected pheochromocytoma were evaluated and compared with biohumoral parameters. We studied 24 consecutive patients (7 M and 17 F; age range 20-66 years). 131I-MIBG scintigraphy and CT were in agreement in 19 patients (79%): of them 7 cases were true positive, and 12 were true negative. Disagreement between the two imaging techniques was observed in 5 patients (21%). In this group, one patient, with positive CT scan, had false negative MIBG study, while 4 patients with negative MIBG scan, had false positive CT. MIBG showed significantly higher (p less than 0.05) specificity (100%), positive predictive value (100%), and accuracy (96%) than CT (75%, 67%, and 83%, respectively). 131I-MIBG scintigraphy is an accurate, noninvasive technique for localizing pheochromocytoma and providing direct tissue characterization, while CT provides more accurate spatial information. In conclusion, CT and MIBG studies are complementary in the evaluation of patients with suspected pheochromocytoma.

3-Iodobenzylguanidine↗
PubMedDate not supplied

Left ventricular dysfunction in coronary artery disease: comparison between rest-redistribution thallium 201 and resting technetium 99m methoxyisobutyl isonitrile cardiac imaging.

BACKGROUND: We compared rest-redistribution thallium 201 and resting technetium 99m methoxyisobutyl isonitrile (MIBI) cardiac imaging in 29 men with angiographically proven coronary artery disease and regional ventricular dysfunction. Left ventricular ejection fraction at radionuclide angiography was 35% +/- 9%. METHODS AND RESULTS: Regional left ventricular wall motion was assessed on gated 99mTc MIBI images according to a 3-point scale (0 = normal, 1 = hypokinetic, 2 = akinetic or dyskinetic). 201Tl and 99mTc MIBI uptake values were analyzed quantitatively. A total of 435 myocardial segments were classified on the basis of wall motion analysis into three groups: group 1 (normal wall motion; n = 201), group 2 (hypokinetic; n = 132), and group 3 (akinetic or dyskinetic; n = 102). 201Tl and 99mTc MIBI uptake values were significantly higher in groups 1 and 2 compared with group 3 (p < 0.05) and in group 1 compared with group 2 (p < 0.05). When 201Tl and 99mTc MIBI uptake values were directly compared, no significant differences in group 1 and 2 were observed. In group 3, 99mTc MIBI uptake (67% +/- 14%) was significantly lower (p < 0.001) than initial (72% +/- 11%) and delayed 201Tl uptake (73% +/- 12%). CONCLUSION: Thus rest-redistribution 201Tl and resting 99mTc MIBI cardiac imaging reflect the severity of left ventricular dysfunction in coronary artery disease. However, in segments with severely impaired regional ventricular function, 201Tl uptake is significantly higher than 99mTc MIBI uptake.

Adult↗
PubMedDate not supplied

[Evaluation of systolic parietal thickening of the left ventricle using technetium-99m methoxy isobutyl isonitrile. Relationship with coronary anatomy].

Forty-three patients (40 men and 3 women, mean age 54 +/- 9 years) with coronary artery disease underwent 99mTc methoxy isobutyl isonitrile (sestamibi) myocardial scintigraphy and coronary arteriography. Sestamibi uptake and wall thickening index (WTI) were quantitatively evaluated in each myocardial segment. Segments were divided into group 1 (normal coronary arteries, no. = 94), group 2 (coronary artery stenosis 50-99%, no. = 79), and group 3 (coronary artery stenosis 100%, no. = 42). Group 3 segments were subdivided into group 3A (with collaterals, no. = 18) and group 3B (without collaterals, no. = 24) segments. Both sestamibi uptake and WTI were significantly lower (p < 0.01) in group 3 than in groups 1 and 2. However, only WTI was significantly reduced (p < 0.01) in group 3B vs group 3A. Diagnostic capabilities (i.e. identification of segments supplied by stenosed coronary arteries) of sestamibi uptake, WTI, and a combination of both variables with a discriminant function were compared by analysis of receiver operator characteristic curve (ROC) areas. The diagnostic capabilities of sestamibi uptake (ROC area = 0.65 +/- 0.04) were significantly lower (p < 0.05) than those of WTI (ROC area = 0.81 +/- 0.03) and discriminant function (ROC area = 0.83 +/- 0.03). In conclusion, our data suggest that combined analysis of myocardial perfusion and regional ventricular function may increase the diagnostic accuracy of sestamibi myocardial scintigraphy in identifying myocardial segments supplied by stenosed coronary arteries.

Cardiomegaly↗
PubMedDate not supplied

[Positron-emission tomography with fluorine-18-deoxyglucose in the staging and control of patients with lymphoma. Comparison with clinico-radiologic assessment].

INTRODUCTION: The clinical applications of fluorine-18-deoxyglucose Positron Emission Tomography (FDG PET) have been proposed on account of experimental evidence of increased glucose metabolism in tumor cells. MATERIAL AND METHODS: We examined 98 lymphoma patients--33 with Hodgkin and 65 with non-Hodgkin disease--with FDG PET and compared its findings with those of clinical and conventional radiologic studies. FDG PET was also used to follow-up 32 patients and the results were once again compared with clinical and radiologic data. RESULTS: During staging, 138 lesions were found, 82 of them (59%) in nodal and 56 (41%) in extranodal locations. Extranodal tumor sites were found in 39 patients (40%), namely 4 with Hodgkin (12%) and 35 with non-Hodgkin (54%) disease. FDG PET findings were in agreement with clinical and radiologic results in all nodal and extranodal lesions, since all of them exhibited abnormally increased FDG uptake. PET detected new tumor sites in 6 patients. In the follow-up, agreement was observed in the majority (78%) of lesions, 30 of them in complete regression, 15 in partial regression and 17 in progression; however, the diagnostic results were in disagreement in the remaining (22%) tumor sites: no abnormal FDG uptake was found in 9 cases despite the persistence of radiologic abnormalities (post-treatment fibrosclerosis). Slightly increased FDG uptake (residual disease) was found in the other 8 lesions, where there was no clinical and/or radiologic evidence of disease. CONCLUSIONS: FDG PET is a functional imaging technique useful to diagnose lymphomas and providing metabolic characterization of cancer abnormalities. Whole body PET permits the simultaneous assessment of nodal and extranodal lymphoma localizations. During the follow-up, FDG PET permits better monitoring of treatment effects than clinical and radiologic examinations.

Female↗