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At least 343 records · Page 19Linked to original sources
PubMed2000

Prescription of proton pump inhibitors before endoscopy. A potential cause of missed diagnosis of early gastric cancers.

BACKGROUND: Early gastric cancer is frequently seen with nonspecific dyspeptic symptoms and subtle endoscopic features. Treatment at this stage of the disease produces a high chance of cure. If the diagnosis is missed at this early stage, then the prognosis may be much poorer depending on the subsequent delay in reaching a diagnosis. OBJECTIVES: To report the healing effect of proton pump inhibitors on early gastric cancer. METHODS: This article reports a case series of 7 patients with ulcerated early gastric cancers indistinguishable as malignant gastric ulcers at endoscopy who were inadvertently prescribed a short course of a proton pump inhibitor prior to a second confirmatory endoscopy. The cases studied were patients with dyspeptic symptoms referred from primary care physicians for upper gastrointestinal endoscopy. RESULTS: In each case the patient became asymptomatic, the endoscopic signs seen at the first endoscopy had resolved, and the lesions could not be recognized even by an experienced endoscopist. If the proton pump inhibitors had been prescribed by the referring physician before the first endoscopy, the diagnosis probably would have been missed. These cases demonstrate the potentially serious masking effect of prescribing a short course of these drugs before making an endoscopic diagnosis. Even though the patient has been referred for endoscopy, the endoscopist may fail to identify the lesion and thus miss the diagnosis. CONCLUSIONS: Primary care physicians must resist the pressures to prescribe proton pump inhibitors before endoscopy, particularly in patients older than 45 years, if the diagnostic yield of gastric cancer in the early curable stages is to be maximized.

Adult↗
PubMed2002

Association of prediagnosis endoscopy with stage and survival in adenocarcinoma of the esophagus and gastric cardia.

BACKGROUND: Barrett esophagus, a consequence of chronic gastroesophageal reflux disease, is a premalignant condition for adenocarcinoma of the esophagus and, possibly, the gastric cardia. However, the actual use and clinical impact of upper gastrointestinal endoscopy in screening and surveillance for Barrett esophagus are unknown. METHODS: A cohort included 1633 patients with adenocarcinoma (777 esophagus, 856 cardia) who were 70 years or older. They were diagnosed between 1993 and 1996 and were identified from the Surveillance, Epidemiology and End Results program registry. All claims for upper endoscopy and a diagnosis of Barrett esophagus from 1991 through 1 year before diagnosis were identified from linked Medicare files. RESULTS: One or more upper endoscopies before diagnosis were performed in 9.7% of patients (13.0% esophagus, 6.8% cardia) and a diagnosis of Barrett esophagus was present in only 3.7% of patients. A shift toward earlier stage at diagnosis was observed in patients with previous endoscopy or Barrett diagnosis. For example, 62% of patients with esophageal and 49% of patients with cardia tumors who underwent previous endoscopy presented with in situ or local stage carcinoma, compared with 35% and 27% of other patients, respectively. Receipt of endoscopy was also associated with a reduced risk of death for esophageal adenocarcinoma (relative hazard 0.73, 95% confidence interval 0.57-0.93; P = 0.01), but not for adenocarcinoma of the cardia. CONCLUSIONS: Receipt of upper endoscopy at least 1 year before diagnosis of adenocarcinoma, which may reflect prediagnosis screening, was associated with an earlier tumor stage and improved survival. These data support the role of endoscopic screening and surveillance for Barrett esophagus and highlight the underdiagnosis of populations at risk.

Adenocarcinoma↗
PubMed2002

[Virtual endoscopy of the urinary tract].

This review article depicts the technique of virtual uro-endoscopy and its diagnostic value and highlights future aspects. The raw data are acquired using CT, MR, or ultrasound. Sufficient contrast between the wall of the hollow organ and its interior is reached by administering gas or contrast medium into the bladder or injecting contrast media i.v. After processing of these data, virtual endoscopic procedures can be watched on a screen in the same way as a cine-film of a conventional endoscopic operation. Virtual endoscopy is a reliable method with a high sensitivity for pathologies larger than 0.5 cm. It is not invasive, and there are situations that cause difficulties in conventional endoscopy (e.g. gross hematuria, diverticula, strictures) that cause no technical problems in virtual endoscopy. Problems encountered in virtual endoscopy are due to its poor sensitivity for pathologies smaller than 0.5 cm, for carcinoma in situ, and for ureteral calculi. So far there are no routine-indications for virtual endoscopy in urology. Nevertheless, it can be of additional value in diagnosis providing the indications are carefully controlled. In future, virtual endoscopy will probably become integrated into the spectrum of urologic diagnostics investigations.

Contrast Media↗
PubMed1998

Virtual endoscopy of the nose and paranasal sinuses.

The purpose of this study was to evaluate the applicability of virtual endoscopy (VE) in the region of the nose and paranasal sinuses on the basis of volume-rendered spiral CT data. Forty-five patients underwent a low-dose spiral CT of the sinuses. The data were transferred to a workstation running software for volume rendering (EasyVision, Philips Medical Systems, Eindhoven, The Netherlands). Six orthogonal views of the maxillary sinuses and the nasopharynx and a fly-through movie of the nose were calculated. Two radiologists evaluated the coronal reconstructions and virtual endoscopy with respect to detectability of pathology using a checklist comprising 10 points. In 30 patients who underwent subsequent endoscopic surgery, surgeons were asked to rank the degree of assistance of the preoperative virtual endoscopy. In general, virtual endoscopy was possible in all 45 patients. The mean time required for path definition and movie calculation for virtual endoscopy were 8 (+/- 2) min and 3 (+/- 1) min, respectively. Overall, more anatomical details were depicted on coronal reconstructions; however, a high degree of similarity between virtual endoscopy and the intraoperative impression was reported by the surgeons. We conclude that virtual endoscopy of the nose and paranasal sinuses may develop into a standard means to guide surgeons during endoscopic interventions.

Adolescent↗
PubMed2004

Endoscopy versus radiography for the diagnosis of acute bacterial rhinosinusitis.

The aim of the study was to estimate the sensitivity and specificity of endoscopy and the diagnostic value of clinical criteria for acute bacterial rhinosinusitis (ABRS). The hospital records of 117 consecutive patients who had symptoms compatible with ABRS and who underwent sinus radiography and flexible nasendoscopy were retrieved. A positive diagnosis was entertained when radiography demonstrated air fluid level, complete opacification or at least 6 mm mucosal thickening and/or endoscopy revealed purulent material within the drainage area of the sinuses. Using a modified version of the Hui and Walter procedure, the sensitivity and specificity of nasendoscopy was calculated against sinus radiography, a standard reference test, with known estimated sensitivity (76%) and specificity (79%). The findings show that 40 patients (34%) had positive endoscopy and radiography. Twenty patients (17%) had positive endoscopy and negative radiography, and vice versa in 15 (13%). In 42 patients (36%) both modalities were negative. Endoscopy yielded a sensitivity of 80% (95% CI, 0.55-1.00) and a specificity of 94% (95% CI, 0.33-1.00). Although estimates seem better than those of radiography, the confidence intervals are quite wide and no firm conclusion is drawn. Neither single nor combination of symptoms, concurrent with two major and one minor factor advocated by the AAO-HNS Task Force on Rhinosinusitis, were associated with a positive diagnosis of ABRS. The data suggest that endoscopy is no less effective than radiography in predicting ABRS, also that clinical criteria are of rather limited diagnostic value, and thus should be supported by other diagnostic tests. Endoscopy is recommended as a first line diagnostic tool for the diagnosis of ABRS in routine ENT practice. If the outcome is negative, radiography may follow.

Acute Disease↗
PubMed2003

Analysis of 153 deaths after upper gastrointestinal endoscopy: room for improvement?

BACKGROUND: Upper gastrointestinal (GI) endoscopy is a widely used procedure that is generally considered to be safe. METHODS: Of a total of 33,854 patients who underwent upper gastrointestinal endoscopy during 1999 under the care of surgeons in Scotland, 153 (0.004%) died. We reviewed the case notes of these 153 patients. RESULTS: Death was directly related to endoscopy in 20 of 153 cases (13%), most commonly due to gastrointestinal perforation or acute pancreatitis. Ninety-one percent (139) of the patients undergoing endoscopy were American Society of Anesthesiologists grades (ASA) 3-5, and 88% received intravenous sedation; an anesthetist was present in 31 cases (20%). Oxygen was administered to 45% of patients during the endoscopy. In 56% of the procedures, there was monitoring of electrocardiograms (ECG), pulse oximetry, or blood pressure readings. CONCLUSIONS: Although deaths after endoscopy may be unavoidable, clinicians undertaking upper GI endoscopy or endoscopic retrograde cholangiopancreatography (ERCP) in ASA 3-5 patients should provide oxygen therapy and cardiovascular monitoring, and keep accurate records. The involvement of an anesthetist in airway management and the administration of intravenous sedation should be actively considered.

Acute Disease↗
PubMed2006

Use of a combination of computed tomography and endoscopy to assess the response to 5-fluorouracil/cisplatin and predict survival in gastric cancer.

BACKGROUND: Response of metastatic sites on computed tomography (CT) has been used to assess response in metastatic gastric carcinoma (MGC); however, the role of endoscopy to evaluate the response of the primary gastric lesion is unclear. We undertook a prospective study to compare prognostic values of endoscopy-based response criteria with those of CT-based response criteria in MGC patients treated with 5-fluorouracil (5-FU) and cisplatin. METHODS: MGC patients naïve to chemotherapy were treated with 5-FU (1000 mg/m(2), days 1-5) and cisplatin (60 mg/m(2), day 1) (FP) every 21 days. Response was assessed by CT [World Health Organization (WHO) criteria/Response Evaluation Criteria In Solid Tumors (RECIST)] every three cycles and/or endoscopy after the third cycle. RESULTS: With a median follow-up of 26.2 months, 103 patients were assessed by CT and endoscopy. There was good concordance between the WHO and RECIST criteria (kappa = 0.91; P = 0.0001), but poor agreement between CT and endoscopic assessments (kappa = 0.17; P = 0.01). On multivariate analysis, both CT (WHO/RECIST) (hazard ratio, 5.20; P < 0.0001) and endoscopic response (hazard ratio, 2.78; P < 0.0001) were significantly associated with survival. The combination of CT and endoscopy defined patients into four groups with distinct prognoses according to chemotherapy response: responders on both tests, responders on CT alone, responders on endoscopy alone, and nonresponders on both tests (hazard ratio, 1.00 versus 2.87 versus 5.35 versus 12.3; P < 0.0001). CONCLUSIONS: The use of endoscopy together with CT provides a better prognostic tool than CT alone in MGC patients treated with FP.

Adult↗
PubMed2000

Evaluation of autonomic nervous function during upper gastrointestinal endoscopy using heart rate variability.

To investigate autonomic nervous function during upper gastrointestinal endoscopy, we analyzed R-R interval variability from electrocardiograms obtained during endoscopy. Holter electrocardiogram recordings were made before and after premedication, and during endoscopy. Time- and frequency-domain analyses of heart rate variability were performed in 54 subjects premedicated with scopolamine butylbromide (SB group) and in 66 subjects premedicated with glucagon (G group). To determine the effect of autonomic imbalance on arrhythmia generation during endoscopy, subjects with arrhythmias (A group) were compared with subjects without arrhythmias (N group). In the SB group, high frequency spectral power (HF power; 0.15 to 0.40 Hz), which reflects parasympathetic activity, decreased significantly after premedication, and decreased further during endoscopy (P < 0.01). Moreover, HF power before premedication or during endoscopy in the A group was significantly lower than that in the N group (P < 0.01). This study suggests that the measurement of HF power prior to endoscopy can identify subjects with reduced HF power. This should allow the prevention of cardiovascular complications related to premedication and endoscope insertion.

Adult↗
PubMed2002

[Competence -- the way to surgical endoscopy].

INTRODUCTION: There is a continuing debate about competence for flexible endoscopy in regard to surgery. STATEMENTS AND DISCUSSION: The theoretical and clinical basis of diagnostic/interventional endoscopy is analyzed; as a result it can be demonstrated that surgery offers ideal prerequisites for performing endoscopy due to specific training and clinical experience. There are specially designed and certified training systems for flexible endoscopy--analogous to approved training courses in minimal-invasive surgery. Relevant progress in interventional endoscopy in the past and present has been obtained by surgical endoscopies. Those involved in interdisciplinary disputes increasingly come to the conclusion that cooperation instead of confrontation should be the aim of all efforts, thus offering advantages to all participants of such a cooperation. CONCLUSIONS: Surgery should preserve and develop further its competence in flexible endoscopy.

Clinical Competence↗
PubMed1990

Prevalence of clinically relevant bacteremia after upper gastrointestinal endoscopy in bone marrow transplant recipients.

PURPOSE: To determine the prevalence of clinically relevant bacteremia after upper endoscopy in patients undergoing bone marrow transplantation. PATIENTS AND METHODS: We retrospectively reviewed the records of 151 patients who received an HLA-identical allogeneic bone marrow transplant (BMT) at the Seattle Veterans Affairs Medical Center between September 1983 and December 1988. Forty-seven patients who required esophago-gastroduodenoscopy (EGD) during their first 100 days after transplant were selected for evaluation. Clinically relevant bacteremia was defined as the development of hypotension, temperature greater than 38.5 degrees C, and a positive blood culture occurring within 24 hours after endoscopy. The presence of acute graft-versus-host disease (GVHD) at the time of endoscopy and the use of prednisone prior to endoscopy were considered possible risk factors for the development of bacteremia. The proportion of subjects who became bacteremic were compared using Fisher's exact test. RESULTS: Within 24 hours following endoscopy, nine patients (19%) developed clinically evident bacteremia (hypotension, temperature greater than 38.5 degrees C, and a positive blood culture). Eight of 14 patients receiving prednisone at the time of endoscopy developed bacteremia, compared to one of 33 not receiving prednisone (p less than 0.01). Nineteen patients had acute GVHD of at least grade 2 at the time of EGD, six of whom developed bacteremia. Although acute GVHD alone did not increase the risk of post-EGD bacteremia in patients not receiving prednisone (one of 21 versus zero of 12, p greater than 0.9), the risk of bacteremia was particularly high in patients with acute GVHD treated with prednisone at the time of EGD (six of seven). CONCLUSION: Allogeneic BMT recipients receiving prednisone for immunoprophylaxis after grafting or for treatment of acute GVHD are at high risk for clinically relevant bacteremia following EGD. Such patients are candidates for antibiotic prophylaxis prior to endoscopy.

Bone Marrow Transplantation↗
PubMed2006

Capsule endoscopy findings in patients with suspected Crohn's disease and biochemical markers of inflammation.

BACKGROUND: Because it provides a direct view of superficial lesions in the small bowel, capsule endoscopy is a promising diagnostic tool for studying patients with suspected Crohn's disease undetected by conventional modalities. AIM: To assess the role of capsule endoscopy in the diagnosis of patients with suspected Crohn's disease. PATIENTS AND METHODS: Thirty-eight patients (16 males, mean age 46.2 years) with suspected Crohn's disease but negative at conventional imaging were examined using capsule endoscopy. They were divided into 2 groups: 12 patients with ongoing symptoms (Group 1), and 26 with ongoing symptoms and biochemical markers of inflammation (Group 2). Capsule endoscopy findings were classified as diagnostic (multiple erosions/ulcerations), suspicious (<or=3 erosions/ulcerations), non-specific and normal. RESULTS: Capsule endoscopy findings were diagnostic for Crohn's disease in 13 (34.2%) patients, suspicious in 2 (5.3%), non-specific in 4 (10.5%) and normal in 19 (50%), with an overall detection rate of 39.5%. The yield of positive findings was 8.3% in Group 1 and 46.2% in Group 2 (p=0.022). Capsule endoscopy findings prompted specific measures or patient management changes in 39.5% of patients. CONCLUSIONS: Capsule endoscopy has a high diagnostic yield in patients with suspected Crohn's disease and both clinical and biochemical markers of inflammation.

Adolescent↗
PubMed2006

The ambulatory endoscopy center (AEC): what it can do for your gastroenterology practice.

Endoscopy accounts for most of the gastroenterologist's professional time and revenue. The thoughtful gastroenterologist in practice must understand the potential sites of service for endoscopy, including either the hospital endoscopy unit or an ambulatory endoscopy center (whether an office endoscopy suite or a licensed, certified, and accredited ambulatory surgery center). Out-of-hospital endoscopy centers have advantages for patients, including convenience, efficiency, economy, and more pleasant surroundings than the hospital. Payers appreciate improved access and reduced costs. For gastrointestinal practices, ambulatory endoscopy centers, particularly ambulatory surgery centers, provide significant advantages, including enhanced reimbursement and cost management, control, efficiency and convenience, quality control, opportunities for clinical research, and marketing and competitive strengths.

Ambulatory Care Facilities↗
PubMed1975

Fibre-optic endoscopy and radiology in the investigation of the ipper gastrointestinatract.

A comparative study is reported of endoscopy and the barium meal in the investigation of the oesophagus, stomach and duodenum, based on 281 endoscopies. There was total agreement between the two methods in 239 instances, including 101 normals, 80 peptic ulcers and nine cancers. In nine instances with unequivocal follow-up information there was definite disagreement, radiology being wrong in two (incorrect confident diagnoses of carcinoma) and endoscopy being wrong in seven (three carcinomas and four ulcers not diagnosed). Of 116 normal barium meals, 15 definite abnormalities were demonstrated by endoscopy, including six peptic ulcers. 'Probable' radiological diagnoses were confirmed by endoscopy in 44 instances. In those where endoscopy disagreed, radiology was definitely shown to be wrong in five, and endoscopy in five. A high degree of accuracy can be achieved by the selected use of both techniques, the information obtained from each considered of equal importance, and neither being regarded as the final arbiter.

Adult↗
PubMed1977

Detection and grading of oesophageal varices by fibre-optic endoscopy and barium swallow with and without Buscopan.

Detection of oesophageal varices is important in the diagnosis of portal hypertension. We have, therefore, compared the results of fibre-optic endoscopy and barium swallow in 56 patients with chronic liver disease. Oesophageal varices were graded as small, moderate or gross by independent observers for each technique. In 12 patients varices were not detected by either method, and in six cases varices were detected by endoscopy when the barium swallow was negative. In 15 of the remaining 38 patients varices were found to be one grade larger at endoscopy than on barium swallow. Since it is possible that varices appear larger at endoscopy because of the Buscopan (hyoscine N-butyl bromide) used as a relaxant, we carried out barium examinations after Buscopan 20 mg i.v. in 23 of the patients. In eight cases varices were one grade larger after Buscopan than on the standard barium swallow, and in two were only detected after Buscopan had been given. Eight cases negative after Buscopan were also negative at endoscopy. Although emergency endoscopy has particular value in locating the site of bleeding in patients with portal hypertension and acute gastrointestinal haemorrhage, the results of the present study suggest that a barium meal with Buscopan is as accurate as endoscopy in the detection of oesophageal varices.

Butylscopolammonium Bromide↗
PubMed2004

Capsule endoscopy is safe and effective after small-bowel resection.

BACKGROUND: Because capsule endoscopy is a relatively new technique, the indications, the contraindications, and the complications of the procedure have not been fully delineated. The present study was undertaken to determine the utility and the safety of capsule endoscopy in patients who have undergone small-bowel resection. METHODS: Ten patients (mean age 48.5 [8.4] years) were included in the study. Eight had undergone surgical resection for Crohn's disease and two for malignancy. Indications for capsule endoscopy included suspected relapse of Crohn's disease or of malignancy, with a negative conventional evaluation that included barium contrast radiography, upper endoscopy, colonoscopy, US, CT, and push enteroscopy. Capsule endoscopy was performed in the standard fashion. OBSERVATIONS: No side effects were observed in any patient. Natural excretion of the capsule was reported at a mean of 72 hours. In 7 patients (70%), capsule endoscopy revealed recurrence of disease in the small bowel: one recurrent malignancy, 6 recurrent Crohn's disease. The information gained was helpful with respect to further treatment for all of these patients. CONCLUSIONS: Capsule endoscopy is safe and effective in the evaluation of patients who have undergone surgical resection of the small bowel for benign or malignant disease.

Crohn Disease↗
PubMed1999

A comparison of transnasal and transoral endoscopy with small-diameter endoscopes in unsedated patients.

BACKGROUND: The aim of this study was to compare use and tolerance of transnasal and transoral diagnostic endoscopy with small-diameter endoscopes in unsedated patients. METHODS: Patients being seen for diagnostic endoscopy were randomly assigned to have an unsedated transnasal or transoral procedure. Two prototype narrow-diameter endoscopes (a 5.3 mm fiberoptic endoscope and a 5.9 mm videoendoscope) were used. RESULTS: Of 170 patients (64 women and 106 men) enrolled, 86 underwent transoral and 84 underwent transnasal endoscopy. The procedure was successfully completed using the transoral route in 85 of 86 patients and using the transnasal route in 74 of 84 patients (p = 0.004). Sixteen patients experienced mild epistaxis after transnasal endoscopy. The larger videoendoscope, when compared with the fiberoptic endoscope, accounted for a significantly higher proportion of failures (8 of 41 vs. 2 of 43, p = 0.046) and cases of epistaxis (12 of 33 vs. 4 of 41, p = 0.007). The time taken for transoral endoscopy was shorter than the transnasal route (oral mean 13.7 +/- 0.5 minutes, nasal mean 15.2 +/- 0.6 minutes, p = 0.054). There was no difference between the 2 groups with respect to tolerance of the procedure. From the endoscopist's perspective, the only statistically significant difference between the 2 groups was that endoscope insertion was easier by the oral route (p = 0.007). CONCLUSIONS: Unsedated transnasal endoscopy with the videoendoscope was less successful compared with the transnasal fiberoptic instrument or when compared with either instrument passed transorally. Use of the larger diameter videoendoscope also resulted in significantly more epistaxis in the transnasal endoscopy group. Endoscopists find transoral introduction of the endoscope easier; this may reflect their relative unfamiliarity with the nasal route. Once intubation has been successfully achieved for either route, patient tolerance is the same.

Adult↗
PubMed1999

Endoscopy-based triage significantly reduces hospitalization rates and costs of treating upper GI bleeding: a randomized controlled trial.

BACKGROUND: Many patients with upper gastrointestinal (GI) bleeding have a benign outcome and could receive less intensive and costly care if accurately identified. We sought to determine whether early endoscopy performed shortly after admission in the emergency department could significantly reduce the health care use and costs of caring for patients with nonvariceal upper GI bleeding without adversely affecting the clinical outcome. METHODS: All eligible patients with upper GI bleeding and stable vital signs were randomized after admission to undergo endoscopy in 1 to 2 days (control) or early endoscopy in the emergency department. Patients with low-risk findings on early endoscopy were discharged directly from the emergency department. Clinical outcomes and costs were prospectively assessed for 30 days. RESULTS: We randomized 110 consecutive stable patients with nonvariceal upper GI bleeding during the 12-month study period. The baseline demographic features, endoscopic findings, and the clinical outcomes were no different between the two groups. However the findings of the early endoscopy allowed us to immediately discharge 26 of 56 (46%) patients randomized to that group. No patient discharged from the emergency department suffered an adverse outcome. The hospital stay (median of 1 day [interquartile range of 0 to 3 days] vs. 2 days [interquartile range of 2 to 3 days], p = 0.0001) and the cost of care ($2068 [interquartile range of $928 to $3960] versus $3662 [interquartile range of $2473 to $7280], p = 0.00006) were significantly less for the early endoscopy group. CONCLUSIONS: Early endoscopy performed shortly after admission in the emergency department safely triaged 46% of patients with nonvariceal upper GI bleeding to outpatient care, which significantly reduced hospital stay and costs.

Adult↗
PubMed1994

The role of endoscopy in inflammatory bowel disease.

Endoscopy has assumed a preeminent role in the diagnostic approach to IBD. It is more sensitive than radiography in detecting early, subtle changes of IBD, both through endoscopic appearance and histologic sampling of mucosa. Endoscopy also appears to be a safe technique in patients presenting with severe forms of colitis and can play an important role in defining the etiologic basis of disease in this subgroup of patients. In addition to its diagnostic role, endoscopy has proven useful in surveying disease activity, through the development of endoscopic disease activity indices. Endoscopy has also found a prominent role in the diagnostic and therapeutic approach to IBD complications. Endoscopic surveillance of chronic UC patients at risk for colon carcinoma has helped to define a therapeutic approach to this serious complication of UC. Endoscopic therapy has been applied to treat stricture formation associated with long-standing CD. Biliary endoscopy also represents the strategy of choice for diagnosing primary sclerosing cholangitis, an extraintestinal complication occurring in 5% of UC patients. Finally, endoscopy may help facilitate the discovery of disease pathogenesis in IBD, through the use of endoscopically recovered biopsy specimens in the research laboratory. Endoscopy allows for ready access to human tissue that has been the cornerstone of disease-related research over the past two decades.

Diagnosis, Differential↗