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PubMed2001

Diagnostic laparoscopy and laparoscopic ultrasonography optimize the staging and resectability of intraabdominal neoplasms.

BACKGROUND: Despite technical improvements, preoperative imaging studies often fail to predict intraoperative findings. We investigated the potential use of diagnostic laparoscopy (DL) and laparoscopic ultrasonography (LUS) for the assessment of disease in patients with abdominal neoplasms. METHODS: Fifty consecutive patients with abdominal neoplasms underwent spiral computed tomography with oral and intravenous contrast using 5-mm contiguous sections. In addition, eight patients underwent ultrasonography, six underwent magnetic resonance imaging, and eight underwent positron emission tomography. All patients then underwent DL and LUS using a 7.5-MHz ultrasound probe. RESULTS: There were 29 men and 21 women with a mean age of 63 years (range, 35-84). Most had a diagnosis of colorectal cancer (19 cases), melanoma (12 cases), or hepatoma (five cases). In nine cases (18%), DL revealed peritoneal metastatic implants not shown on preoperative images. In 18 cases (36%), LUS was more accurate than preoperative imaging. Combined DL and LUS findings radically changed the operative management in 16 patients (32%). CONCLUSION: As compared with preoperative imaging, the combination of DL and LUS provides more accurate information regarding staging and resectability. Moreover, it helps to determine the extent of operation and reduces the number of unnecessary laparotomies. DL and LUS should be used as an adjunct to preoperative imaging studies in patients with primary or metastatic intraabdominal neoplasms.

Abdominal Neoplasms↗

PubMed2002

Quantitative assessment of clinical signs for the detection of classical swine fever outbreaks during an epidemic.

The performance of clinical signs as a diagnostic test for the detection of classical swine fever (CSF) outbreaks during the 1997-1998 CSF epidemic in The Netherlands was evaluated by constructing and analysing a receiver operating characteristic (ROC) curve. This curve assesses the discriminating ability of a diagnostic test over a range of test signals. The cut-off values for a defined diagnostic test to detect CSF outbreaks were set by different combinations of clinical signs observed. The area under the ROC curve, which is a quantitative measure of test performance, was significantly (P<0.001) larger than the area under the random ROC curve. This indicates that clinical signs have a significantly higher performance as a diagnostic test for the detection of CSF than for flipping a coin. However, the gain in diagnostic performance compared to a random process is not as much as we would wish it to be. The optimal efficient diagnostic test combined a sensitivity of 72.7% with a specificity of 52.7%, with a combination of the following clinical signs: unsteady gait/ataxia, not eating, not reacting to antibiotic treatment, conjunctivitis, hard faecal pellets.

Animals↗

PubMed2004

[Candida- and Aspergillus-antibody-Elisa--expected positive antibody results in sera of the clinical-mycological routine diagnostics].

Based on the ELISA results of more than 15000 serum samples of clinical mycological routine diagnostics, the expected frequency of positive antibody ELISA results within the immunoglobulin classes IgM, IgG and IgA was determined, to optimize the diagnostic assessment of first or single result of Candida or Aspergillus antibody ELISA. In general diagnostics the expected frequency of positive antibody ELISA results of the first sample within the immunoglobulin classes were as follows: Candida antibody IgM 6.1%; IgG 6.0%; IgA 2.1% and Aspergillus antibody IgM 11.4%; IgG 22.1% and IgA 5.1%, respectively. Using the Candida antibody ELISA as confirmation test only, percentages of positive antibody results in the first sample were 2.5 to 3 times higher than in general diagnostics. In follow-up examinations the Candida antibodies showed different kinetics within the immunoglobulin classes compared to those of the Aspergillus antibodies.

Antibodies, Fungal↗

PubMed2001

Refinement of the 14C-urea breath test for detection of Helicobacter pylori.

BACKGROUND: Helicobacter pylori is recognized as the main etiological factor for chronic gastritis, peptic ulcer and possibly also gastric malignancies. A 14C-urea breath test was successively refined to correctly diagnose the presence of H. pylori. METHODS: After intake of a 14C-urea cocktail, 14CO2 in breath was trapped in benzethoniumhydroxide/ethanol. Serology by ELISA, followed by Western blot, was used as reference method for confirmation of presence or absence of H. pylori. RESULTS: Breath measurements at 10 and 20 min were determined to be optimal for diagnostic purposes. With 2.5 microCi of 14C-urea, a sensitivity of 86% and specificity of 100% was obtained for the 10-min values. Corresponding data for the 20-min values were 86% and 99%, respectively. When 50 mmol L(-1) citric acid was added to the 2.5 microCi 14C-urea cocktail, separation between positive and negative results became more distinct along with improved sensitivity of 91% and specificity of 100%. As the isotope amount was reduced to 1.0 microCi in the citric acid-containing cocktail, a sensitivity of 93% and specificity of 100% were obtained at both 10 and 20 min. CONCLUSION: Diagnostic urea breath test has a high concordance with H. pylori serology, combining ELISA and Western blot. Stepwise refinements proved the optimal urea breath test cocktail to include 1.0 microCi 14C-urea in citric acid solution with breath measurement at 10 min.

Adult↗

PubMed2002

Optimisation of conditions of visualisation of dental crowns in dental radiography.

Digital X-ray imaging systems are an alternative to conventional intraoral radiograms. In the paper there are discussed the possibilities of application of different digital radiography tools as well as density measurements in optimization of diagnostics of pathological lesions of teeth crowns. There were analyzed 1,491 digital intraoral radiograms obtained in 985 patients in the Digora Soredex digital radiography system. On all taken X-ray pictures there were evaluated the crowns of teeth in cases of primary and secondary caries, dental fillings, internal resorption, traumatic lesions of incisors as well as the relationships between deep carietic lesions and pulp horns as well as root furcation. An attempt was made to assess the possibilities of differentiation of cervical caries and cervical burn-out. In the paper there were presented the optimal options of digital radiography software in diagnostics of the discussed pathological lesions.

Crowns↗

PubMed1998

Impact of human immunodeficiency virus type-1 infection on the initial bacteriologic and radiographic manifestations of pulmonary tuberculosis in Uganda. Makerere University-Case Western Reserve University Research Collaboration.

SETTING: TB Treatment Centre, Kampala, Uganda. OBJECTIVE: To evaluate the impact of human immunodeficiency virus (HIV) co-infection on the bacteriologic and radiographic presentation of pulmonary tuberculosis (TB) in Uganda, a nation with high rates of Mycobacterium tuberculosis and HIV infection. DESIGN: To compare baseline characteristics among HIV-infected and non-HIV-infected adults with initial newly-diagnosed episodes of culture-confirmed pulmonary TB screened for participation in a randomized prospective TB treatment trial. RESULTS: Negative and paucibacillary (very scanty or scanty) sputum acid fast bacilli (AFB) smears were more frequent in HIV-infected patients presenting with pulmonary TB (P = 0.007). More HIV-infected individuals also had sputum cultures that required 7-8 weeks incubation until positivity than non-HIV-infected patients (P < 0.01). Lower lung field and diffuse pulmonary infiltrates were more frequent among HIV-infected patients. Rates of atypical X-ray presentations and cavitary disease were comparable between HIV-seropositive and -seronegative patients; however, atypical disease was more frequent in HIV-infected patients with small tuberculin reactions or tuberculin anergy (PPD = 0 mm). CONCLUSION: HIV co-infection was associated with a higher frequency of negative and paucibacillary sputum AFB smears. The differences in the diagnostic yields of microscopy and culture between HIV-infected and non-HIV-infected individuals were small and do not, in our opinion, significantly affect the utility of these important diagnostic tests in developing countries. Examining more than one sputum specimen and monitoring cultured specimens for a full 8 weeks may assist in optimizing the diagnostic yield. Upper lobe infiltrates and cavitary disease are still the most frequent radiographic presentations of pulmonary TB in HIV-infected and non-HIV-infected adults in countries with a high prevalence of TB.

Adult↗

PubMed1987

Statistical diagnosis and the influence of diagnostic error.

The optimal class of rules for allocating subjects, on the basis of an observable symptom profile, to sick or well states is based on the likelihood-ratio scale. This scale is estimated from a training set where the symptoms and true disease status are simultaneously measured. In the important case where true disease status is unavailable and only a "noisy" diagnosis can be performed, it is shown that exactly the same optimal class of allocation rules is obtained. This is true under very general assumptions of diagnostic error. Special cases are examined, providing insight into the dynamics of such diagnostic error. In particular, the conditions under which sensitivity, specificity, and the overall correct classification rate are underestimates of the true quantities are investigated.

Biometry↗

PubMed2025

Hierarchical integration of mNGS, PCR, and other conventional methods for precision TB diagnostics.

UNLABELLED: This study systematically compared the diagnostic accuracy of seven assays for detecting the Mycobacterium tuberculosis complex, including metagenomic next-generation sequencing (mNGS), droplet digital polymerase chain reaction, real-time quantitative polymerase chain reaction, EasyNAT MTC, GeneXpert MTB/RIF, interferon-gamma release assay (IGRA), and acid‒fast staining (AFS). We try to select appropriate combinations of tuberculosis (TB) detection methods for regions with varying levels of medical resources, based on sensitivity, cost-effectiveness, and operational feasibility. A retrospective analysis was conducted on 141 samples collected from patients with suspected active TB at The First Affiliated Hospital of Sun Yat-sen University between April 2022 and April 2024. Among these samples, there were 100 cases assigned to the case group and 41 cases to the control group, based on the tuberculosis diagnostic criteria. Historical data for Xpert, IGRA, and AFS were collected, and parallel experiments using mNGS, droplet digital PCR (ddPCR), real-time quantitative polymerase chain reaction (RT-qPCR), and EasyNAT were conducted on all samples. Diagnostic performance was evaluated by comparing it with the final clinical diagnoses. Sensitivity, specificity, positive predictive value, negative predictive value, and receiver operating characteristic (ROC) curve analysis were conducted, along with DeLong tests for statistical comparison. Compared with the final clinical diagnosis, mNGS demonstrated the highest sensitivity (100%), followed by IGRA (79.2%), EasyNAT (79.1%), RT-qPCR (78.0%), ddPCR (75.8%), Xpert (75.3%), and AFS (16.7%). The specificity was 100% for both Xpert and AFS, followed by ddPCR (97.6%), RT-qPCR (95.1%), EasyNAT (92.7%), IGRA (72.7%), and mNGS (75.6%). ROC analysis revealed a significantly greater area under the ROC curve for mNGS (0.878) than for ddPCR (0.817, P = 0.031). DeLong tests revealed statistically significant differences in diagnostic performance between mNGS and ddPCR (P < 0.05) and between IGRA and AFS (P < 0.01). mNGS uniquely identified the pathogens involved in co-infection and quantified pathogen-specific sequencing reads. Through a comprehensive evaluation of the diagnostic efficacy, cost-effectiveness, and timeliness of tuberculosis detection methods, we propose corresponding combinations of TB testing approaches for regions with different healthcare resources. For undeveloped regions with limited resources, a combination of AFS +EasyNAT + chest X-ray is recommended. Primary care facilities may additionally employ IGRA + RT-qPCR. Intermediate-level hospitals can incorporate Xpert MTB/RIF for drug resistance testing, while tertiary hospitals or specialized centers should, on the basis of these fundamental tests, utilize mNGS for diagnosis and ddPCR for therapeutic monitoring in patients with complex mixed infections. IMPORTANCE: This study is the first to comprehensively evaluate the diagnostic efficacy, cost-effectiveness, and timeliness of seven TB detection methods in a single-center cohort. Our findings provide actionable solutions for optimizing TB diagnostics in diverse healthcare ecosystems, aligning with the WHO's End TB Strategy to ensure equitable access to rapid diagnostics.

Humans↗

PubMed2005

The role of lumbar puncture as a diagnostic tool in 2005.

Analysis of cerebrospinal fluid (CSF) obtained by lumbar puncture (LP) is fundamental to the management of inflammatory disease of the central nervous system (CNS), particularly that due to infection. This review summarises the role of lumbar puncture, anatomy and pathophysiology of CSF, techniques of obtaining CSF, indications, contraindications and complications of LP, methods of analysis and some of the implications of specific changes in CSF. The CNS is protected by unique immunological barriers, and has some unique responses to processes that breach these barriers. While clues in the epidemiology, history and clinical features of potential CNS inflammatory disease may be important in guiding early empirical treatment which may obviate adverse outcomes, many pathological processes cannot be distinguished or appropriately treated without analysis of CSF. When appropriate assessments are made of the indications, risks and potential to alter management, LP is a relatively safe procedure with a high diagnostic yield. Optimal performance and use of LP requires individual skill and judgment, and often benefits from close liaison with several disciplines, including emergency, intensive care, diagnostic laboratory, clinical imaging, neurology and infectious/ communicable diseases specialists. Understanding of the sensitivity, specificity and variation of CSF testing is critical to its effective use. Some CSF testing is sensitive, specific and timely, but other CNS disease processes will generate obscure and ambiguous results, and interpretation may benefit from liaison with experienced specialists in several fields. Polymerase chain reaction (PCR) testing has changed the practice of LP and is likely to generate further evolution. Some findings on CSF analysis may have implications beyond the individual patient - the consequences of the diagnosis of meningococcal meningitis, emerging pathogens such as West Nile virus or Nipah virus, and the identification of anthrax meningitis in the USA may be quite profound on both a local and global scale.

Journal Article↗

PubMed1979

Algebraic framework of an optimization problem in diagnosis.

A formal analysis of an optimization problem in medical diagnosis is presented. The mathematical model of the diagnostic process corresponds in this work to an abstract machine definition which is based on the following sets and functions: Set of possible pathological states (diseases) of a patient, set of diagnostic tests (examination methods), set of all possible results of the tests (symptoms and signs), function which chooses successive tests, function performing a test (i.e., assigning to a given test its result), function assigning to each symptom a certain subset of the set of diseases. For a given abstract machine a class of pairs of graphs is formed; their analysis leads to the identification of a class of pairs of subgraphs which corresponds to an optimized diagnostic procedure. The optimization consists of a comparison of the distances between the initial and terminal vertices of the graphs and of a choice of a shortest route to a final diagnosis. For the considered class of pairs of subgraphs a mathematical model of the optimized diagnostic process is reconstructed.

Diagnosis↗

PubMed2000

Predicting recovery from acute asthma in an emergency diagnostic and treatment unit.

OBJECTIVE: Optimal use of emergency diagnostic and treatment unit (EDTU) resources for treatment of acute asthma should be facilitated by the selection of patients with a high probability of discharge from the EDTU. The study goal was to identify characteristics of the patient or exacerbation that could be used to predict recovery of pulmonary function within 12 hours. METHODS: Comprehensive cohort design in an urban public hospital. The subjects were 269 patients with moderately severe asthma exacerbations. Data were collected for historical and presenting features and response to treatment over 12 hours. Two outcomes were examined: 1) discharge from the EDTU and 2) achieving 50% predicted peak expiratory flow rate (PEFR) within 12 hours. RESULTS: The two outcomes showed good concordance. The third-treatment PEFR was found to be predictive of both discharge and reaching 50% predicted PEFR within 12 hours. Since the objective measure of reaching 50% predicted PEFR is more readily defined and thus more generalizable, the authors focused on this outcome when describing prediction zones. Patients with 40% or higher PEFR after third treatment had an 89% probability of reaching 50% predicted in 12 hours, while those with a third-treatment PEFR lower than 32% predicted had only a 22% probability. CONCLUSIONS: A simple objective measure of pulmonary function early in treatment discriminated among those with high, low, and intermediate probabilities of achieving a specified level of PEFR within 12 hours. Awareness of this probability could assist clinicians attempting to predict discharge from the EDTU and facilitate decision making regarding utilization of EDTU resources.

Adult↗

PubMed1980

Computer-assisted interpretation of electro- and vectorcardiograms. Chapter IV. Achievements in the field of computer-assisted interpretation of electrocardiograms.

The most important advantage of computer-assisted ECG/VCG interpretation in our center is the enhancement of the diagnostic accuracy of ECG interpretation, as compared to that reported in the literature for the visual analysis of ECGs and VCGs. Favourable side effects are also obtained from the optimization of various functions involved n ECG data processing, like data handling, editing, reporting, storage and retrieval. Improvement of the arrhythmia program and creation of a new pediatric VCG program are currently in progress in our laboratory. Computerized electrocardiography has made us aware of the limitations of conventional, visual reading of electrocardiograms. Thanks to the current efforts towards standardization of the quantitative analysis of ECGs and VCGs and towards optimization of diagnostic criteria, computerized electrocardiography will undoubtedly lead to a generalized improved accuracy of ECG interpretation.

Belgium↗

PubMed1997

Simplified sample processing combined with a sensitive one-tube nested PCR assay for detection of Pneumocystis carinii in respiratory specimens.

Early diagnosis of Pneumocystis carinii pneumonia, a life-threatening complication in immunosuppressed patients, may lower morbidity and mortality. We have developed a one-tube nested PCR assay for the detection of P. carinii in respiratory specimens. Four primers were selected from the sequence of the small-subunit rRNA gene of P. carinii to amplify a 265-bp fragment, and their specificities for P. carinii were confirmed by both theoretical evaluations (by computer-assisted comparison with the sequences in GenBank) and empirical evaluations (with DNA from medically important fungi and diagnostic samples). The assay was optimized for routine diagnostic use. Processing of the clinical samples is rapid and simple (digestion with proteinase K directly in PCR buffer at room temperature in the presence of 10% Chelex 100 and no further purification steps). Bovine serum albumin (1 mg/ml) and glycerol (10%) in the amplification buffer reduced the number of samples inhibitory to the PCR, as assessed by control reactions containing a size-modified target. A total of 749 clinical specimens (312 bronchoalveolar lavage, 403 sputum or induced sputum, and 34 other specimens) from 507 patients (295 human immunodeficiency virus [HIV]-infected and 164 non-HIV-infected patients and 48 patients whose HIV status was unknown) were tested by PCR, and the results were compared with those of an indirect immunofluorescence assay (IFA). Concordant results were obtained for 732 samples (646 negative and 86 positive). There were 17 discrepant results: 12 were PCR positive and IFA negative, and 5 were PCR negative and IFA positive. After resolution of the discrepant results by review of the patients' clinical data, the sensitivity and specificity were 94.8 and 99.1%, respectively, for PCR and 93.8 and 100%, respectively, for IFA. In conclusion, the short procedure time and the technical ease of this PCR assay render it suitable for implementation in routine diagnostic laboratories.

Animals↗

PubMed2001

Assessing ADHD across settings: contributions of behavioral assessment to categorical decision making.

Adapted methods of behavioral assessment to assess home and school functioning in a way that maps directly to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., [DSM-IV]; American Psychiatric Association, 1994). The study was conducted in a school-based sample with 5- to 12-year-old children referred to a school intervention team. A multigate set of procedures was used to assign children to one of 3 groups: attention deficit hyperactivity disorder (ADHD), inattentive group; ADHD, combined group; and a non-ADHD control group. The ADHD Rating Scale-IV was used to assess parent and teacher ratings of ADHD symptoms as delineated in DSM-IV. The findings suggest that the use of a fixed cutoff point (i.e., 6 or more symptoms), which is employed in the DSM-IV, is often not the best strategy for making diagnostic decisions. The optimal approach depends on whether diagnostic information is being provided by the parent or teacher and whether the purpose of assessment is to conduct a screening or a diagnostic evaluation. Also, the results indicate that a strategy that aggregates symptoms in the order in which they are accurate in predicting a diagnosis of ADHD is a more effective strategy than the approach used in DSM-IV, which aggregates any combination of a specific number of items. Implications for using methods of behavioral assessment to make diagnostic decisions using DSM-IV criteria are discussed.

Attention Deficit Disorder with Hyperactivity↗

PubMed2004

[The problem of optimization in cardiology].

Optimization is understood as choice of the best version out of the competitive decisions. The strategy and tactics of prevention is presented from this point of view. Optimization of diagnostic investigations is viewed from the positions of continuum with quantitative assessment of results. Characteristics of loads and heart activity, as recommendations suggest, should be in agreement in stress tests. Optimization of dynamic investigations of biochemical markers is described on the model of acute coronary syndrome. Optimization of therapy is based on the determination of criteria of optimum. This statement is illustrated by the example of antihypertensive therapy. Optimization of pharmacotherapy must envisage the preservation of favorable effect of protective natural mechanisms in the form of autoregulation and adaptation to intermittent ischemia (preconditioning).

Cardiology↗

PubMed1998

Changes over time in optimal duplex threshold for the identification of patients eligible for carotid endarterectomy.

BACKGROUND AND PURPOSE: Two surgical trials established that carotid endarterectomy is beneficial to symptomatic patients who have a severe internal carotid artery (ICA) stenosis on angiograms. Duplex ultrasonography-derived hemodynamic parameters show a good correlation with angiography and are often used for detecting severe ICA stenoses. However, duplex performance is ultrasound machine and operator dependent. Over time both may change, possibly affecting duplex performance. We compared duplex performance of 2 time periods in 1 specific vascular laboratory using angiography as the gold standard. METHODS: Consecutive patients who underwent both angiography and duplex examinations of the ICA were evaluated (first period, 60 patients; second period, 61 patients). Peak systolic velocity and several other hemodynamic parameters and ratios were analyzed by receiver operating characteristic curves in their ability to detect severe ICA stenoses. The optimal parameter and threshold were determined for each period. Subsequently, duplex test characteristics were compared after the optimal thresholds of both the first and the second periods were applied in the second period. RESULTS: In both periods peak systolic velocity of the ICA was the best test parameter; areas under the receiver operating characteristic curve were similar (0.957 and 0.954, respectively). However, the optimal threshold was different. The optimal threshold in the second period was 270 cm/s. When the optimal threshold of 210 cm/s of the first period was applied in the second period, test characteristics changed significantly. Sensitivity increased from 98% to 100%, and specificity decreased from 85% to 71% (P=0.004). CONCLUSIONS: The optimal threshold for detecting severe ICA stenoses with duplex ultrasonography in our laboratory changed over time. Individual laboratories should assess duplex accuracy regularly and adjust adopted criteria if necessary to keep diagnostic performance optimal.

Adult↗

PubMed1996

Thin-section computed tomography scans detect medullary cysts in patients believed to have juvenile nephronophthisis.

Juvenile nephronophthisis (NPH) and medullary cystic kidney disease are an important cause of chronic renal failure in children and young adults. Medullary cysts are regarded as the hallmark of this condition. The diagnostic techniques that were used previously were not conclusive in most cases to demonstrate medullary cysts. We studied the role of thin-section (1.5-mm) computed tomography (CT) scan as an optimal imaging diagnostic technique. Three children who were admitted to our hospital consecutive with a clinical diagnosis of NPH were included. We found that the thin-section CT scan demonstrates the medullary cysts in all patients. We recommend CT scan as the investigation of choice in patients with clinical features suggestive of nephronophthisis-cystic renal medulla complex.

Child↗

PubMed1995

Integration of transbronchial and percutaneous approach in the diagnosis of peripheral pulmonary nodules or masses. Experience with 1,027 consecutive cases.

A study to evaluate the usefulness of the integration of the transbronchial and percutaneous approaches in the diagnosis of peripheral pulmonary nodules or masses (PPN/M) was conducted. The authors used both procedures, performed by a single diagnostic team, a pulmonologist, radiologist, and cytopathologist, who were all simultaneously present in the radiologic suite during the maneuvers. From January 1985 to June 1993, under fluoroscopic guidance, the authors performed 557 transbronchial pulmonary biopsies (TBPB), 483 transbronchial needle aspirations (TBNA), and 652 percutaneous needle aspirations (PCNA) on 1,027 consecutive patients referred because of a PPN/M (mean diameter, 3.5 cm; range, 0.8 to 8 cm). The procedure used was as follows: (1) bronchoscopy with exploration of the upper airways and bronchial tree, followed by TBNA and immediate cytologic assessment (ICA); (2) at least three TBPB; (3) if TBNA was diagnostic, the procedure was stopped; if not, a second pass with the needle was performed and then the bronchoscope was removed; (4) if the second TBNA was not diagnostic, PCNA with ICA was performed up to a maximum of three needle passes. Diagnostic sensitivity for malignant lesions was as follows: 53.9% for TBPB, 69.3% for TBNA, 75.4% for TBPB and TBNA together, 93.2% for PCNA, and 95.2% overall. The percentage of benign nodules correctly defined was 41.4% for TBPB, 17.4% for TBNA, 45.8% for PCNA, and 59.5% overall. Examination of the upper airways and bronchial tree was positive for lesions endoscopically visible in 12.6% of cases. The authors' experience shows that transbronchial and percutaneous approaches must be considered complementary and that their integrated use not only increases diagnostic yield but also permits important information to be obtained for disease staging. The creation of teams able to use both approaches with the cytopathologist present for ICA should be encouraged to optimize the diagnostic management of PPN/M with a reduction in diagnostic and hospitalization time and consequent cost saving.

Adolescent↗