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PubMed1998

Factors associated with the initiation of smoking by Kuwaiti males.

PURPOSE: To estimate the age patterns in cumulative probability of smoking initiation among Kuwaiti adult males and to study the differentials in smoking initiation in relation to factors such as age-cohort, marital status, educational level, income, type of residence, and history of smoking among family members and friends. METHODS: A stratified three stage cluster sampling design was implemented for the selection of the sample. A self-administered questionnaire was completed by 1798 Kuwaiti adult males working in different ministries. RESULTS AND IMPLICATIONS: Of the 1798 respondents, 34.4% were classified as current smokers, 17.7% as former smokers and 47.9% as non-smokers. The highest probability of smoking initiation (among current and former smokers) was found for the age group 15-20 years, where almost 29% of the respondents initiated smoking. In the univariate analysis, marital status, education, income, type of residence, and history of smoking among family members and friends showed significant variation in the age-patterns of initiation. In the Cox proportional hazard regression model, education, type of residence, and history of smoking among family members and friends were found to be independently associated with the risk of initiation. The highest risk of initiation (Relative Risk (RR) = 1.85; 95% CI: 1.62-2.10) was found among those who had a history of smoking in family and friends. Individuals in the lowest education category (RR = 1.64; 95% CI: 1.32-2.04) and those residing in apartments (RR = 1.65; 95% CI: 1.43-1.92) were at a higher risk of initiation compared with those who had university education or those who resided in villas. The results of the study should prompt further efforts to develop tobacco control policies in Kuwait and the other Arabian Gulf countries to help establish norms for not initiating smoking through persistent messages to not start or to stop smoking. There is also a need to enhance awareness about the influence of smokers in family or friends on other people to initiate smoking.

Adolescent↗
PubMedDate not supplied

Trace-element status in milk and plasma of Kuwaiti and non-Kuwaiti lactating mothers.

There is a wide variation in the reported data on the concentrations of trace elements in human milk from different countries, but such data are not available for Kuwait. The objective of this study was to analyze the concentration of zinc, copper, manganese, and iron in milk and plasma of Kuwaiti and non-Kuwaiti mothers during prolonged lactation. Milk samples (from 34 donors) were collected early in the morning before feeding the infant. Trace elements were analyzed using atomic absorption spectrophotometry. Protein content and activity of superoxide dismutase were assayed spectrophotometrically. Concentration of zinc, copper, iron, and total protein and activity of superoxide dismutase in milk and of only zinc in plasma of Kuwaiti mothers were significantly higher than those of non-Kuwaitis. Concentration of zinc, copper, manganese, and total protein in milk of both groups decreased as lactation continued but that of milk iron and plasma trace elements remained unchanged. The data of Kuwaiti mothers are consistent with those of previous reports on hyperuricemia, and the prevalence of obesity was found to be higher in the Kuwaiti population than in other countries. High protein content in association with high concentration of trace elements in milk of Kuwaiti versus non-Kuwaiti mothers may indicate that protein content in milk is an important determining factor for the concentration and bioavailability of these elements.

Adult↗
PubMed1995

Mesenteric vein thrombosis: is it one disease?

OBJECTIVES: to compare the clinical course and outcome of mesenteric vein thrombosis due to known causes and mesenteric vein thrombosis of unknown aetiology. DESIGN: a retrospective study. SETTING: two major general hospitals in Kuwait. SUBJECTS: 12 patients who had mesenteric vein thrombosis due to known causes and seven patients who had mesenteric vein thrombosis of unknown aetiology were treated over eight years. CHIEF OUTCOME MEASURES: severity of clinical findings and outcome. RESULTS: There was no statistical difference between the two groups in the clinical presentation or in outcome. CONCLUSION: 36% of mesenteric vein thrombosis occurred without an obvious cause although the disease appeared to be the same. More work on the aetiology of this condition is required.

Adult↗
PubMed2000

Sensitization to aeroallergens among patients with allergic rhinitis in a desert environment.

BACKGROUND: The causative allergens of allergic rhinitis in desert environments are uncertain. OBJECTIVE: To determine the sensitizing aeroallergens in patients with allergic rhinitis in Kuwait, a desert country. METHODS: A total of 706 patients aged 6 to 64 years (mean 34.3 years) with allergic rhinitis were studied. Sera from the patients were screened for specific IgE to 14 inhalant allergens by the CAP-RAST method. RESULTS: Specific IgE to any allergen was detected in 86.3% of patients. The prevalence rates for allergen groups were: pollens (77.3%), house dust (62.3%), and molds (14.7%). The individual allergens with the highest positive rates were pollens of the weed Chenopodium (64.3%); Bermuda grass (55.0%), and Prosopis tree (50.3%). These plants were all imported and cultivated for the purpose of "greening" the desert. German cockroach (48.2%) and house dust mites (32.4% to 39.2%) were the most prevalent indoor sensitizers. With the exception of the molds, sensitization rates were higher for males than females. The youngest age group (6 to 17 years) had significantly higher sensitization rates than the older ones, particularly with respect to the molds (P < .01 to .001). Severe sensitization was more common with Alternaria than the other allergens and in general mold sensitization was more frequently associated with severe symptoms. Polysensitization was very common, with 81.8% of all sensitized patients positive to more than one allergen. CONCLUSIONS: Pollens of the local horticultural plants are the main sensitizing allergens among patients with allergic rhinitis in this desert environment. The practices that "green" the desert seem to also encourage allergen sensitization.

Adolescent↗
PubMed1999

DNA restriction patterns produced by pulsed-field gel electrophoresis in Moraxella catarrhalis isolated from different geographical areas.

Pulsed field gel electrophoresis (PFGE) of the genomic DNA of Moraxella catarrhalis was done in 172 strains isolated from sputum of patients with respiratory infections in Nagasaki (130 strains), Europe (14 strains), Thailand (6 strains), Uganda (3 strains), Bangladesh (5 strains) and Kuwait (14 strains). Restriction endonuclease with SmaI generated 4-16 DNA fragments ranging from 1000 kb to 24.25 kb and was classified into 31 major groups. It was found that there were wide variations of DNA restriction patterns of strains isolated from the same and different geographical areas. DNA restriction patterns of strains isolated in Nagasaki during the last 12 years showed dynamic changes of the predominant strains in each time period. We conclude from this study that PFGE is a suitable method to document interstrain variation in M. catarrhalis.

Adult↗
PubMed1999

Use of mass vaccination with a reduced dose of REV 1 vaccine for Brucella melitensis control in a population of small ruminants.

Mass vaccination with reduced dose 1/50 Rev 1 strain live vaccine (1-2 10(9) colony forming units), administered subcutaneously, over a four and a half year period reduced the prevalence of Brucella melitensis in Kuwait's small ruminant population from 5.8% in 1993 to 2.02% in 1997. Serological test results using the Rose Bengal Plate Test, Rivanol Agglutination Test and Complement Fixation showed no evidence of persistence of positive serology in animals nine or more months after vaccination. Questionnaires and post-vaccination flock inspections found that the effects on gestation (abortions) were minimal--and not proven to be due to the vaccine. The conclusion from these findings is that mass vaccination with reduced dose Rev 1 administered by the subcutaneous route is a practical field strategy for control of Brucella melitensis.

Abortion, Veterinary↗
PubMed1999

Urologic injuries in the Gulf War.

This study aims to compare the urologic injuries treated at Kuwait during the Gulf War with those recently reported by the United States urologic surgeons. Gunshot caused the majority of the injuries (58%) on our side of the battle compared with fragmentation injuries (83%) on the other side. We had statistically significant higher renal and ureteric injuries (14/35 compared with 5/30; p<0.04, Chi-square). This difference can be explained by the use of the flak jackets on the other side or the difference of the type of weapons used. Our management had a similar preservative approach. Only 4/12 of renal injuries (33%) had nephrectomy. Two ureteric injuries were missed by general surgeons which were successfully managed by the urologists. This study supports the presence of urologists within military surgical teams.

Abdominal Injuries↗
PubMed1999

Factors associated with obesity in Kuwaiti children.

The prevalence of adult obesity in Kuwait is among the highest in the Arab peninsula, and cardiovascular disease, for which obesity is a risk factor, is the leading cause of death. This study reports familial and environmental factors associated with childhood obesity; in addition to adverse effects of obesity on children's serum lipids, lipoproteins, apolipoproteins, insulin, and blood pressure profiles. The authors carried out a pair-matched case-control study including 460 obese (body mass index >90th percentile of the age/sex specific reference value of the National Center for Health Statistics), school children 6 to 13 years old matched by age and gender to 460 normal weight controls. We ascertained obese children in a cross-sectional survey of a representative sample of 2400 school children selected from 20 schools by multistage stratified random sampling. Biochemical variables and blood pressure were adversely affected in obese children. The conditional logistic regression analysis showed that family history of obesity, and diabetes mellitus, respiratory and bone diseases in child were significant associated factors with obesity after adjusting for social and behavioural factors. Physical activity and parental social class were not significant. We recommend early preventive measures with emphasis on families in which one or both parents are overweight.

Adolescent↗
PubMed2004

Lactic acidosis and developmental delay due to deficiency of E3 binding protein (protein X) of the pyruvate dehydrogenase complex.

Pyruvate dehydrogenase deficiency is an important cause of primary lactic acidosis. Most cases occur as a result of mutations in the gene for the E1 alpha subunit of the complex, with a small number resulting from mutations in genes for other components, most commonly the E3 and E3-binding protein subunits. We describe pyruvate dehydrogenase E3-binding protein deficiency in two siblings in each of two unrelated families from Kuwait. The index patient in each family had reduced pyruvate dehydrogenase activity in cultured fibroblasts and no detectable immunoreactive E3-binding protein. Both were homozygous for nonsense mutations in the E3-binding protein gene, one involving the codon for glutamine 266, the other the codon for tryptophan 5.

Acidosis, Lactic↗
PubMed2000

Asthma in the desert: spectrum of the sensitizing aeroallergens.

BACKGROUND: Bronchial asthma is common in Kuwait, a desert country, but the sensitizing allergens are uncertain. This study investigated the sensitizing allergens in Kuwaiti patients with extrinsic asthma. METHODS: A total of 553 asthmatics (male:female ratio: 1.4; mean age: 31.7 years [range 3-76 years]) and 112 matched controls were studied. Sera from all patients/subjects were tested by the CAP-RAST method for specific IgE to 14 locally relevant inhalant allergens. RESULTS: Specific IgE to at least one allergen was detected in 87.2% of the patients compared with 24.1% of controls. Among the confirmed extrinsic asthmatics, the sensitization rates for the allergen groups were as follows: pollens (87.1%), house dust (76.1%), and molds (30.3%). The three most prevalent sensitizing pollens were from Chenopodium (70.7%), Bermuda grass (62.9%), and Prosopis (62.7%), all of which are horticultural plants imported for the purpose of "greening" the desert. For all allergens, except the molds, the prevalence rate was higher in males than females, but age had only a weak effect. Severe asthma occurred significantly more frequently among mold-sensitized patients. CONCLUSIONS: These results show that even in a desert environment, pollens and house-dust allergens may be important sensitizing allergens. They also illustrate how practices that "green" the desert can affect public health.

Adolescent↗
PubMed2003

Butyrylcholinesterase activity and pregnancy-associated differences in immunologically relevant peripheral blood leukocyte populations.

PROBLEM: Toxic anticholinesterases (AC) are known contributors to negative pregnancy outcome. Impairment of detoxification mechanisms may correlate with occurrence of pregnancy disorders in Kuwait. METHOD OF STUDY: Butyrylcholinesterase (BuChE), an enzyme which detoxifies AC was evaluated in 18 Kuwaiti women with pregnancy-induced hypertension (PIH), compared with 15 healthy pregnant and eight healthy non-pregnant women. T-lymphocyte subpopulations were measured by flow cytometry, and BuChE activity was measured by spectrophotometry. RESULTS: Unlike the PIH group, the normal pregnancy group exhibited a significant increase in BuChE activity compared with non-pregnant control subjects (P = 0.04). Within the PIH cohort, inverse correlations were observed between BuChE activity and percentage of CD4+ CD25+ cells (P = 0.001), and CD8+ CD25+ cells (P = 0.007). CONCLUSIONS: Elevated BuChE activity in normal pregnancy may correlate with better ability to clear pregnancy-threatening toxins, while lesser ability to do this in PIH women may be a contributor to disease. The fact that PIH subjects with large subpopulations of activated T cells also exhibited low BuChE activity further suggests a correlation between susceptibility to pregnancy loss and decreased activity of the enzyme.

Adult↗
PubMed1997

Body mass index and prevalence of obesity changes among Kuwaitis.

OBJECTIVES: To compare temporal changes in BMI, overweight (BMI > 25 kg/m2) and obesity (BMI > 30 kg/m2) between two periods, among adult Kuwaitis. DESIGN: Comparison of two independent cross-sectional samples of Kuwaitis studied in 1980-81 and 1993-94. SUBJECTS: 2067 (896 men and 1171 women) and 3435 (1730 men and 1705 women) adult Kuwaitis (aged > or = 18 y), drawn from primary health care (PHC) clinics and studied for nutritional assessment and for prevalence of obesity in 1980-81 and 1993-94, respectively. MEASUREMENTS: Weight was measured in kilograms and height in meters to obtain the body mass index (BMI), which is the weight in kilograms divided by the height in meters squared (kg/m2). BMI > 25 and > 30 kg/m2 were classified as overweight and obesity, respectively. RESULTS: Mean BMI (kg/m2) increased significantly (P < 0.001) by 10.0 and 6.2% (2.5 and 1.7 kg/m2) among men and women, respectively. Prevalence of overweight and obesity (BMI > 25 and > 30 kg/m2) increased by 20.6 and 15.4% and by 13.7 and 8.4% among men and women, respectively. After controlling for sociodemographic differences between the two study periods, mean BMI was 2.0 and 1.6 kg/m2 higher in 1993-94 than in 1980-81 among men and women, respectively. Prevalence of overweight and obesity (BMI > 25 and > 30 kg/m2) also increased among both genders between the two periods (OR = 2.1, 95% CI 1.7-2.7 and OR = 1.9, 95% CI 1.5-2.4, for men and OR = 2.2, 95% CI 1.6-3.0 and OR = 1.4, 95% CI-1.0-1.9, for women). CONCLUSIONS: BMI, prevalence of overweight and obesity increased among Kuwaitis between 1980-81 and 1993-94, probably due to the effects of modernization, affluence, increased food consumption and the concomitant changes to sedentary lifestyles. The rate of temporal changes in BMI and obesity were higher, by comparison, in Kuwait than in selected other countries.

Adolescent↗
PubMed2002

Multiple coronary risk factors in healthy older Kuwaiti males.

OBJECTIVE: The objective was to examine the percentage and severity of obesity and some common biochemical coronary heart disease (CHD) risk factors in a sample of healthy Kuwaiti adult males > or =45 y of age. We also sought to determine the percentage of males at increased risk due to the presence of multiple CHD risk factors. DESIGN: The study was a cross-sectional study. SETTING: The study was conducted in all men who underwent a mandatory job related physical examination or who sought to obtain retirement benefits. SUBJECTS: A total of 740 healthy Kuwaiti males between the ages of 45 to 80 y. RESULTS: In all, 37% of the men were obese, 26% had elevated glucose values and 52% had elevated or high cholesterol levels. Some had multiple risk factors for CHD, including age > or =45 y, obesity, male gender, hyperglycemia and hypercholesterolemia. Blood glucose values increased consistently from younger (45-54 y) to older age groups (55-64 and > or =65 y). Blood glucose values varied inversely with education level. CONCLUSIONS: In societies with relatively uniform income levels, educational level may be a better indicator of chronic disease risk than income per se. These results, showing a high percentage of men with several risk factors and high mean values, suggesting more severe risk, suggest that immediate action should be taken to develop a public health intervention strategy to educate Kuwaiti men to become aware of the causes and correlates of CHD and how to decrease their risk for CHD and heart attack, the leading cause of death in Kuwait.

Aged↗
PubMed1997

Changes in body mass index (BMI) and prevalence of obesity among Kuwaitis 1980-1994.

OBJECTIVE: To compare temporal changes in body mass index (BMI) (kg/m2) and prevalence of obesity (BMI > 25 and > 30 kg/m2) among adult Kuwaitis between two periods 14 y apart. DESIGN: Comparison of two independent cross-sectional samples of Kuwaitis studied in 1980-1981 and 1993-1994. SUBJECTS: 2067 (896 men and 1171 women) and 3435 (1730 men and 1705 women) adult Kuwaitis (aged > or = 18 y), drawn from primary health care (PHC) clinics and studied for nutritional assessment and for prevalence of obesity in 1980-1981 and 1993-1994, respectively. MEASUREMENTS: BMI, which is the weight in kilograms divided by the height in meters squared (kg/m2), was based on measured weight and height. Obesity was defined as BMI > 25 kg/m2 (grade 1) and BMI > 30 kg/m2) (grade 2). RESULTS: Mean BMI increased significantly (P < 0.001) by 10.0% and 6.2% (2.5 and 1.7 kg/m2) among men and women, respectively. Prevalence of obesity (BMI > 25 and > 30 kg/m2) increased by 20.6% and 15.4% and by 13.7% and 8.4% among men and women, respectively. After controlling for sociodemographic differences between the two study periods, BMI was 2.0 and 1.6 kg/m2 higher in 1993-1994 than in 1980-1981 among men and women respectively. The risk of obesity (BMI > 25 and > 30 kg/m2) also increased among both genders between the two periods (OR = 2.1, 95% CI 1.7-2.7 and OR = 1.9, 95% CI 1.5-2.4, for men and OR = 2.2, 95% CI 1.6-3.0 and OR = 1.4, 95% CI 2.2 CI-1.0-1.9, for women). CONCLUSION: BMI and prevalence of obesity increased among Kuwaitis between 1980-1981 and 1993 and 1994 probably due to the effects of modernization, affluence, increased food consumption and the concomitant changes to sedentary lifestyles. The rate of temporal changes in BMI and obesity were higher, by comparison, in Kuwait than in selected other countries.

Adolescent↗
PubMed1999

Metabolic and anthropometric determinants of serum Lp(a) concentrations and Apo(a) polymorphism in a healthy Arab population.

BACKGROUND: Blood lipoprotein(a) Lp(a) concentrations are an important risk factor for atherosclerosis. The basis for this atherogenic property of Lp(a) and the factors that influence its cross-population levels, however, remain poorly understood. OBJECTIVES: To investigate the relationship between serum Lp(a) and metabolic and anthropometric parameters in a healthy Kuwaiti population. DESIGN: Cross-sectional study. SUBJECTS: 177 (72 male, 105 female) randomly recruited healthy Kuwait Arabs aged 17-60 y MEASUREMENTS: Metabolic parameters in serum: Lp(a), apo(a) phenotypes, lipids and lipoproteins, glucose and urate. Anthropometric parameters: body mass index (BMI) and waist:hip-ratio (WHR). RESULTS: The distribution of Lp(a) concentrations was positively skewed (median 153 mg/l, range 0-1086). Women had higher concentrations-(194, 0-1086) than men (117, 0-779), P = 0.069. Lp(a) and insulin concentrations were significantly higher when the men and women were obese. In all subjects, there were significant correlations between Lp(a) and BMI (r = 0.23), total cholesterol (TC) (r = 0.17) and LDL (r = 0.20). Lp(a) correlated only with glucose in men (r = 0.28). In women it correlated with age (r = 0.20), BMI (r = 0.30), BP (r = 0.20), TC (r = 0.20) and LDL (r = 0.26). Multivariate analyses confirmed BMI and low-density lipoprotein (LDL) as the significant determinants of serum Lp(a). On apo (a) phenotyping, 114 (67%), 51 (30%) and 6 (4%) had single, double and null phenotypes respectively. The isoforms and their corresponding kringle IV repeat numbers were: F (14 repeats in 3%, mean Lp(a) 497 mg/l); S1 (19 repeats in 14%, mean 245 mg/l); S2 (23 repeats in 16%, mean 264 mg/l); S3 (27 repeats in 35%, mean 236 mg/l); and S4 (35 repeats in 28%, mean 235 mg/l). DISCUSSION AND CONCLUSION: The results from the Kuwaiti population studied suggest that: (1) serum Lp(a) concentrations and distribution are similar to the pattern in Caucasians and Asians but not African-Americans or Africans; (2) serum Lp(a) is variably influenced by BMI and LDL--the impact of either factor differs between the sexes; (3) there is a high frequency of the single-banded phenotype; (4) contrary to reports in some Caucasian and Asian populations, there is no simple relationship between kringle IV repeat numbers and plasma Lp(a) concentrations.

Adolescent↗
PubMed2002

Subjective need and orthodontic treatment experience in a Middle East country providing free orthodontic services: a questionnaire survey.

The aims of this study were to explore orthodontic treatment experience, subjective need for treatment, and perceptions of teeth and dental appearance in relation to background factors such as funding system, area of living, age, gender, ethnicity, and socioeconomic status. The subjects were 1076 randomly selected second-year high school students from a rural (Jahra) and an urban (Capital) area of Kuwait, with a mean age of 15.1 years. Kuwaiti citizens constituted 79% of the sample, and the rest were of other Arab origins. The data were collected using a questionnaire. Orthodontic treatment rate was significantly higher for Kuwaitis (10%) than for non-Kuwaitis (2%). Among Kuwaiti subjects, urban area of living and female gender increased the odds of receiving orthodontic treatment. Subjective treatment need was 36%, with no difference between Kuwaiti and non-Kuwaiti subjects, but Kuwaitis in the rural area expressed subjective treatment need less often than those in the urban area. The results suggest that access to free-of-cost orthodontic treatment was likely to affect treatment rate, whereas it did not seem to influence the self-perceived need for treatment. Gender and area of living may be significant for the distribution of free-of-cost orthodontic treatment.

Adolescent↗
PubMed2001

Cryptosporidiosis in Kuwaiti children: seasonality and endemicity.

OBJECTIVE: To detect the incidence of cryptosporidial infection in children presenting with gastrointestinal symptoms at the local hospital in Kuwait. METHODS: Over a period of 3 years, September 1995 to August 1997, a single fecal sample from 3549 children was analyzed by modified saframin-methylene blue (SM-B) staining and a direct immunofluorescence test for the presence of Cryptosporidium oocysts. RESULTS: Cryptosporidium oocysts were detected in 51 (10%) children with diarrhea. Prevalence was highest (73%) in children > 2 years of age compared with children < 2 years of age. The maximum number of cases, 38 of 51 (75%), was seen during the months January to April, indicating a marked seasonal variation. Polyparasitism was common in children with diarrhea; however, 43 of the 51 (84%) children with cryptosporidiosis had cryptosporidium infection only. Blastocystis hominis and Endolimax nana were the most common parasites detected (38% and 15%, respectively). Forty-seven of the 51 (90%) children with cryptosporidiosis were Kuwaiti and gave no history of travel abroad, suggesting that the infection was acquired indigenously. Sociodemographic information on children with cryptosporidiosis suggests three possible modes of transmission of infection: drinking contaminated water stored in overhead water tanks, person to person, or contact with infected animals. CONCLUSION: In this study, we observed water-borne transmission of cryptosporidium infection in children with diarrhea. The infection is seasonal and endemic.

Age Factors↗
PubMed1999

Value of radiologically guided fine needle aspiration cytology (FNAC) in the diagnosis of spinal tuberculosis: a study of 29 cases.

FNAC is a simple diagnostic tool for the initial evaluation of various deep seated pathological lesions. This study describes the applicability and practical aspects of the technique in establishing the diagnosis of spinal tuberculosis (TB) with the aid of radiographic guidance. The study was conducted in a major teaching hospital in Kuwait between the years 1985 and 1994. Twenty-nine patients (M:F = 18:11 and age range 8-72 years) with clinically and/or radiologically suspected spinal TB were seen in the Department of Cytology, Mubarak Al Kabeer Hospital. The patients were re-examined by either computed tomography (CT) scanning (n = 19) or fluoroscopy (n = 10) to localize the lesion for FNAC. FNAC smears were routinely stained with Papanicolaou and Diff Quik stains and one smear of each case was stained with Ziehl-Neelsen (Z-N) stain for acid-fast bacilli (AFB). Aspirated purulent material or syringe washings of dry aspirates were also submitted for microbiological cultures including AFB. Radiological and cytological findings were recorded in each case. Radiological findings included: bony rarefaction and destruction (93.1%), narrowed disc space (89.7%), soft tissue calcification (65.5%) and para-vertebral abscess formation (51.7%). Cytological findings included: epithelioid cell granulomas (89.7%), granular necrotic background (82.8%) and lymphocytic infiltration (75.9%). Smears were positive for AFB in 51.7% of cases. A positive AFB culture was obtained in 82.8% of cases, including all cases with positive AFB on smear by Z-N stain. Radiologically guided FNAC with AFB culture is a simple, reliable and practical approach to diagnosing spinal TB lesions. With a high diagnostic yield, it allows immediate initiation of specific treatment, helps to avoid invasive diagnostic procedures, and decreases hospitalization time.

Adolescent↗