Biomedical subjects

A Rudisch

Publications and source records attributed to A Rudisch.

At least 19 recordsLinked to original sources

PubMed2007

Condylar injury: magnetic resonance imaging findings of temporomandibular joint soft-tissue changes.

Recent studies have suggested magnetic resonance imaging (MRI) as useful in the evaluation of soft-tissue changes that occur in the temporomandibular joint (TMJ) after acute condylar trauma. The aim of this study was to investigate whether MRI findings of disc displacement, capsular tear and haemarthrosis are linked to the degree of condylar injury. Nineteen patients were assigned a diagnosis of uni- or bilateral condylar fracture (n=17), or condylar contusion with a uni- or bilateral diagnosis of TMJ sprain/strain (n=2). Condylar injuries were classified as grade I (absence of condylar fracture), grade II (type I, II or III condylar fracture), and grade III (type IV, V or VI condylar fracture). Bilateral sagittal and coronal MR images were obtained immediately after injury to establish the presence or absence of disc displacement, haemarthrosis and capsular tear. The data revealed a significant relationship between the degree of condylar injury and the MRI findings of capsular tear (P=0.000) and haemarthrosis (P=0.000), and between the MRI diagnoses of capsular tear and haemarthrosis (P=0.000). There was good diagnostic agreement between the presence of grade III condylar injury and the MRI diagnoses of capsular tear (K=0.62) and haemarthrosis (K=0.60). The results suggest that degree of condylar injury is related to MRI findings of capsular tear and haemarthrosis, and that MRI to supplement diagnosis of grade III condylar injury is warranted.

Adolescent↗

PubMed2005

Sagittal wrist motion of carpal bones following intraarticular fractures of the distal radius.

Forty patients (mean age, 37 years) with intraarticular C2 and C3 Colles fractures were treated by open reduction, internal fixation and bone grafting. At a mean follow-up of 8 years radiocarpal and midcarpal motion was evaluated, the depth of the articular surface of the distal radius in the sagittal plane was measured and the presence of arthritis was noted. The fractures healed with a mean palmar tilt of 6 degrees , a mean ulnar tilt of 18 degrees and ulna variance within 1 mm of the contralateral side. The depth of the articular surface of the distal radius was 1.3 mm greater than the uninvolved side. Measurement of carpal bone angles relative to the radius in maximum flexion and extension revealed lunate extension of 23 degrees , lunate flexion of 15 degrees , capitate extension of 62 degrees , capitate flexion of 40 degrees . There was a significant correlation between articular surface depth and radiocarpal motion.

Adolescent↗

PubMed2005

Diagnostic quality of dynamic high-resolution ultrasonography of the TMJ--a pilot study.

The aim of this study was to compare sensitivity, specificity, accuracy and positive and negative predictive value for high-resolution ultrasonography (HR-US) in diagnosing degenerative changes, effusion and disk displacement using magnetic resonance imaging (MRI) as a reference. Over a period of 6 months, 100 patients with TMJ disorders (200 TMJs) were investigated by an experienced radiologist with HR-US and magnetic resonance imaging (MRI). The MRI investigation showed degenerative changes in 190 joints (95%), while an effusion was found in 59 (29.5%) joints. At closed-mouth position a disc dislocation was found in 138 joints (69%) and in maximum-mouth-opening position disc dislocation was diagnosed in 76 joints (38%). In the determination of degenerative changes HR-US showed a sensitivity of 94%, a specificity of 100% and an accuracy of 94%. In the detection of effusion HR-US yielded a sensitivity of 81%, a specificity of 100% and an accuracy of 95%. In the determination of disk displacement at closed-mouth position HR-US showed a sensitivity, specificity and an accuracy of 92% each. At maximum-mouth-opening position HR-US reached a sensitivity of 86%, a specificity of 91% and an accuracy of 90%. The results of the current study imply that HR-US is a valuable diagnostic imaging method of the TMJ which can be used as an alternative method to a MRI-investigation, but is yet not able to replace it. Further studies have to be done to reduce false-negative results.

False Negative Reactions↗

PubMed2004

Dorsal scapholunate ligament reconstruction using a periosteal flap of the iliac crest.

INTRODUCTION: To report a new technique for scapholunate ligament reconstruction, using a periosteal flap of the iliac crest. MATERIALS AND METHODS: In 12 patients with static SL instability, a periosteal flap was harvested from the anterior portion of the iliac crest. Following repositioning of the carpals, the flap was fixed to the scaphoid and lunate between an incompletely osteotomised scale at the dorsal horn of the scaphoid and lunate. Pin fixation of the scapholunate (SL) and CL interval secured postoperative reduction for 8 weeks. A forearm plaster cast was worn for 12 weeks. RESULTS: Eleven patients, all male, were available for follow-up at an average of 29 months. The interval between trauma and surgery averaged 15 months. The preoperative SL angle measured 77 deg, CL angle was -10 deg, and SL gap amounted to 5.2 mm. At follow-up, SL angle was 59 deg, CL angle measured -2 deg, and SL gap was 2.1 mm. SL gap, SL angle, and CL angle improved significantly from preoperative to follow-up values. According to the clinical grading system of Green and O'Brian, 6 patients scored in the excellent and good category and 5 in the fair category. Using the radiologic grading system of Gickel and Millender, 9 patients scored as excellent and good, whereas the 2 poor results were due to failure of the technique. CONCLUSION: The technique enables reduction of the SL angle and SL gap in patients with static reducible scapholunate instability. The initial results are quite encouraging.

Bone Transplantation↗

PubMed2004

Cerebral vasculitis in a patient with hereditary complete C4 deficiency and systemic lupus erythematosus.

We describe the case of a female patient with hereditary complete C4 deficiency and systemic lupus erythematosus. She had suffered from lupus nephritis in early childhood. At the age of 23 years she developed severe lupus with skin disease and life-threatening cerebral vasculitis. Her cerebral disease was unresponsive to high-dose steroids, intravenous immunoglobulin, fresh frozen plasma and plasma exchange. Improvement was achieved with immunoadsorption in combination with mycophenolate mofetil. The patient made a complete recovery and is maintained in complete remission on mycophenolate and low-dose steroids.

Adult↗

PubMed2003

Validation of the clinical diagnostic criteria for temporomandibular disorders for the diagnostic subgroup of degenerative joint disease.

Research is needed to assess the validity of the Clinical Diagnostic Criteria for Temporomandibular Disorders (CDC/TMD). The purpose of this study was to test the reliability of the clinical diagnosis of temporomandibular joint (TMJ) degenerative joint disease (DJD) as compared with the magnetic resonance imaging (MRI) 'gold standard'. The TMJ DJD group comprised 48 joints in 24 consecutive patients who were assigned a clinical bilateral diagnosis of TMJ DJD. The TMJ non-DJD group consisted of 82 joints in 41 consecutive patients without a TMJ-related diagnosis of TMD. Bilateral sagittal and coronal MR images were obtained subsequently to establish the corresponding diagnosis of degenerative joint changes. An MRI diagnosis of osteoarthrosis (OA) was defined by the presence of flattening, subchondral sclerosis, surface irregularities, and erosion of the condyle or presence of condylar deformities associated with flattening, subchondral sclerosis, surface irregularities, erosion and osteophyte. For the CDC/TMD interpretations, the positive predictive of DJD for OA was 67%, and for the presence of degenerative joint changes 88%. The overall diagnostic agreement for DJD was 44.6% with a corresponding K-value of 0.01. Most of the disagreement was due to false-negative interpretations of asymptomatic joints. The results suggest CDC/TMD to be predictive for degenerative joint changes but insufficient for determination of OA. Patients assigned a clinical TMJ-related diagnosis of DJD may need to be supplemented by evidence from MRI to determine the presence or absence of OA.

Adult↗

PubMed2003

Effect of scanning level and muscle condition on ultrasonographic cross-sectional measurements of the anterior masseter muscle.

With the disadvantage of computed tomography showing cumulative biological effects and magnetic resonance imaging posing a problem in clinical availability and cost, several authors described the technique of ultrasonography to measure non-invasively local cross-sectional dimensions (LCSDs) of masseter muscle sites. However only few studies addressed the issue of 'technique-related factors for intra- and inter-observer reliability' to gain more consistent testing and diagnosis. The purpose of the present study was to determine (1) whether the scanning level and/or the muscle condition may affect LCSD measurements and (2) whether measurements made at identical levels may be reproducible. The study included 35 subjects with signs and symptoms of temporomandibular disorders. Bilateral ultrasonographic investigation was performed with a linear (B-scan) 7.5 Mhz small-part transducer to register LCSDs of the anterior masseter muscle on three different levels. Scans were made on the relaxed and contracted muscle. Measurements were made in two sessions with a time interval of at least 5 min. Data were analysed for reproducibility by using the intra-class correlation coefficient (ICC) and the method error (ME). Scanning level and muscle condition had a significant effect on muscle measurements (P = 0.000). There was no difference in LCSD between the right and left muscle (P = 0.531). Measurements recorded at a given site were consistent across the testing sessions (P = 0.058). The scanning level with highest reproducibility was halfway between the origin and insertion (ICC = 0.92; ME = 6.2%). The data suggest that ultrasonography is a reliable method for measuring LSCDs of the anterior masseter muscle.

Adult↗

PubMed2003

Temporomandibular joint internal derangement: detection with 12.5 MHz ultrasonography.

The purpose of this study was to determine whether 12.5 MHz ultrasonography (US) could be used to assess the presence or absence of temporomandibular joint (TMJ) internal derangement (ID). In 48 consecutive patients with TMJ disorders 192 TMJ positions were investigated by US to analyse the functional disc-condyle relationship (DCR). In order to compare the respective findings with those of a diagnostic method offering a high accuracy, coronal and sagittal magnetic resonance imaging was carried out immediately afterwards. With US showing a sensitivity of 0.58 and 0.75, and a specificity of 0.92 and 0.84 for disc displacement with and without reduction, the data revealed US to be marginal in detecting the presence, but sensitive in detecting the absence of the respective types of a TMJ ID. In addition, with a positive predictive value of 0.83 and 0.71, and a negative predictive value of 0.81 and 0.87 for disc displacement with and without reduction, the results indicate that US may be insufficient in establishing a correct diagnosis for the presence or absence of the respective types of TMJ ID. Regarding the diagnosis of absence or presence of TMJ ID, the results demonstrate high-resolution (HR)-US to be sensitive in detecting the absence, and reliable in predicting the presence of TMJ ID. In view of the fact that the 12.5 MHz US technique proved to be a reliable diagnostic aid for the detection of normal, and the prediction of abnormal DCR, the results of this study should be of further interest and encourage research in its potential uses and diagnostic capabilities.

Adolescent↗

PubMed2003

Risk factors for temporomandibular joint pain in patients with disc displacement without reduction - a magnetic resonance imaging study.

The purpose of this study was to evaluate whether the magnetic resonance (MR) imaging variables of temporomandibular joint (TMJ) internal derangement, osteoarthrosis and/or effusion may predict the presence of pain in patients with a clinical disorder of an internal derangement type (ID)-III. The relationship between TMJ ID-III pain and TMJ internal derangement, osteoarthrosis and effusion was analysed in MR images of 84 TMJs in 42 patients with a clinical unilateral diagnosis of TMJ ID-III pain. Criteria for including a TMJ ID-III pain patient were report of orofacial pain referred to the TMJ, with the presence of unilateral TMJ pain during palpation, function and/or unassisted or assisted mandibular opening. Bilateral sagittal and coronal MR images were obtained to establish the presence or absence of TMJ internal derangement, osteoarthrosis and effusion. Using chi-square analysis for pair-wise comparison, the data showed a significant relationship between the MR imaging findings of TMJ ID-III pain and those of internal derangement (P=0.01) and effusion (P=0.00). Of the MR imaging variables considered simultaneously in the multiple logistic regression analysis, osteoarthrosis (P=0.82) and effusion (P=0.08) dropped out as non-significant in the diagnostic TMJ pain group when compared with the TMJ non-pain group. The odds ratio that a TMJ with an internal derangement type of disk displacement without reduction might belong to the pain group was strong (2.7:1) and highly significant (P=0.00). Significant increases in risk of TMJ pain occurred with 'disk displacement without reduction in combination with osteoarthrosis' (5.2:1) (P=0.00) and/or 'disk displacement without reduction in combination with osteoarthrosis and effusion' (6.6:1) (P=0.00). The results suggest that TMJ pain is related to internal derangement, osteoarthrosis and effusion. However, the data re-emphasize the aspect that these MR imaging variables may not be regarded as the unique and dominant factors in defining TMJ pain instances.

Adolescent↗

PubMed2003

Temporomandibular joint osteoarthrosis diagnosed with high resolution ultrasonography versus magnetic resonance imaging: how reliable is high resolution ultrasonography?

The purpose of this study was to determine whether 12.5 MHz ultrasonography (US) could be used to assess the presence or absence of temporomandibular joint (TMJ) condylar osteoarthrosis. In 40 consecutive patients with TMJ disorders, 80 TMJs were investigated by US to analyse the condylar morphology. In order to compare the respective findings with those of a diagnostic method offering a high accuracy, coronal and sagittal magnetic resonance imaging was carried out immediately afterwards. With US showing a sensitivity of 87%, and a specificity of 20%, the data revealed US to be sensitive in detecting the presence, but insufficient in detecting the absence of osteoarthrosis. In addition, with a positive predictive value of 88%, and a negative predictive value of 18%, the results indicate that US may be valuable in diagnosing the presence, but insufficient in diagnosing the absence of osteoarthrosis. In view of the fact that the 12.5 MHz US technique proved to be a valuable diagnostic aid for the detection and prediction of abnormal condylar morphology, the results of this study should be of further interest and encourage research in its potential uses and diagnostic capabilities.

Adolescent↗

PubMed2003

Cross-sectional characteristics of the masseter muscle: an ultrasonographic study.

Cross-sections of the masseter muscle may now be measured non-invasively using ultrasonography. The purpose of the present study was to determine (1) whether the scanning level may affect cross-sectional measurements and (2) whether measurements made at identical levels may be reproducible. The study included 42 asymptomatic volunteers. Unilateral ultrasonographic investigation was performed with a linear (B-scan) 7.5 Mhz small-part transducer to register cross-sections of the masseter muscle on five different levels. Scans were made on the relaxed and contracted muscle. Measurements were made in two sessions with a time interval of at least 5 min. Statistical analysis consisted of univariate analysis of variance for repeated measurements. Data were analysed for reproducibility by using the method error and measurement error. For the ultrsonographic measurements the main effects of the variables 'session' (P=0.0001), 'level' (P=0.0001), and 'condition' (P=0.0001) were significant. Analysis of simple session-within-level effects revealed a significant difference between the repeated measurements for the most upper level (P=0.022), the upper level (P=0.012), and the most lower level (P=0.0001) of the relaxed muscle. An additional significant effect was found for the most lower level of the contracted muscle (P=0.015). Cross-sections evaluated at the middle (method error=0.31 mm; measurement error=2.0%) and lower level (method error=0.32 mm; measurement error=2.4%) of the contracted muscle were the most reproducible. The conclusion is that ultrasonography is a reproducible method for measuring cross-sections at the middle and lower level of the contracted masseter muscle.

Adolescent↗

PubMed2003

[Diffusion-weighted MRI--a new parameter for advanced rectal carcinoma?].

PURPOSE: To evaluate the predictive value of apparent diffusion coefficient (ADC) on therapy outcome of combined chemoradiation in patients with primary carcinoma of the rectum. MATERIALS AND METHOD: Prior to standardized, combined, neoadjuvant chemoradiation, 16 patients with primary carcinoma of the rectum (cT3) were examined with magnetic resonance imaging (MRI). Diffusion-weighted spin echo echo-planar images (SE-EPI) and contrast-enhanced T 1 -weighted spin echo (SE) images at 1.5 Tesla were obtained. The mean ADC of the tumor region was calculated and correlated with the therapy outcome substantiated by postsurgical histopathologic staging. RESULTS: Tumor down-staging (pT0-2) occurred in 9 patients (therapy responders) and no down-staging (pT3) in 7 patients (therapy non-responders). The mean ADC measured 0.476 +/- 0.114 x 10(-3) mm 2/s in the responder group and 0.703 +/- 0.085 x 10(-3) mm 2/s in the non-responder group. Comparison of the mean ADC between the groups reached statistical significance (p = 0.001). CONCLUSION: The mean ADC might be a new quantitative parameter to predict therapy outcome of combined preoperative chemoradiation in patients with primary carcinoma of the rectum.

Adenocarcinoma↗

PubMed2003

Reliability and temporal variation of masseter muscle thickness measurements utilizing ultrasonography.

Muscle thickness may now be measured in the clinic by ultrasonography. The purpose of this study was to test (i) whether the position of the transducer on the muscle affects muscle thickness measurements and (ii) whether measurements from identical locations vary over time. Muscle thickness of one masseter muscle side was measured in each of 30 volunteers. Measurements were recorded at five different locations on the lateral surface of each muscle. Four measurement sessions were performed, and two sets of measurements were recorded at each session. Spatial position of the transducer had a clear effect on the muscle thickness measurements (P < 0.0001). Measurements made at the most upper and middle level were less and greater (P < 0.0001), respectively, than those made at the upper, lower, and most lower levels. Measurements from various positions did not differ (P > 0.05) when made at the same level. Masseter thickness measurements recorded at a given site were consistent across all of the testing sessions (P=0.575). The data suggest that reliable interpretation of longitudinal measurements of masseter thickness obtained with ultrasonography requires accurate repositioning of the transducer. Ultrasonography may be used to investigate the effect of specific treatment modalities on masseter thickness measurements.

Adult↗

PubMed2002

Effect of stabilization-type splints on the asymmetry of masseter muscle sites during maximal clenching.

Patients with temporomandibular disorders may present with a cluster of joint and muscle disorders characterized primarily by pain, joint sounds and irregular or deviating jaw function. Maxillary stabilization-type splints represent the best standard therapy, so the purpose of this study was to evaluate changes in local maximal clenching-related asymmetry patterns of masseter muscle sites associated with the immediate 'application of splint therapy' using the diagnostic approach of high-resolution gray-scale ultrasonography. The study included 24 patients who had signs and symptoms of temporomandibular disorders. Ultrasonographic investigation was performed with a linear (B-scan) 7.5 Mhz small-part transducer to visualize the antero-superior, antero-inferior, medio-superior, medio-inferior, postero-superior, and postero-inferior sites of the masseter muscle. To assess local maximal clenching-related muscle asymmetry patterns and to evaluate the respective effect of occluding splints, the 'absolute asymmetry index' was used, with the mean maximum muscle diameter of the respective right and left sides calculated from three consecutive measurements before and after splint insertion. Comparing the values assessed before splint insertion with those after splint insertion revealed a significant decrease in local maximal clenching-related muscle asymmetry values for the antero-inferior masseter muscle site (P < 0.05). The results of this study suggest stabilization-type splints to have a site-specific effect in the immediate reduction of local maximal clenching-related muscle asymmetries. Further studies are warranted to evaluate muscle-site specific effects in patient and non-patient groups and to relate these effects to pre-treatment variables like bite force, preferred chewing side, facial morphology and occlusion.

Adult↗

PubMed2002

Magnetic resonance imaging findings of internal derangement in temporomandibular joints without a clinical diagnosis of temporomandibular disorder.

The purpose of this study was to assess the prevalences of magnetic resonance (MR) imaging findings of internal derangement (ID) in temporomandibular joints (TMJs) without a specific clinical diagnosis of temporomandibular disorder (TMD), and to investigate whether in this TMJ group the variable of pain may be linked to MR imaging findings of ID. The study comprised 109 patients, who were assigned a clinical uni- or bilateral TMJ-related diagnosis of 'absence of TMD'. Bilateral sagittal and coronal MR images were obtained subsequently to establish the prevalence of TMJ ID. An MR imaging diagnosis of ID was found in 99 (55.9%) of the 177 TMJs investigated. About 30.3% of the closed mouth-related TMJ positions characterized by disc displacement presented with anterior disc displacement, while 27.3% had anterolateral and 25.3% anteromedial disc displacement. Analysis of the data revealed the presence of TMJ pain to be associated with significantly more MR imaging diagnoses of disc displacement without reduction than disc displacement with reduction (P < 0.05), while there was no significant difference in the prevalences of ID and those of absence of ID (P > 0.05). Using chi-square analysis, no significant relationship was found between the presence of TMJ pain and the MR imaging diagnosis of TMJ ID (P=0.93). Use of the kappa statistical test indicated poor diagnostic agreement between the presence of TMJ pain and the MR imaging diagnosis of ID (kappa=0.01). The results suggest TMJs with a clinical diagnosis of 'absence of TMD' to be associated with a high rate of IDs, while in these instances the clinical variable of TMJ pain may have no effect on prevalences of MR imaging diagnoses TMJ ID. The data confirm the aspect of clinical diagnostic criteria as an unreliable instrument in predicting MR imaging diagnoses of TMJ ID.

Adolescent↗

PubMed2002

Ultrasonographic assessment of local cross-sectional dimensions of masseter muscle sites: a reproducible technique?

Local cross-sectional dimensions (LCSDs) of masseter muscle sites may now be measured non-invasively using ultrasonography. The purpose of the present study was to determine (i) whether the muscle site may affect LCSD measurements and (ii) whether measurements made at identical sites may be reproducible. The study included 17 patients who had signs and symptoms of temporomandibular disorders (TMD). Bilateral ultrasonographic investigation was performed with a linear (B-scan) 7.5 MHz small-part transducer to visualize the antero-superior, antero-inferior, medio-superior, medio-inferior, postero-superior, and postero-inferior sites of the masseter muscle. Measurements were made in two sessions with a time interval of at least five minutes. Data were analysed for reproducibility by using the intraclass correlation coefficient (ICC) and the method error (ME). Muscle site had no significant effect on muscle measurements (P = 0.090). Measurements from the various side-related sites did not differ significantly (P = 0.425). Measurements recorded at a given site were consistent across the testing sessions (P = 0.605). The muscle site with highest reproducibility was the medio-inferior site (ICC = 0.92; ME = 6.4%). The data suggest that ultrasonography is a reproducible method for measuring LSCDs of the masseter muscle.

Adolescent↗

PubMed2002

Validation of the clinical diagnostic criteria for temporomandibular disorders for the diagnostic subgroup - disc derangement with reduction.

Research is needed to assess the validity of the clinical diagnostic criteria for temporomandibular disorders (CDC/TMD). The purpose of this study was to test the reliability of the clinical diagnosis of temporomandibular joint (TMJ) internal derangement type (ID)-I as compared with the magnetic resonance imaging (MRI) 'gold standard'. The study comprised 168 TMJs in 84 patients, who were assigned a clinical TMJ-related diagnosis of ID-I (disc displacement with reduction) in at least one TMJ. Bilateral sagittal and coronal MR images were obtained subsequently to establish the corresponding diagnosis of the disc-condyle relationship. For the CDC/TMD interpretations, the positive predictive value (PPV) of ID-I for disc displacement with reduction (DDR) was 44%, and for the presence of an ID 69%. The overall diagnostic agreement for ID-I was 47.6% with a corresponding K-value of 0.05. Most of the disagreement was the result of the false-positive interpretations of ID-I, and false-negative interpretations of an 'absence of ID'. The results suggest CDC/TMD for ID-I to be insufficient reliable for determination of ID and/or DDR. Patients assigned a clinical TMJ-related diagnosis of ID-I may need to be supplemented by evidence from MRI to determine the functional 'disc-condyle relationship'.

Adolescent↗

PubMed2002

Magnetic resonance imaging findings of osteoarthrosis and effusion in patients with unilateral temporomandibular joint pain.

The purpose of this study was to investigate the relationship between the presence of temporomandibular joint (TMJ) pain and the magnetic resonance (MR) imaging findings of osteoarthrosis (OA), and effusion. The study comprised 112 consecutive TMJ pain patients. Criteria for including a patient were report of unilateral pain near the TMJ, with the presence of unilateral TMJ pain during palpation, function, and/or unassisted or assisted mandibular opening. Bilateral sagittal and coronal MR images were obtained to establish the presence or absence of TMJ OA, and/or effusion. Comparison of the TMJ side-related data showed a significant relationship between the clinical finding of TMJ pain and the MR imaging diagnoses of TMJ OA (P=0.000), and TMJ effusion (P=0.000). Further, there was a significant relationship between the MR imaging diagnosis of TMJ OA and TMJ effusion (P=0.000). Use of the Kappa statistical test indicated poor diagnostic agreement between the presence of TMJ pain and the MR imaging diagnosis of TMJ OA (K=0.22), TMJ effusion (K=0.29), and TMJ 'OA and effusion' (K=0.30). The study's findings suggest that while clinical pain is correlated to TMJ-related MR imaging findings, clinical pain in and of itself, is not reliable for predicting the presence of TMJ OA and/or effusion. Validation of MR imaging diagnoses would involve the investigation of cross-sectional and longitudinal evidence to assess decisive differences in terms of prognosis and/or treatment outcome.

Adolescent↗