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David L Simel

Publications and source records attributed to David L Simel.

13 recordsLinked to original sources
PubMed2006

Do opiates affect the clinical evaluation of patients with acute abdominal pain?

CONTEXT: Clinicians have traditionally withheld opiate analgesia from patients with acute abdominal pain until after evaluation by a surgeon, out of concern that analgesia may alter the physical findings and interfere with diagnosis. OBJECTIVE: To determine the impact of opiate analgesics on the rational clinical examination and operative decision for patients with acute abdominal pain. DATA SOURCES AND STUDY SELECTION: MEDLINE (through May 2006), EMBASE, and hand searches of article bibliographies to identify placebo-controlled randomized trials of opiate analgesia reporting changes in the history, physical examination findings, or diagnostic errors (those resulting in "management errors," defined as the performance of unnecessary surgery or failure to perform necessary surgery in a timely fashion). DATA EXTRACTION: Two authors independently reviewed each study, abstracted data, and classified study quality. A third reviewer independently resolved discrepancies. DATA SYNTHESIS: Studies both in adults (9 trials) and in children (3 trials) showed trends toward increased risks of altered findings on the abdominal examination due to opiate administration, with risk ratios for changes in the examination of 1.51 (95% confidence interval [CI], 0.85 to 2.69) and 2.11 (95% CI, 0.60 to 7.35), respectively. When the analysis was restricted to the 8 adult and pediatric trials that reported significantly greater analgesia for patients who received opiates compared with those who received placebo, the risk of physical examination changes became significant (risk ratio, 2.13; 95% CI, 1.14 to 3.98). These trials exhibited significant heterogeneity (I2 = 68.6%; P = .002), and only 2 trials distinguished clinically significant changes such as loss of peritoneal signs from all other changes; consequently, we analyzed risk of management errors as a marker for important changes in the physical examination. Opiate administration had no significant association with management errors (+0.3% absolute increase; 95% CI, -4.1% to +4.7%). The 3 pediatric trials showed a nonsignificant absolute decrease in management errors (-0.8%; 95% CI, -8.6% to +6.9%). Across adult and pediatric trials with adequate analgesia, opiate administration was associated with a nonsignificant absolute decrease in the risk of management errors (-0.2%; 95% CI, -4.0% to +3.6%). CONCLUSIONS: Opiate administration may alter the physical examination findings, but these changes result in no significant increase in management errors. The existing literature does not rule out a small increase in errors, but this error rate reflects a conservative definition in which surgeries labeled as either delayed or unnecessary may have met appropriate standards of care. In published research reports, no patient experienced major morbidity or mortality attributable to opiate administration.

Abdomen, Acute↗
PubMed2006

Does the clinical examination predict lower extremity peripheral arterial disease?

CONTEXT: Lower extremity peripheral arterial disease (PAD) is common and associated with significant increases in morbidity and mortality. Physicians typically depend on the clinical examination to identify patients who need further diagnostic testing. OBJECTIVE: To systematically review the accuracy and precision of the clinical examination for PAD. DATA SOURCES, STUDY SELECTION, AND DATA EXTRACTION: MEDLINE (January 1966 to March 2005) and Cochrane databases were searched for articles on the diagnosis of PAD based on physical examination published in the English language. Included studies compared an element of the history or physical examination with a reference standard of ankle-brachial index, duplex sonography, or angiogram. Seventeen of the 51 potential articles identified met inclusion criteria. Two of the authors independently extracted data, performed quality review, and used consensus to resolve any discrepancies. DATA SYNTHESIS: For asymptomatic patients, the most useful clinical findings to diagnose PAD are the presence of claudication (likelihood ratio [LR], 3.30; 95% confidence interval [CI], 2.30-4.80), femoral bruit (LR, 4.80; 95% CI, 2.40-9.50), or any pulse abnormality (LR, 3.10; 95% CI, 1.40-6.60). While none of the clinical examination features help to lower the likelihood of any degree of PAD, the absence of claudication or the presence of normal pulses decreases the likelihood of moderate to severe disease. When considering patients who are symptomatic with leg complaints, the most useful clinical findings are the presence of cool skin (LR, 5.90; 95% CI, 4.10-8.60), the presence of at least 1 bruit (LR, 5.60; 95% CI, 4.70-6.70), or any palpable pulse abnormality (LR, 4.70; 95% CI, 2.20-9.90). The absence of any bruits (iliac, femoral, or popliteal) (LR, 0.39; 95% CI, 0.34-0.45) or pulse abnormality (LR, 0.38; 95% CI, 0.23-0.64) reduces the likelihood of PAD. Combinations of physical examination findings do not increase the likelihood of PAD beyond that of individual clinical findings. However, when combinations of clinical findings are all normal, the likelihood of disease is lower than when individual symptoms or signs are normal. A PAD scoring system, which includes auscultation of arterial components by handheld Doppler, provides greater diagnostic accuracy. CONCLUSIONS: Clinical examination findings must be used in the context of the pretest probability because they are not independently sufficient to include or exclude a diagnosis of PAD with certainty. The PAD screening score using the hand-held Doppler has the greatest diagnostic accuracy.

Ankle↗
PubMed2005

Is this patient having a stroke?

CONTEXT: Patients suspected of having a stroke or transient ischemic attack require accurate assessment for appropriate acute treatment and use of secondary preventive interventions. OBJECTIVE: To update a 1994 systematic review of the accuracy and reliability of symptoms and findings on neurological examination for the evaluation of patients with suspected stroke or transient ischemic attack. DATA SOURCES: We identified potential articles dated between 1994 and 2005 by multiple search strategies of the MEDLINE database and review of article and textbook bibliographies along with private collections. STUDY SELECTION: Selected articles provided primary data or appropriate summary statistics of the accuracy and/or reliability of the history or physical examination for diagnosis or short-term prognosis of patients with neurological signs prompting a consideration of stroke. Articles addressing accuracy also needed to provide a final diagnosis following neuroimaging and all relevant laboratory tests. DATA EXTRACTION: The authors reviewed and abstracted data for estimating sensitivities, specificities, positive and negative likelihood ratios (LRs). Reliability assessment was based on reported kappa (kappa) statistics or intraclass correlation coefficients as appropriate. DATA SYNTHESIS: The prior probability of a stroke among patients with neurologically relevant symptoms is 10%. Based on studies using modern neuroimaging, the presence of acute facial paresis, arm drift, or abnormal speech increases the likelihood of stroke (LR of > or =1 finding = 5.5; 95% CI, 3.3-9.1), while the absence of all 3 decreases the odds (LR of 0 findings = 0.39; 95% CI, 0.25-0.61). The accurate determination of stroke subtype requires neuroimaging to distinguish ischemic from hemorrhagic stroke. Early mortality increases among those with any combination of impaired consciousness, hemiplegia, and conjugate gaze palsy (LR of > or =1 finding = 1.8; 95% CI, 1.2-2.8 and LR of 0 findings = 0.36; 95% CI, 0.13-1.0). Symptoms associated with high agreement for the diagnosis of stroke or transient ischemic attack vs no vascular event are a sudden change in speech, visual loss, diplopia, numbness or tingling, paralysis or weakness, and non-orthostatic dizziness (kappa = 0.60; 95% CI, 0.52-0.68). The reliabilities of individual neurological findings vary from slight to almost perfect, but can be improved with standardized scoring systems such as the National Institutes of Health Stroke Scale. Based on examination findings, stroke vascular distribution can be determined with moderate to good reliability (kappa = 0.54; 95% CI, 0.39-0.68). CONCLUSIONS: The history and clinical findings provide the basis for evaluating patients with possible stroke and choosing appropriate treatments. Focusing on 3 findings (acute facial paresis, arm drift, or abnormal speech) might improve diagnostic accuracy and reliability.

Emergency Medical Services↗
PubMed2005

Does this patient have myasthenia gravis?

CONTEXT: Clinicians must be able to diagnose myasthenia gravis, since delays in establishing the diagnosis may put patients at risk for complications from this treatable disease. OBJECTIVE: To determine if items in the history and examination or results of simple tests change the likelihood of myasthenia gravis as a diagnosis. DATA SOURCES: MEDLINE search of English-language articles (January 1966-January 2005) using the terms myasthenia gravis, diagnosis, and test, and a search of bibliographies of retrieved articles. STUDY SELECTION: Studies evaluating a particular symptom or sign in patients both with and without myasthenia gravis. Of 640 articles retrieved, 33 were eligible for review. Of these, 15 met inclusion criteria and form the basis of this review. DATA EXTRACTION: Two authors independently reviewed each study to determine eligibility, abstracted data using a standardized instrument, and classified study quality using previously published criteria. DATA SYNTHESIS: A history of "speech becoming unintelligible during prolonged speaking" and the presence of the peek sign increase the likelihood of myasthenia gravis (likelihood ratio [LR], 4.5; 95% confidence interval [CI], 1.2-17.0 and LR, 30.0; 95% CI, 3.2-278.0, respectively). Their absence does not significantly reduce the likelihood of myasthenia gravis. The identified studies only assessed 1 other historical feature and sign each ("food remaining in the mouth after swallowing" and quiver eye movements, respectively), and neither of these significantly changes the likelihood of myasthenia. The ice test is useful when the response is abnormal (summary positive LR, 24.0; 95% CI, 8.5-67.0) and diminishes the likelihood of myasthenia gravis when the response is normal (summary negative LR, 0.16; 95% CI, 0.09-0.27). A positive response to an anticholinesterase medication (mainly edrophonium test) increases the probability of a diagnosis of myasthenia gravis (summary positive LR, 15.0; 95% CI, 7.5-31.0), and a negative response reduces the diagnostic probability of myasthenia (summary negative LR, 0.11; 95% CI, 0.06-0.21). An abnormal sleep test result is useful in confirming the diagnosis (LR, 53.0; 95% CI, 3.4-832.0). The rest and sleep tests make the probability of myasthenia unlikely when results are normal (LR, 0.52; 95% CI, 0.29-0.95 and LR, 0.01; 95% CI, 0.00-0.16, respectively). CONCLUSIONS: Items in the history and physical examination along with results of certain simple tests performed in the office (ice test, sleep test, and edrophonium test) are useful in predicting the likelihood of myasthenia gravis. These results must be interpreted with caution, however, given the high prevalence of disease in the populations reported in clinical studies. This review is limited by the small number of signs and symptoms scientifically studied and reported in the literature. Future studies evaluating the value of common historical features and easy maneuvers commonly known and practiced by experts in the clinical diagnosis of myasthenia are needed.

Cholinesterase Inhibitors↗
PubMed2005

Does this patient have influenza?

CONTEXT: Influenza vaccination lowers, but does not eliminate, the risk of influenza. Making a reliable, rapid clinical diagnosis is essential to appropriate patient management that may be especially important during shortages of antiviral agents caused by high demand. OBJECTIVES: To systematically review the precision and accuracy of symptoms and signs of influenza. A secondary objective was to review the operating characteristics of rapid diagnostic tests for influenza (results available in <30 min). DATA SOURCES: Structured search strategy using MEDLINE (January 1966-September 2004) and subsequent searches of bibliographies of retrieved articles to identify articles describing primary studies dealing with the diagnosis of influenza based on clinical signs and symptoms. The MEDLINE search used the Medical Subject Headings EXP influenza or EXP influenza A virus or EXP influenza A virus human or EXP influenza B virus and the Medical Subject Headings or terms EXP sensitivity and specificity or EXP medical history taking or EXP physical examination or EXP reproducibility of results or EXP observer variation or symptoms.mp or clinical signs.mp or sensitivity.mp or specificity.mp. STUDY SELECTION: Of 915 identified articles on clinical assessment of influenza-related illness, 17 contained data on the operating characteristics of symptoms and signs using an independent criterion standard. Of these, 11 were eliminated based on 4 inclusion criteria and availability of nonduplicative primary data. DATA EXTRACTION: Two authors independently reviewed and abstracted data for estimating the likelihood ratios (LRs) of clinical diagnostic findings. Differences were resolved by discussion and consensus. DATA SYNTHESIS: No symptom or sign had a summary LR greater than 2 in studies that enrolled patients without regard to age. For decreasing the likelihood of influenza, the absence of fever (LR, 0.40; 95% confidence interval [CI], 0.25-0.66), cough (LR, 0.42; 95% CI, 0.31-0.57), or nasal congestion (LR, 0.49; 95% CI, 0.42-0.59) were the only findings that had summary LRs less than 0.5. In studies limited to patients aged 60 years or older, the combination of fever, cough, and acute onset (LR, 5.4; 95% CI, 3.8-7.7), fever and cough (LR, 5.0; 95% CI, 3.5-6.9), fever alone (LR, 3.8; 95% CI, 2.8-5.0), malaise (LR, 2.6; 95% CI, 2.2-3.1), and chills (LR, 2.6; 95% CI, 2.0-3.2) increased the likelihood of influenza to the greatest degree. The presence of sneezing among older patients made influenza less likely (LR, 0.47; 95% CI, 0.24-0.92). CONCLUSIONS: Clinical findings identify patients with influenza-like illness but are not particularly useful for confirming or excluding the diagnosis of influenza. Clinicians should use timely epidemiologic data to ascertain if influenza is circulating in their communities, then either treat patients with influenza-like illness empirically or obtain a rapid influenza test to assist with management decisions.

Clinical Laboratory Techniques↗
PubMed2004

Patient and clinician satisfaction with a store-and-forward teledermatology consult system.

The aim of this study was to assess satisfaction with and acceptance of a store and forward teledermatology consult system among patients, referring primary-care clinicians, and consultant dermatologists. As part of a randomized clinical trial that compared the clinical and economic outcomes of store and forward teledermatology to a conventional referral process, we conducted satisfaction assessments among participating patients, referring primary-care clinicians, and consultant dermatologists. Survey questions included issues related to the timeliness of each consult process, the confidence participants displayed in each consult modality, and assessments of overall satisfaction and preferences. A majority of referring clinicians (92%) and dermatologist consultants (75%) reported overall satisfaction with the teledermatology consult process. Ninety-five percent of referring clinicians reported that teledermatology resulted in more timely referrals for their patients. This finding was validated by the observation that teledermatology patients reached a point of initial intervention significantly sooner than did patients in usual care (41 days versus 127 days, p = 0.0001). Teledermatology patients reported satisfaction with the outcome of their teledermatology consultation 82% of the time. However, patients did not express a clear preference for a consult method. A total of 41.5% of patients preferred teledermatology, 36.5% preferred usual care, and 22% were neutral. Our study showed a high level of satisfaction among all users of a store-and-forward teledermatology consult system, and, in some cases, our survey results could be validated with observed clinical outcomes.

Attitude of Health Personnel↗
PubMed2003

Does this patient have pulmonary embolism?

CONTEXT: Experienced clinicians' gestalt is useful in estimating the pretest probability for pulmonary embolism and is complementary to diagnostic testing, such as lung scanning. However, it is unclear whether recently developed clinical prediction rules, using explicit features of clinical examination, are comparable with clinicians' gestalt. If so, clinical prediction rules would be powerful tools because they could be used by less-experienced health care professionals to simplify the diagnosis of pulmonary embolism. Recent studies have shown that the combination of a low pretest probability (using a clinical prediction rule) and a normal result of a D-dimer test reliably excludes pulmonary embolism without the need for further testing. OBJECTIVE: To evaluate and demonstrate the accuracy of pretest probability assessment for pulmonary embolism using clinical gestalt vs clinical prediction rules. DATA SOURCES: The MEDLINE database was searched for relevant articles published between 1966 and March 2003. Bibliographies of pertinent articles also were scanned for suitable articles. STUDY SELECTION: To be included in the analysis, studies were required to have consecutive, unselected patients enrolled; participating physicians in the studies, blinded to the results of diagnostic testing, had to estimate pretest probability of pulmonary embolism; and validated diagnostic methods had to be used to confirm or exclude pulmonary embolism. DATA EXTRACTION: Three reviewers independently scanned titles and abstracts for inclusion of studies. An initial MEDLINE search identified 1709 studies, of which 16 involving 8306 patients were included in the final analysis. DATA SYNTHESIS: A clinical gestalt strategy was used in 7 studies, and in the low, moderate, and high pretest categories, the rates of pulmonary embolism ranged from 8% to 19%, 26% to 47%, and 46% to 91%, respectively. Clinical prediction rules were used in 10 studies, and 3% to 28%, 16% to 46%, and 38% to 98% in the low, moderate, and high pretest probability groups, respectively, had pulmonary embolism. CONCLUSIONS: The clinical gestalt of experienced clinicians and the clinical prediction rules used by physicians of varying experience have shown similar accuracy in discriminating among patients who have a low, moderate, or high pretest probability of pulmonary embolism. We advocate the use of a clinical prediction rule because it has shown to be accurate and can be used by less-experienced clinicians.

Adult↗
PubMed2003

Does this child have acute otitis media?

CONTEXT: Acute otitis media (AOM) is one of the most common problems in pediatrics. An accurate diagnosis of AOM can guide proper treatment and follow-up. OBJECTIVE: To systematically review the literature regarding precision and accuracy of history taking and physical examination in diagnosing AOM in children. DATA SOURCES: We searched MEDLINE for English-language articles published from 1966 through May 2002. Bibliographies of retrieved articles and textbooks were also searched. STUDY SELECTION: We located studies with original data on the precision or accuracy of history or physical examination for AOM in children. Of 397 references initially identified, 6 met inclusion criteria for analysis. DATA EXTRACTION: Two authors independently reviewed and abstracted data to calculate likelihood ratios (LRs) for symptoms and signs. DATA SYNTHESIS: Four studies of symptoms used clinical diagnosis as the criterion standard and were limited by incorporation bias. Ear pain is the most useful symptom (positive LRs, 3.0-7.3); fever, upper respiratory tract symptoms, and irritability are less useful. One study of clinical signs used tympanocentesis as the criterion standard, and we adjusted the results to correct for verification bias. A cloudy (adjusted LR, 34; 95% confidence interval [CI], 28-42), bulging (adjusted LR, 51; 95% CI, 36-73), or distinctly immobile (adjusted LR, 31; 95% CI, 26-37) tympanic membrane on pneumatic otoscopy are the most useful signs for detecting AOM. A distinctly red tympanic membrane is also helpful (adjusted LR, 8.4; 95% CI, 6.7-11) whereas a normal color makes AOM much less likely (adjusted LR, 0.2; 95% CI, 0.19-0.21). CONCLUSIONS: Although many of the studies included in this analysis are limited by bias, a cloudy, bulging, or clearly immobile tympanic membrane is most helpful for detecting AOM. The degree of erythema may also be useful since a normal color makes otitis media unlikely whereas a distinctly red tympanic membrane increases the likelihood significantly.

Acute Disease↗
PubMed2003

Staphylococcus aureus bacteremia after median sternotomy: clinical utility of blood culture results in the identification of postoperative mediastinitis.

BACKGROUND: Mediastinitis is a complication of coronary artery bypass graft surgery (CABG) that can be difficult to diagnose. This study evaluated the utility of blood culture results in identifying patients with mediastinitis. METHODS AND RESULTS: All unique patients undergoing CABG at our institution over a 60-month study period (n=5500) and all blood cultures performed on these patients or=1 blood culture drawn within 90 days of CABG. Mediastinitis occurred in 46 of 60 (76.7%) patients with blood cultures positive for Staphylococcus aureus, 15 of 126 (11.9%) patients with blood cultures positive for other pathogens, 37 of 669 (5.5%) patients with blood cultures with no growth, and 44 of 4645 (0.9%) patients with no blood cultures obtained. The isolation of S aureus from even 1 blood culture drawn after or=1 blood culture obtained after CABG. CONCLUSIONS: Among patients with blood cultures drawn after CABG, S aureus bacteremia strongly suggests the presence of mediastinitis.

Academic Medical Centers↗
PubMed2003

An economic analysis of a store and forward teledermatology consult system.

Our objective was to assess the economic impact of store-and-forward teledermatology in a United States Department of Veterans Affairs (VA) health care setting. Patients being referred to the Dermatology Consult Service from the Primary Care Clinics at the Durham, North Carolina VA Medical Center were randomized either to usual care or to a teledermatology consultation. Fixed and variable costs for both consult modalities were identified using a microcosting approach. The observed clinical outcomes from the randomized trial generated probability and effectiveness measures that were inserted into a decision model. A cost analysis and a cost-effectiveness analysis that compared the two consult modalities was performed. Teledermatology was not cost saving when compared to usual care using observed costs and outcomes. Sensitivity analyses indicated that teledermatology has the potential to be cost saving if clinic visit costs, travel costs, or averted clinic visits were higher than observed in the study. Teledermatology was cost-effective for decreasing the time required for patients to reach a point of initial definitive care. Cost-effectiveness ratios ranged from $0.12-0.17 (U.S.) per patient per day of time to initial intervention.

Adolescent↗
PubMed2002

Teledermatology's impact on time to intervention among referrals to a dermatology consult service.

The aim of this study was to determine if a teledermatology consult system, using store-and-forward digital imaging technology, results in patients achieving a shorter time from referral date to date of initial definitive intervention when compared to a traditional referral process. Patients being referred to the dermatology consult service from the primary care clinics at the Durham VA Medical Center were randomized to either a teledermatology consultation or usual care. A usual care consultation consisted of a text-based electronic consult request. A teledermatology consultation included digital images and a standardized history, in addition to the text-based electronic consult. Time to initial definitive intervention was defined as the time between referral date and the date the patient was scheduled for a clinic visit for those patients that the consultant requested a clinic-based evaluation, or the time between referral date and the date the consult was answered by the consultant if a clinic visit was not required. Patients in the teledermatology arm of the study reached a time to initial definitive intervention significantly sooner than did those patients randomized to usual care (median 41 days versus 127 days, p = 0.0001, log-rank test). Additionally, 18.5% of patients in the teledermatology arm avoided the need for a dermatology clinic-based visit compared to zero patients avoiding a dermatology clinic visit in the usual care arm of the study (p < 0.001, z-test). Teledermatology consult systems can result in significantly shorter times to initial definitive intervention for patients compared to traditional consult modalities, and, in some cases, the need for a clinic-based visit can be avoided.

Aged↗
PubMedDate not supplied

Does this woman have an acute uncomplicated urinary tract infection?

CONTEXT: Symptoms suggestive of acute urinary tract infection (UTI) constitute one of the most common reasons for women to visit clinicians. Although the clinical encounter typically involves taking a history and performing a physical examination, the diagnostic accuracy of the clinical assessment for UTI remains uncertain. OBJECTIVE: To review the accuracy and precision of history taking and physical examination for the diagnosis of UTI in women. DATA SOURCES: We conducted a MEDLINE search for articles published from 1966 through September 2001 and manually reviewed bibliographies, 3 commonly used clinical skills textbooks, and contacted experts in the field. STUDY SELECTION: Studies were included if they contained original data on the accuracy or precision of history or physical examination for diagnosing acute uncomplicated UTI in women. One author initially screened titles and abstracts found by our search. Nine of 464 identified studies met inclusion criteria. DATA EXTRACTION: Two authors independently abstracted data from the included studies. Disagreements were resolved by discussion and consensus with a third author. DATA SYNTHESIS: Four symptoms and 1 sign significantly increased the probability of UTI: dysuria (summary positive likelihood ratio [LR], 1.5; 95% confidence interval [CI], 1.2-2.0), frequency (LR, 1.8; 95% CI, 1.1-3.0), hematuria (LR, 2.0; 95% CI, 1.3-2.9), back pain (LR, 1.6; 95% CI, 1.2-2.1), and costovertebral angle tenderness (LR, 1.7; 95% CI, 1.1-2.5). Four symptoms and 1 sign significantly decreased the probability of UTI: absence of dysuria (summary negative LR, 0.5; 95% CI, 0.3-0.7), absence of back pain (LR, 0.8; 95% CI, 0.7-0.9), history of vaginal discharge (LR, 0.3; 95% CI, 0.1-0.9), history of vaginal irritation (LR, 0.2; 95% CI, 0.1-0.9), and vaginal discharge on examination (LR, 0.7; 95% CI, 0.5-0.9). Of all individual diagnostic signs and symptoms, the 2 most powerful were history of vaginal discharge and history of vaginal irritation, which significantly decreased the likelihood of UTI when present (LRs, 0.3 and 0.2, respectively). One study examined combinations of symptoms, and the resulting LRs were more powerful (24.6 for the combination of dysuria and frequency but no vaginal discharge or irritation). One study of patients with recurrent UTI found that self-diagnosis significantly increased the probability of UTI (LR, 4.0). CONCLUSIONS: In women who present with 1 or more symptoms of UTI, the probability of infection is approximately 50%. Specific combinations of symptoms (eg, dysuria and frequency without vaginal discharge or irritation) raise the probability of UTI to more than 90%, effectively ruling in the diagnosis based on history alone. In contrast, history taking, physical examination, and dipstick urinalysis are not able to reliably lower the posttest probability of disease to a level where a UTI can be ruled out when a patient presents with 1 or more symptoms.

Acute Disease↗