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Biomedical subjects

J B Emans

Publications and source records attributed to J B Emans.

At least 19 recordsLinked to original sources
PubMed2001

Surgical treatment of congenital kyphosis.

STUDY DESIGN: In this study, 26 cases of congenital kyphosis and kyphoscoliosis treated surgically were retrospectively reviewed. OBJECTIVE: To assess the clinical outcomes and surgical indications for posterior only versus anteroposterior surgery in the child. SUMMARY OF BACKGROUND DATA: Congenital kyphosis usually is progressive without surgical intervention. Current recommended treatment includes posterior arthrodesis for deformities of less than 50 degrees to 60 degrees, and anterior release or decompression, anterior fusion, and posterior instrumented arthrodesis for large deformities and cord compression. METHODS: Cases involving myelodysplasia, spinal dysgenesis, and skeletal dysplasia were excluded from the study. Kyphoscoliosis was included if the kyphotic deformity was greater than the scoliotic deformity. Patients were grouped by age and surgical technique. The patients in group P1 underwent posterior arthrodesis at an age younger than 3 years, and those in group P2 underwent the procedure at an age older than 3 years. The patients in group AP1 underwent anterior and posterior procedures at an age younger than 3 years, and those in group AP2 underwent the procedures at an age older than 3 years. The preoperative deformity, complications, and postoperative deformity correction were analyzed. There were nine Type 1 (failure of formation), nine Type 2 (failure of segmentation), and eight Type 3 (mixed) deformities. Four patients had associated spinal dysraphism. Three patients with Type 1 deformities had clinical or radiographic evidence of cord compression. RESULTS: In Group P1, five patients at an average age of 16 months underwent posterior arthrodesis alone for an average kyphotic deformity of 49 degrees. The immediate postoperative correction improved over a period of 6 years and 9 months by an additional 10 degrees, resulting in a final deformity of 26 degrees. Pseudarthrosis developed in two patients, requiring fusion mass augmentation or anterior arthrodesis. Neither patient was instrumented. In Group P2, five patients at an average age of 13 years and 7 months underwent posterior arthrodesis with instrumentation for kyphotic deformity of 59 degrees. Approximately 30 degrees of intraoperative correction was achieved safely using compression instrumentation and positioning. No further correction occurred with growth. The final residual kyphotic deformity was 29 degrees after a follow-up period of 4 years and 5 months. In Group AP1, seven patients underwent anterior release or vertebra resection for deformity correction and posterior arthrodesis for an average kyphotic deformity of 48 degrees at the age of 16 months. There were no iatrogenic neurologic injuries. The final residual kyphotic deformity was 22 degrees after a follow-up period of 6 years and 3 months. In Group AP2, nine patients underwent anterior release or decompression with posterior arthrodesis for kyphotic deformity of 77 degrees at the age of 11 years and 6 months. The deformity was corrected to 37 degrees, with no significant loss over a follow-up period of 5 years and 2 months. There were two postoperative neurologic complications. CONCLUSIONS: After reviewing their experience, the authors made the following observations: 1) The pseudarthrosis rate was low even without routine augmentation of fusion mass if instrumentation was used; 2) gradual correction of kyphosis may occur with growth in patients younger than 3 years with Types 2 and 3 deformities after posterior fusion, but appears to be unpredictable; 3) the risk of neurologic injury with anterior and posterior fusion for kyphotic deformity was associated with greater age, more severe deformity, and preexisting spinal cord compromise.

Adolescent↗
PubMed2001

Role of flexion-extension radiographs in blunt pediatric cervical spine injury.

OBJECTIVE: To determine whether flexion-extension cervical spine radiography (FECSR) is abnormal in children who have sustained blunt cervical spine injury (CSI) when standard cervical spine radiography (SCSR) demonstrates no acute abnormalities. METHODS: This was a blinded radiographic review of 129 patients < or = 16 years of age evaluated at an academic pediatric trauma center during July 1990-March 1996. All patients had SCSR (anteroposterior/lateral views) and FECSR performed for a trauma-related event within seven days of injury. RESULTS: Of 46 patients without acute abnormalities on SCSR, one patient (with final clinical diagnosis of "no CSI") had acute abnormalities on FECSR (95% CI = 0.06% to 11.5%). Of 50 patients with isolated loss of lordosis on SCSR, no patient had acute abnormalities on FECSR (95% CI = 0% to 5.8%). The FECSR review revealed no acute abnormalities in 75 of 83 patients (90.4%) with suspicious findings for CSI viewed on SCSR (95% CI = 81.9% to 95.7%). Complications during FECSR were noted in one patient with transient paresthesias (0.8%) (95% CI = 0.02% to 4.2%). CONCLUSIONS: In children who underwent acute radiographic evaluation of blunt cervical spine trauma, FECSR was unlikely to be abnormal when no acute abnormality or isolated loss of lordosis was evident on SCSR. In a subset of patients with suspicious findings for occult CSI on SCSR, FECSR was useful in ruling out ligamentous instability in the acute, posttrauma setting.

Adolescent↗
PubMed1999

Spinal fusion in patients with congenital heart disease. Predictors of outcome.

The strong association between congenital heart disease and spinal deformity is well established, but data on the risks and outcome of spinal fusion surgery in patients with congenital heart disease are scarce. The purpose of this study was to identify predictors of perioperative risk and outcome in a large series of children and adolescents with congenital heart disease who underwent spinal fusion for scoliosis or kyphosis. In the authors' retrospective analysis of 74 consecutive patients with congenital heart disease undergoing spinal fusion, there were two deaths (2.7%) and 18 significant complications (24.3%) in the perioperative period. Preoperative cyanosis (arterial oxygen saturation < 90% at rest) with uncorrected or incompletely corrected congenital heart disease was associated with both deaths. Complications occurred in nine of 18 (50%) patients with cyanosis and in 11 of 56 (20%) patients without cyanosis. As judged by multivariate analysis the best predictors of perioperative outcome were the overall physical status of the patient as represented by the American Society of Anesthesiologists' preoperative score and a higher rate of intraoperative blood loss. Seventeen of 43 patients (40%) with an American Society of Anesthesiologists score of 3 or higher experienced complications including two perioperative deaths. Successful spinal fusion and correction were achieved in 97% of patients. Children and adolescents with congenital heart disease can undergo elective spinal fusion with risks that relate to overall cardiac status. Careful assessment of preoperative status by pediatric cardiologists and cardiac anesthesiologists familiar with surgical treatment of patients with congenital heart disease will assist the orthopaedic surgeon in providing the most realistic estimate of risk.

Adolescent↗
PubMed1999

Occipitocervical fusions in children. Retrospective analysis and technical considerations.

This report presents a retrospective analysis of the authors' experience with occipitocervical fusions in children and adolescents during the last 2 decades. A description of an operative technique devised by the senior author (JEH), and a comparison of the results using this and other methods of fusion are given. Twenty-three patients underwent occipitocervical fusion. Fifteen of the patients were operated on using the authors' technique. To achieve stable fixation of the distal cervical vertebra a threaded Kirschner wire was passed transversely through the spinous process; occipital fixation was achieved by the traditional method of wiring corticocancellous bone graft to the skull through burr holes. The occipital wires then were wrapped around the Kirschner wire and the graft was cradled in the resulting nest. Halo immobilization was used in 10 patients for an average of 12.5 weeks (range, 6-24 weeks). Twenty-two patients achieved successful fusion at an average followup of 5.8 years (range, 1-14.33 years). Several complications, including transient quadriplegia in one patient, pseudarthrosis in two (one of which persists), hardware fixation failure in one, unintended distal extension of the fusion, pneumonia, wound infection, halo pin infection, skin breakdown under the halo vest, hydrocephalus, cerebrospinal fluid leak, and traumatic fusion fracture were encountered. Results using the technique described herein are comparable with or better than the results reported in the previous literature, and the results of the patients in this series in whom the technique was not used.

Adolescent↗
PubMed1997

Spinal deformity in myelodysplasia. Correction with posterior pedicle screw instrumentation.

STUDY DESIGN: A retrospective review of transpedicular instrumentation used in a series of 24 patients with myelodysplastic spinal deformities and deficient posterior elements. OBJECTIVE: To describe the usefulness and efficacy of these instruments in the treatment of complicated myelodysplastic spinal deformity. METHODS: The mean preoperative scoliosis was 75.7 degrees (range, 39-130 degrees) in the 22 patients with scoliotic deformities; 4 patients with thoracic hyperkyphoses averaged 70.5 degrees (range, 46-90 degrees) and 10 patients with lumbar kyphoses averaged 80.5 degrees (range, 42-120 degrees). The instrumentation extended to the sacrum in 4 patients and the pelvis in 9; 10 patients also underwent anterior release and fusion and 7 underwent concomitant spinal cord detethering. At an average follow-up of 4.0 years (2.0-7.7 years; one patient died at 8 months), all patients have fused (with the exception of two lumbosacral pseudarthroses). RESULTS: At last follow-up, deformity measured 32.1 degrees scoliosis (range, 6-85 degrees), 30.8 degrees thoracic kyphosis (range, 24-35 degrees), and 0.0 degree lumbar kyphosis (range, 35 degrees kyphosis to 29 degrees lordosis). Three patients lost some neurologic function after surgery; two recovered within 6 months and one has incomplete recovery. No ambulatory patient lost the ability to walk. Five patients required additional surgical procedures; in three cases, there was instrumentation breakage associated with pseudarthrosis or unfused spinal segments. CONCLUSIONS: Pedicle screw instrumentation is uniquely suited to the deficient myelodysplastic spine. Compared with historical control subjects, these devices have proven capable of significant correction of both scoliotic and kyphotic deformities. This instrumentation appears particularly useful in preserving lumbar lordosis in all patients and may preserve more lumbar motion in ambulatory myelodysplasia patients.

Adolescent↗
PubMed1997

Lumbar pedicle screws versus hooks. Results in double major curves in adolescent idiopathic scoliosis.

STUDY DESIGN: A retrospective assessment of the effectiveness of lumbar pedicle screws versus laminar hooks in lumbar curve correction with double major curves in adolescent idiopathic scoliosis. OBJECTIVE: To determine if pedicle screw fixation of the lumbar spine has any advantage compared with multiple laminar hook instrumentation in the treatment of double major curves in adolescent idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: Although hooks have been used most commonly, pedicle screws may offer advantages in correction and maintenance of reduction of the lumbar curve in adolescent idiopathic scoliosis. METHODS: A consecutive series of 39 patients with double major curves underwent thoracic and lumbar instrumentation by a single surgeon. Lumbar pedicle screws and hooks were used in 20 patients (Group S) and in 19 patients only lumbar hooks were used (Group H). Thoracic Cotrel-Dubousset instrumentation with hooks was the same in both groups. Preoperative age, gender, bracing, and Cobb angles were similar in both groups. Preoperative, 1-month postoperative, and latest follow-up standing posteroanterior and lateral spine radiographs were blinded to the surgeon and lumbar instrumentation covered to hide its identity. Measurements included Cobb angles, preoperative flexibility, lumbar and thoracic apical vertebral deviation, and reduction of lateral tilt and lateral displacement of the first free lumbar vertebra below the instrumentation. Percent correction, maintenance of correction at follow-up, and total levels fused were calculated. RESULTS: The mean follow-up was 3.5 years (range, 2-8 years), which was similar for Groups H and S. Pedicle screws appear to offer some advantage in lumbar curve correction, maintenance of correction, and correction of the uninstrumented spine below the fusion when compared with the use of hooks alone. Horizontalization of the first free lumbar vertebra below the instrumentation percent correction of tilt: 62% screws vs. 11% hooks; P = 0.0003), residual tilt (8 degrees screws vs. 17 degrees hooks; P = 0.004), and loss of horizontalization at follow-up (5% screws vs. 26% hooks) were dramatically better for the group using screws. Lumbar curve correction (72% screws vs. 60% hooks; P = 0.026), loss of lumbar curve correction (5% screws vs. 13% hooks), and correction of lateral apical vertebral deviation (2.2-cm screws vs. 1.5-cm hooks or 63% vs. 31%; P = 0.013) were better when screws were used. There was no significant difference in loss of correction of the thoracic curves (35% vs. 37%) or any difference in loss of correction of lateral displacement of the thoracic apical vertebra (12% vs. 14%). There was no difference in total levels fused, operative blood loss, operative time, or ultimate patient outcome. No patients in either group had spinal imbalance at latest follow-up. There were no complications related to pedicle screw placement. Two cases of transient postoperative superior mesenteric artery syndrome (duodenal obstruction by the superior mesenteric artery) in the pedicle screw group are attributed to acute correction of the lumbar scoliosis and thoracolumbar kyphosis with resultant lordosis at the thoracolumbar junction. CONCLUSIONS: Lumbar pedicle screws may offer greater lumbar curve correction, better maintenance of correction, and greater correction of the uninstrumented spine below double major curves. No complications were associated with the placement of pedicle screws.

Adolescent↗
PubMed1997

Surgery of the spine in myelodysplasia. An overview.

Significant spinal deformity is particularly common in nonambulatory patients with myelodysplasia. Progressive deformity may be caused by congenital anomalies, paralytic collapse, hip contractures, or spinal cord tethering. Existing or projected functional impairment should be the principle indication for treatment. Surgical treatment is complicated by poor soft tissue coverage, associated contractures, lack of sensation, weak bone, and absence of posterior elements. Successful fusion can be achieved by circumferential (anterior and posterior) fusion and current rigid segmental instrumentation. The unique deformities and bony anatomy require individualized techniques to achieve fixation.

Arthrodesis↗
PubMed1997

A meta-analysis of the efficacy of non-operative treatments for idiopathic scoliosis.

With use of data culled from twenty studies, members of the Prevalence and Natural History Committee of the Scoliosis Research Society conducted a meta-analysis of 1910 patients who had been managed with bracing (1459 patients), lateral electrical surface stimulation (322 patients), or observation (129 patients) because of idiopathic scoliosis. Three variables - the type of treatment, the level of maturity, and the criterion for failure - were analyzed to determine which had the greatest impact on the outcome. We also examined the effect of the type of brace that was used and the duration of bracing on the success of treatment. The number of failures of treatment in each study was determined by calculating the total number of patients who had unacceptable progression of the curve (as defined in the study), who could not comply with or tolerate treatment, or who had an operation. The percentage of patients who completed a given course of treatment without failure, adjusted for the sample sizes of the studies in which that treatment was used, yielded the weighted mean proportion of success for that treatment. The weighted mean proportion of success was 0.39 for lateral electrical surface stimulation, 0.49 for observation only, 0.60 for bracing for eight hours per day, 0.62 for bracing for sixteen hours per day, and 0.93 for bracing for twenty-three hours per day. The twenty-three-hour regimens were significantly more successful than any other treatment (p < 0.0001). The difference between the eight and sixteen-hour regimens was not significant, with the numbers available. Although lateral electrical surface stimulation was associated with a lower weighted mean proportion of success than observation only, the difference was not significant, with the numbers available. This meta-analysis demonstrates the effectiveness of bracing for the treatment of idiopathic scoliosis. The weighted mean proportion of success for the six types of braces included in this review was 0.92, with the highest proportion (0.99) achieved with the Milwaukee brace. We found that use of the Milwaukee brace or another thoracolumbosacral orthosis for twenty-three hours per day effectively halted progression of the curve. Bracing for eight or sixteen hours per day was found to be significantly less effective than bracing for twenty-three hours per day (p < 0.0001).

Adolescent↗
PubMed1995

Progressive kyphosis and neurologic compromise complicating spondylothoracic dysplasia in infancy (Jarcho-Levin syndrome).

STUDY DESIGN: This is a case report and review of the literature. OBJECTIVE: To review the orthopedic literature regarding the spinal abnormalities found with spondylothoracic dysplasia, and to present the history and management of severe kyphosis with neurologic impairment in an infant with spondylothoracic dysplasia. SUMMARY OF BACKGROUND DATA: Spondylothoracic dysplasia (Jarcho-Levin syndrome) is a rare form of short-limbed dwarfism characterized by extensive vertebral and chest-wall abnormalities. Although the spinal anomalies generally are radiographically severe, no patient previously reported in the English orthopedic literature has required surgical stabilization. METHODS: The clinical findings, course, and surgical management of an infant with spondylothoracic dysplasia and severe congenital kyphosis are presented. This patient required anterior decompression and anterior/posterior spinal fusion to obtain stabilization. The follow-up from the index surgical procedure was 2 years. RESULTS: The patient underwent an initial anteroposterior fusion and decompression at 5 months of age. She underwent revision of both anteroposterior procedures 7 months later because of pseudarthroses and a progressive kyphosis. Her residual neurologic abnormality was minimal and she appeared to have a stable fusion at 24 months post-index procedure. CONCLUSIONS: The spinal abnormalities associated with spondylothoracic dysplasia may not be as benign as previously reported. Sagittal, as well as frontal, plane deformities may exist secondary to multiple hemivertebrae. Longer life span, possibly due to improved pulmonary care, may increase the incidence of deformities requiring intervention.

Dwarfism↗
PubMed1995

Does bracing affect bone density in adolescent scoliosis?

STUDY DESIGN: This is a case-control, cross-sectional analysis of bone density. OBJECTIVES: To determine if bracing during growth affects bone density in adolescent idiopathic scoliosis and whether the effect is local or systemic. SUMMARY OF BACKGROUND DATA: Data concerning the effect of bracing on bone mass in adolescents with idiopathic scoliosis are nonexistent. We were concerned that bone mass loss resulting from long-term brace use may be permanent and may predispose to problems with osteoporosis. METHODS: Healthy adolescent females (n = 85) with scoliosis measuring 20-45 degrees and treated either by brace or observation were studied. Dietary calcium, activity level, body mass index, and pubertal status were evaluated. Scoliosis was measured by Cobb angle. Bone mineral density at the hip and spine were measured by dual energy x-ray absorptiometry to differentiate local versus systemic effects of bracing. Lateral scans of the L3 vertebral body were used to minimize the influence of the pedicles, the effect of the scoliosis, and the interference of the ilium. RESULTS: Mean age, height, and weight were similar between braced and observed groups. After adjusting for curve, Cobb angle, body mass index, activity, and diet, two-way analysis of covariance showed L3 and femoral bone mineral density was the same for braced and observed patients, and pubertal status affected spinal bone mineral density but had no effect on femoral bone mineral density. Pubertal status and body mass index accounted for 53% of the variation in spine bone mineral density and was not affected by brace use. Cobb angle, curve pattern, activity, and diet were not associated with bone mineral density. CONCLUSION: Brace treatment does not adversely affect bone mass at the spine and hip in children with idiopathic scoliosis.

Absorptiometry, Photon↗
PubMed1995

Predicting the integrity of vertebral bone screw fixation in anterior spinal instrumentation.

STUDY DESIGN: Using 2-week-old calf lumbar vertebrae as a model for the human adolescent spine, the strength and rigidity of different methods of anterior spinal screw fixation and the use of noninvasive techniques for predicting bone screw stability before surgery and screw insertional torque intraoperatively were investigated. OBJECTIVES: The objectives were to determine what factors most affect the strength and rigidity of screw fixation, to determine the strongest and most rigid type of screw fixation for anterior spinal instrumentation, and to determine if noninvasive measurements of bone density before surgery by dual energy x-ray absorptiometry or quantitative computed tomography and if intraoperative measurement of screw insertional torque can be used to predict the in vivo strength and rigidity of vertebral screw fixation. SUMMARY OF BACKGROUND DATA: Anterior spinal instrumentation is an efficient method to correct spinal deformities in the thoracolumbar and lumbar spine. Fewer vertebrae are instrumented and arthrodesed, allowing for greater spine mobility. The forces transmitted to each vertebra are higher, perhaps accounting for the clinical failure rate of 13-30% at the metal bone interface from screw cut out. METHODS: Quantitative computed tomography and dual energy x-ray absorptiometry were used to assess the bone density of 24, 2-week-old calf lumbar vertebrae. Four different methods of vertebral screw fixation were evaluated: unicortical screw, bicortical screw, bicortical screw and washer, and bicortical screws and staple. The maximal screw insertional torque was measured for each specimen. Each vertebral body-screw construct failed in a mode simulating in vivo screw cut out. The applied moment and rotatory displacement were recorded. Ash density was measured for each vertebral body after removing all hardware. RESULTS: Noninvasive measures of bone density varied linearly with ash density (P < 0.01). Screw insertional torque varied linearly with bone mineral content and bone mineral density (r2 = 0.50) and was correlated with the yield moment for all types of fixation except the staple. Density measured by quantitative computed tomography did not affect rigidity or yield moment. Post hoc analysis showed that the screw-staple construct was the strongest and most rigid form of fixation. CONCLUSIONS: Measurement of bone density before surgery using dual energy x-ray absorptiometry and intraoperative measurement of screw insertional torque can be used to assess the stability of anterior spinal instrumentation. A bicortical screw inserted through a Dwyer-type staple provided the strongest and most rigid form of fixation.

Absorptiometry, Photon↗
PubMed1995

Childhood scoliosis: clinical indications for magnetic resonance imaging.

We retrospectively reviewed the magnetic resonance imaging studies that had been made for ninety-five patients who had idiopathic scoliosis. We wished to determine if we could identify any criteria that should be met before these studies are performed. The study group included thirty-one male patients and sixty-four female patients. The average age at the time of the imaging study was thirteen years (range, one to twenty-eight years). The average curve was 41 degrees (range, 11 to 95 degrees). Fourteen patients were seen to have an intraspinal abnormality on the imaging study: twelve had a syrinx, one had a syrinx and an astrocytoma of the spinal cord, and one had dural ectasia. Five of the eight patients who were less than eleven years old and who had a left thoracic curve had an intraspinal abnormality on the imaging study, but this combination of factors did not indicate the need for operative intervention. Four of the intraspinal abnormalities in the fourteen patients necessitated neurosurgical intervention; if the criteria for obtaining the imaging study had been restricted to neck pain and headache--particularly with exertion--and neurological findings such as ataxia, weakness, and a cavus foot, these abnormalities would have been diagnosed.

Adolescent↗
PubMed1994

Spinal deformity associated with neurenteric cysts in children.

STUDY DESIGN: Neurenteric cysts are uncommon lesions originating from the primitive foregut that may involve adjacent vertebrae and spinal cord. Little is known regarding the natural history of these cysts and associated spinal deformity in children. Five patients with these cysts managed at the authors' institution from 1955 to 1993 were reviewed. OBJECTIVES: The goal of this retrospective review was to determine the natural history of these cysts in children, and to assess the surgical management in each of the five patients. METHODS: Medical charts and radiographic records were reviewed and, when possible, the patients were re-evaluated clinically. RESULTS: All patients had significant anterior vertebral defects, and four had severe kyphosis at presentation. Major complications occurred in three of the four patients treated surgically. CONCLUSIONS: Iatrogenic complications of surgical management of these cysts can be limited by combined anterior and posterior approaches, providing the most complete exposure and maximal stabilization of the associated deformity.

Child↗
PubMed1993

A statistical comparison between natural history of idiopathic scoliosis and brace treatment in skeletally immature adolescent girls.

Thirty-two adolescent girls braced for late onset idiopathic scoliosis at Children's Hospital, Boston were compared with thirty-two untreated girls from Our Lady's Hospital for Sick Children, Dublin, Ireland paired on the basis of curve size and site and age at diagnosis. All were Risser 0 at diagnosis. Study period for the braced group was from brace initiation to part-time brace wearing and, for the controls, from diagnosis to last review. There was no statistically significant difference between the groups on any parameter of curve progression. This study raises questions about the efficacy of spinal orthoses in modifying the natural history of late-onset idiopathic scoliosis and removes the ethical problems inherent in a prospective trial in which the only treatment permitted to the control group is surgery.

Adolescent↗
PubMed1993

Atypical idiopathic scoliosis: MR imaging evaluation.

The authors analyzed the clinical and imaging findings in 30 consecutive pediatric, adolescent, and young adult patients who underwent MR imaging because of atypical features of idiopathic scoliosis. Atypical clinical and plain radiographic features included early onset (n = 4), rapid progression (n = 19), pain (n = 17), other neurologic symptoms or signs (n = 12), associated syndromes (n = 4), a convex left thoracic or thoracolumbar curve (n = 18), a kyphotic component (n = 7), and pedicle thinning (n = 4). MR imaging demonstrated 17 abnormalities in 11 patients: lumbar disk protrusions (n = 1), patulous intradural space (dural ectasia) (n = 3), hydrosyringomyelia (n = 7), Chiari I malformation (n = 5), and cord astrocytoma (n = 1). Significant associations with abnormal MR imaging findings were shown for patients with pain, weakness, abnormal neurologic findings, and atypical curvatures. Furthermore, there was a striking association of convex left thoracic or thoracolumbar scoliosis with hydrosyringomyelia (six of seven cases). On the basis of these results, "atypical" spinal curvatures at radiography and "atypical" clinical features should prompt performance of additional diagnostic studies.

Adolescent↗