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Results for “Colonoscopy”

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PubMed1999

Colonoscopy and technetium-99m white cell scan in children with suspected inflammatory bowel disease.

OBJECTIVES: To determine the utility of the technetium-labeled autologous white cell scintigraphy (Tc-WCS) for detecting intestinal inflammation in children with suspected inflammatory bowel disease (IBD). Tc-WCS was compared with colonoscopy and histologic examination. STUDY DESIGN: Forty-eight children (26 boys; median age, 10 years; range, 2-17 years) with symptoms and signs suggesting IBD had colonoscopy with exploration of terminal ileum and mucosal biopsies. The scans were judged to be abnormal if activity was seen in the gut within the first hour. RESULTS: Twenty-one patients had a diagnosis of IBD (Crohn's disease, 13; ulcerative colitis, 5; indeterminate colitis, 3); results of scintigraphy were positive in 16 and negative in 5 (sensitivity, 76.2%); the latter had a moderate degree of intestinal inflammation. In 27 patients, IBD was ruled out. Results of scintigraphy were negative in children with non-specific colitis and in those with lymphoid hyperplasia of the terminal ileum, whereas results were positive in 6 of 12 patients with spondyloarthropathy. In children with IBD, there was a significant correlation between results of scintigraphy and endoscopy for the intensity of inflammation (r = 0.70); however, there was a poor correlation regarding the number of involved segments (r = 0.30) because in 16 patients, endoscopy revealed additional diseased segments as compared with scintigraphy. CONCLUSIONS: A positive Tc-WCS result indicates the presence of an inflammatory process of the gut, whereas a negative test result does not rule out intestinal inflammation, especially when the latter is of moderate degree. Colonoscopy and biopsy are the investigations of choice to establish the diagnosis of IBD and are superior to Tc-WCS in assessing topographic extension of IBD.

Adolescent↗

PubMed1980

Colonoscopy and the detection of dysplasia in patients with longstanding ulcerative colitis.

The role of colonoscopy in the surveillance of patients with ulcerative colitis for dysplasia was investigated in 43 patients with longstanding disease extending proximally beyond the splenic flexure. The examination was well tolerated and no complications were recorded. Dysplasia was found in 9 patients in one or more biopsies and was severe in 2, moderate in 1, and mild in 6. Both the patients with severe dysplasia had a carcinoma at subsequent operation. Colonoscopy may allow complete examination of the colon and biopsy of suspicious lesions and, since dysplasia may spare the rectum, colonoscopy with biopsy is a desirable component of any surveillance programme of the at-risk colitic.

Adolescent↗

PubMed2003

Memories of colonoscopy: a randomized trial.

Patients' memories of the past may influence their decisions about the future, yet memories are imperfect and susceptible to bias. We tested whether a memory failure observed in psychology experiments could be applied in a clinical setting to lessen patients' memories of the pain of an unpleasant medical procedure. We studied consecutive outpatients undergoing colonoscopy who were medically stable, mentally competent, and able to speak English (n=682). By random assignment, half the patients had a short interval added to the end of their procedure during which the tip of the colonoscope remained in the rectum. Pain during the procedure was measured with a ten point intensity scale. Memory following the procedure was measured using both a rating scale and a ranking task. Randomization resulted in two similar groups. As theorized, patients who underwent the extended procedure experienced the final moments as less painful (1.7 vs. 2.5 on a ten point intensity scale, P<0.001), rated the entire experience as less unpleasant (4.4 vs. 4.9 on a 10 cm visual analogue scale, P=0.006), and ranked the procedure as less aversive compared to seven other unpleasant experiences (4.1 vs. 4.6 with eight as the worst, P=0.002). Rates of returning for a repeat colonoscopy (median duration of follow-up 5.3 years) averaged 50.4% and were slightly higher (odds ratio=1.41, P=0.038) for those who underwent the longer procedure controlling for prior colonoscopy, procedure indications, and abnormal findings. Memory failures observed in experimental conditions can be found in clinical settings involving awake patients and may offer opportunities for improving patients' willingness to undergo future unpleasant medical procedures.

Adult↗

PubMed2002

Screening colonoscopy in balance. Issues of implementation.

Although colonoscopy is currently considered an option for colon cancer screening, its choice as a preferred screening test is not supported by data, recommendations, or cost-effectiveness analysis. The use of colonoscopy in postpolypectomy surveillance constitutes a huge potential effort that should be appropriately anticipated and managed. Noninvasive methods for colon cancer screening may reduce the need for colonoscopy in the future.

Clinical Trials as Topic↗

PubMedDate not supplied

Barium enema following incomplete colonoscopy.

The purpose of this article is to describe our findings on barium enema in patients who have had incomplete colonoscopy. For patients undergoing colonoscopy and barium enema within 6-months of each other between 1991 and 1997, barium enemas were reevaluated for redundant anatomy as well as lesions. Seventy-seven women and 30 men underwent 108 barium enemas. The most common finding was a redundant colon in 68% (55/81) of study patients, but only 33% (9/27) of control (complete colonoscopy) patients.

Adult↗

PubMed2003

Propofol versus midazolam/fentanyl for outpatient colonoscopy: administration by nurses supervised by endoscopists.

BACKGROUND & AIMS: Propofol is under evaluation as a sedative for endoscopic procedures. We compared nurse-administered propofol to midazolam plus fentanyl for outpatient colonoscopy. METHODS: One hundred outpatients undergoing colonoscopy were randomized to receive propofol or midazolam plus fentanyl, administered by a registered nurse and supervised only by an endoscopist. Endpoints were patient satisfaction, procedure and recovery times, neuropsychologic function, and complications. RESULTS: The mean dose of propofol administered was 277 mg; mean doses of midazolam and fentanyl were 7.2 mg and 117 microg, respectively. Mean time to sedation was faster with propofol (2.1 vs. 6.1 min; P<0.0001), and depth of sedation was greater (P<0.0001). Patients receiving propofol reached full recovery sooner (16.5 vs. 27.5 min; P=0.0001) and were discharged sooner (36.5 vs. 46.1 min; P=0.01). After recovery, the propofol group scored better on tests reflective of learning, memory, working memory span, and mental speed. Six minor complications occurred in the propofol group: 4 episodes of hypotension, 1 episode of bradycardia, and 1 rash. Five complications occurred with the use of midazolam and fentanyl: one episode of oxygen desaturation requiring mask ventilation and 4 episodes of hypotension. Patients in the propofol vs. midazolam and fentanyl groups reported similar degrees of overall satisfaction using a 10-cm visual analog scale (9.3 vs. 9.4, P>0.5). CONCLUSIONS: Nurse-administered propofol resulted in several advantages for outpatient colonoscopy compared with midazolam plus fentanyl, but did not improve patient satisfaction.

Adjuvants, Anesthesia↗

PubMed2003

A case-cohort study for the disease natural history of adenoma-carcinoma and de novo carcinoma and surveillance of colon and rectum after polypectomy: implication for efficacy of colonoscopy.

The disease natural history of colorectal neoplasm regarding two opposing theories, adenoma-carcinoma sequence and de novo carcinoma theory, is controversial and rarely quantified. The aims of this study are therefore to estimate the dwelling times of adenoma-carcinoma sequence by adenoma size and histological type, taking de novo carcinoma into account. The efficacy of polypectomy was therefore estimated making allowance for two pathways. A case-cohort design, underpinning a cohort with 13 908 subjects (including 10 496 normal subjects, 2652 polyps, 760 colorectal cancers) who underwent the first examination of colonoscopy between 1979 and 1998, was devised to estimate parameters associated with two opposing theories by randomly selecting 305 normal subjects, 300 patients with polyps, and 116 colorectal cancers from the cohort. All the 2652 polyps were linked to national cancer registry to ascertain 25 invasive carcinomas after polypectomy. For the five-state model associated with adenoma size, dwelling times of small (0.6-1 cm) and large adenoma (>1 cm) are 7.75 and 5.27 years for the model without considering de novo, and 17.48 and 15.90 years for the model taking de novo carcinoma into account. Similar findings are observed for the model associated with histological type. The estimated proportions of de novo carcinoma are 31.87% from the model by adenoma size and 27.81% from the model by histological type. Compared to size less than 5 mm, patients with adenoma size between 6 and 10 mm and patients with adenoma size larger than 1 cm have 2.17-fold (0.67-10.74) and 4.25-fold (1.23-14.70), respectively, for the risk of malignant transformation. There are similar findings for the model by histological type. The estimates of overall efficacy of colonoscopy in reducing CRC is 73% for the model allowing for de novo carcinoma and 88% for the model without considering de novo carcinoma theory. The efficacy of diminutive adenoma and small adenoma increases with follow-up years, whereas the efficacy of large adenoma decreases with follow-up years. In conclusion, about 30% of cancers arising from de novo sequence are demonstrated. This finding, together with the adenoma-carcinoma sequence associated with adenoma size and histological type, is important for the estimation of dwelling times, the efficacy of colonoscopy, and the surveillance of polyp after polypectomy.

Adenoma↗

PubMed2001

Surveillance colonoscopy or chemoprevention with COX-2 inhibitors in average-risk post-polypectomy patients: a decision analysis.

OBJECTIVES: Clinical trials are currently underway evaluating the efficacy of COX-2 inhibitors in decreasing the incidence of adenomas and colorectal carcinoma in 'average' risk individuals. AIM: To use decision analysis to compare the cost-effectiveness of celecoxib to surveillance colonoscopy in 'average' risk patients who had undergone prior adenoma resection. METHODS: A model of the natural history of adenomas after endoscopic polypectomy was constructed using probabilities from the literature. Cost estimates were obtained from available Medicare reimbursement rates and supplemented by the literature. Three strategies were evaluated: (i) no surveillance; (ii) colonoscopic surveillance; and (iii) celecoxib chemoprevention. We compared total costs and performed cost-effectiveness analysis between these strategies. The outcome measures were years of life saved and 'high-grade' adenoma prevented. Sensitivity analyses were performed on selected variables. RESULTS: Our base-case analysis assumed a 50% risk reduction in the incidence of adenomas among patients using celecoxib. No surveillance was associated with a cost of $1014 per patient, and colonoscopic surveillance with a cost of $1572 per patient, whereas celecoxib use was associated with a total cost of $11,503. Ten years after the index colonoscopy, 15% of patients in the no surveillance strategy developed 'high-grade' lesions compared to 13% of patients in the colonoscopic surveillance group and 6% in the celecoxib group. There was a small gain in years of life saved (0.006) favouring celecoxib over colonoscopic surveillance. The incremental cost-effectiveness ratio of celecoxib vs. colonoscopy was $141 871 per 'high-grade' adenoma prevented and $1,715,199 per year of life saved. The most important variables in determining the cost-effectiveness of celecoxib were its cost and its efficacy. CONCLUSION: Chemoprevention with COX-2 inhibitors in 'average-risk' postpolypectomy patients is a more expensive strategy compared to colonoscopic surveillance.

Adenoma↗

PubMed2002

Safety and efficacy of two reduced dosing regimens of sodium phosphate tablets for preparation prior to colonoscopy.

OBJECTIVES: To evaluate the safety and efficacy of two reduced dosing regimens of sodium phosphate tablets (Visicol, InKine Pharmaceutical Co. Inc., Blue Bell, PA, USA) for colon cleansing prior to colonoscopy. METHODS: In a randomized, multicentre, endoscopist-blinded clinical study, adults undergoing colonoscopy received either 28 tablets (42 g) or 32 tablets (48 g) of sodium phosphate for colon cleansing. The endoscopist used a validated four-point scale to rate the overall quality of colon cleansing, as well as cleansing in the ascending colon. Adverse events were collected and evaluated. RESULTS: The quality of overall colon cleansing was 'excellent' or 'good' in 84% or more of both groups, with no significant difference between the two doses. No patient had a preparation rated as 'inadequate' or required a repeat procedure. All patients were able to complete the assigned dose of tablets, and there were no deaths, serious adverse events or dropouts from the study. CONCLUSIONS: A reduced tablet regimen for sodium phosphate tablets, using either 28 or 32 tablets, is well tolerated and effective for colon cleansing prior to colonoscopy.

Cathartics↗

PubMed2002

Low-salt bowel cleansing preparation (LoSo Prep) as preparation for colonoscopy: a pilot study.

BACKGROUND: Currently available colon cleansing preparations are often poorly tolerated. AIM: To evaluate the efficacy of a low-volume, low-salt preparation for colonoscopy. METHODS: This was a pilot study in patients scheduled for colonoscopy. The preparation consisted of 34 g of magnesium citrate and four bisacodyl tablets the day before the procedure, and one bisacodyl suppository on the morning of the procedure. RESULTS: Twenty patients (age range, 49-81 years; all males) were entered into the study. There were no significant side-effects associated with the preparation. All rated the taste as 'tolerable or better'. The examination was considered to be adequate, with no limitations, in 17 patients (85%), and was scored as good to excellent (no solid stool) in 11 (55%), acceptable (small amounts of solid stool) in six (30%) and poor in three (15%: two in-patients and one out-patient). Importantly, two of the failures then received a standard polyethylene glycol preparation and again failed to show adequate colon preparation. CONCLUSIONS: This pilot study showed that the low-salt colon cleansing preparation was an effective alternative preparation for colonoscopy.

Administration, Oral↗

PubMed2002

Routine colonic mucosal biopsy and ileoscopy increases diagnostic yield in patients undergoing colonoscopy for diarrhea.

BACKGROUND AND AIMS: In patients undergoing colonoscopy for diarrhea, when the examination is normal, the role of routine mucosal biopsy remains controversial, particularly in the open-access setting. It is uncertain whether routine ileoscopy adds anything to colonoscopy alone. We aimed to assess the yield of mucosal biopsy and ileoscopy in patients with diarrhea. METHODS: We retrospectively reviewed all colonoscopies performed for diarrhea over a 9-year period in a tertiary referral center with an open-access service. We then selected cases where the examination was normal and biopsies were performed. The histopathology reports of these selected cases were then reviewed. RESULTS: There were 1131 cases identified. The mucosal examination was normal in 465 cases (41%); 362 of these had colonic biopsies performed. Histology was normal in 316 cases (87%) and was non-specific in 28 cases (8%). Significant histopathology was present in 18 cases (5%) with a significantly higher prevalence of microscopic colitis in patients above 60 years old. Ileoscopy was performed in 508 cases and was abnormal in 26 cases (5%). The abnormality on ileoscopy was the sole abnormality in 13 cases (3%). CONCLUSIONS: Routine colonic mucosal biopsy and ileoscopy each identify significant additional pathology in 5% of cases when investigating patients with diarrhea, and are recommended as routine practice in this setting. We found ileal biopsy unhelpful when ileoscopy was normal.

Biopsy↗

PubMed2002

Small bowel obstruction: is routine colonoscopy necessary after resolution?

BACKGROUND: Small bowel obstruction is common in clinical practice and is most often due to adhesions. The aim of this study was to determine the significance of colon cancer presenting as a small bowel obstruction at a single institution and to find out whether routine colonoscopy was necessary in patients who had spontaneous resolution of their small bowel obstruction. METHODS: A retrospective review of the medical records of patients presenting with small bowel obstruction from 1995 to 2000 at the Prince of Wales Hospital was performed. The clinical outcomes were obtained from the medical records and the clinical notes of each surgical consultant. RESULTS: Over the study period, 251 patients presented with small bowel obstruction. The mean age at presentation was 63.8 years (range 21-95 years). A total of 149 patients (59.4%) were treated conservatively with an average hospital stay of 4.6 days (range 1-20 days). Another 100 patients (39.8%) were treated operatively with a mean time from presentation to operation of 2.2 days (range <24 h-14 days). The remaining two patients (0.8%) were managed palliatively because of known metastatic disease. At laparotomy, 13 patients (13%) had a colon cancer identified. A further three patients were identified to have a colon cancer on follow up colonoscopy. However, only one of the three patients had had a previous laparotomy, that is, only 0.7% (1/149) of patients with a spontaneously resolved small bowel obstruction (presumably secondary to adhesions) had actually had colon cancer. CONCLUSIONS: The overall incidence of small bowel obstruction secondary to colon cancer is significant at 6.4%. However, as the incidence of colon cancer in patients who had had a previous laparotomy and spontaneous resolution of their obstruction was very low at 0.7%, routine colonoscopy does not seem warranted.

Adult↗

PubMed2002

The effect of self-selected music during colonoscopy on anxiety, heart rate, and blood pressure.

The purpose of this study was to examine the effects of music therapy on self-reported and physiological signs of anxiety among ambulatory patients undergoing colonoscopy. Thirty-two patients were randomly assigned to either an experimental group who listened to music during the colonoscopy or a standard procedure no music control group. Before and after the procedure, subjects completed the State Anxiety Inventory. Physiological signs of anxiety, including heart rate and blood pressure, were monitored at four time points during the procedure. Repeated measures analysis of variance indicated a significant group by time interaction on the physiological signs of anxiety. Post hoc analysis indicated that heart rate and systolic and diastolic blood pressure significantly decreased among the music intervention group during the procedure while remaining unchanged in the control group. No significant effect of the treatment was observed on the State Anxiety Inventory, although a trend indicated that the music intervention decreased state anxiety. Finally, the group who received the music intervention required less physician-administered sedation during the procedure than did the control group. These findings indicate that music therapy has the potential to reduce physiological indicators of anxiety and the need for sedation among individuals undergoing a colonoscopy.

Aged↗

PubMed2001

Screening and surveillance colonoscopy in chronic Crohn's colitis.

BACKGROUND & AIMS: Unlike ulcerative colitis, there are few reports on the efficacy of surveillance colonoscopy in patients with chronic Crohn's colitis and therefore little agreement as to whether routine surveillance is indicated. We report on 259 patients with chronic Crohn's colitis who underwent screening and subsequent surveillance colonoscopy and biopsy since 1980. METHODS: Biopsies were performed at 10-cm intervals and from strictures and polypoid masses. Pathology was classified as normal, dysplasia (indefinite, low-grade, high-grade), or carcinoma. RESULTS: A total of 663 examinations were performed on 259 patients. The median interval between examinations was 24 months; examinations were performed more frequently (1-6 months) in patients with dysplasia on biopsy. A thinner-caliber colonoscope was required to complete 12% of screening examinations and 23% of surveillance examinations. The pediatric colonoscope helped increase our yield of neoplasia by 19%. The screening and surveillance program detected dysplasia or cancer in 16% (10 indefinite, 23 low-grade, and 4 high-grade dysplasias and 5 cancers). A finding of definite dysplasia or cancer was associated with age >45 years and increased symptoms. By life table analysis, the probability of detecting dysplasia or cancer after a negative screening colonoscopy was 22% by the fourth surveillance examination. CONCLUSIONS: Colonoscopic surveillance should be strongly considered in chronic extensive Crohn's colitis.

Adolescent↗

PubMed1999

An initial experience with screening for colon polyps using spiral CT with and without CT colography (virtual colonoscopy)

BACKGROUND: Computed tomographic (CT) colography (virtual colonoscopy) is a new imaging method for detection of colon polyps and cancer. OBJECTIVE: To evaluate the sensitivity of CT colography for polyp detection in a population without symptoms that included persons without colon neoplasia and with radiologists blinded to colonoscopic findings. METHODS: Forty-six persons without symptoms underwent spiral CT followed by same-day colonoscopy with subsequent inspection of two-dimensional axial CT images, interactive multiplanar images, and surfaced and volume-rendered images of the colon (three-dimensional CT colography). RESULTS: Three-dimensional CT colography was superior to two-dimensional axial imaging for detection of colon polyps. Three-dimensional CT colography depicted 1 of 4 (25%) adenomas 2 cm in diameter or larger, 6 of 10 (60%) adenomas 1 to 1.9 cm, 6 of 14 (43%) 6 to 9 mm, and 7 of 65 (11%) 5 mm in diameter or smaller. Three-dimensional CT colography showed a polyp that might have led to colonoscopy in 3 of 4 (75%) patients whose largest adenoma was 2 cm or larger, 5 of 6 (83%) patients with largest adenoma 1 to 1.9 cm, 3 of 7 (43%) patients with largest adenoma 6 to 9 mm, and 4 of 16 patients (25%) with largest adenoma 5 mm or smaller. Large, flat adenomas of the right colon were difficult to identify with three-dimensional CT colography. The specificity of three-dimensional CT colography for patients with adenomas 1 cm in diameter or larger was 89%. Examination of patients with missed adenomas after unblinding indicated that meticulous bowel preparation and adequate distention are critical to accurate interpretation. Perceptual errors were common. CONCLUSIONS: CT colography as performed in this study is not adequate as a colorectal cancer screening test. Several technical factors that appear critical to accurate performance of CT colography are defined.

Adenocarcinoma↗

PubMed1999

Water intubation of the sigmoid colon: water instillation speeds up left-sided colonoscopy.

BACKGROUND AND STUDY AIMS: Rapid passage through the sigmoid and descending colon is important during flexible colonoscopy, and colonoscopists have developed several techniques and tricks for achieving this. The present study was designed to explore the effect of instilling 200 ml of water into the first bend of the sigmoid on the speed of passage of the endoscope from the rectum to the left colonic (splenic) flexure. PATIENTS AND METHODS: A prospective study of 100 successive single-handed colonoscopies was carried out, using randomly either the water intubation technique (50 patients) or the traditional method (50 controls) to compare the time needed to pass the endoscope from the rectum to the left colonic flexure. RESULTS: The results indicate that water intubation allowed the endoscope to be advanced through the sigmoid and descending colon in a median time (fiftieth percentile) of 154.5 seconds, compared to 223.5 seconds using the traditional technique. Water intubation speeds up the insertion time by 31%. This difference was highly significant statistically (P<0.0001). The difference remained significant when the data for men and women were analyzed separately. There was no statistically significant difference in the formation of N loops, or in incidentally formed alpha loops between the two study groups. CONCLUSION: The water intubation technique is more efficient than the traditional method, particularly in difficult left-sided colonoscopies, but it is equally safe.

Adult↗

PubMed1999

Quality assurance and colonoscopy.

BACKGROUND AND STUDY AIMS: Little is known concerning the usefulness and feasibility of quality assurance programs in gastrointestinal departments. The aim of this study was to identify the indicators of quality in colonoscopy, to check their use in clinical practice, and to identify their threshold values. MATERIALS AND METHODS: A prospective study was performed in four endoscopic units. In the first phase, a questionnaire was used to identify the indicators that were considered important and easy to record; in the second phase, the selected items were prospectively recorded. RESULTS: Data from 603 colonoscopies were evaluated. The selected indicators were: rate of cecal intubation, rate of examinations with normal findings, rates of complications, appropriateness of indications, use of a washing machine for disinfection, duration of the disinfection procedure, rate of procedures repeated due to poor colon cleansing, rate of operative procedures, length of waiting time, rate of procedures performed for follow-up of known disease, experience of the operator, and rate of procedures performed with the patient under conscious sedation. A striking difference emerged between the technical standards at three centers, which were fairly good, and the standard at the fourth center, which was less satisfactory. The length of the waiting time was high in all centers, as well as the rate of examinations conducted with an inappropriate indication. The rate of procedures performed under conscious sedation varied widely between the centers. CONCLUSIONS: The study of the indicators of quality of colonoscopy is feasible and easy to perform in clinical practice, and can be useful for quality assurance programs.

Adolescent↗

PubMed2000

Synergistic sedation with low-dose midazolam and propofol for colonoscopies.

BACKGROUND AND STUDY AIMS: Patients undergoing colonoscopy are often sedated with benzodiazepines and long-acting opiates. Since low-dose midazolam also acts synergistically with short-acting propofol, we compared this synergistic sedation with a standard combination of midazolam and the opioid nalbuphine for colonoscopies. PATIENTS AND METHODS: A total of 79 patients presenting for colonoscopies were randomly assigned to the following protocols. Patients in group I (n = 32) received a median dose of 9 mg midazolam (interquartile range [IQR] 6 to 12); 20 patients (59%) needed additional nalbuphine (median 20 mg, IQR 10 to 20). Patients in group II (n = 47) received 2 mg midazolam and repeated injections of propofol (median 100 mg, IQR 53 to 145) with a maximal bolus of 50 mg. RESULTS: Patients treated with the synergistic sedation (group II) recovered remarkably sooner after the procedure compared with those in group I, with a median time to discharge of 17 minutes vs. 93 minutes (P<0.001). Of the patients treated with analgosedation (group I), 28 % were unable to take part in a reaction time measurement and attention awareness test 1 hour after the procedure. All patients treated with the synergistic sedation were able to participate (P=0.002), and performed better. Despite a lower proportion of complete amnesia, patients treated with synergistic sedation more often rated the procedure as comfortable (81% vs. 50 %). Quality of sedation from the point of view of the endoscopist, and cardiorespiratory parameters, were similar in both groups. CONCLUSIONS: Low-dose midazolam combined with propofol is an effective and economic alternative to benzodiazepine-based analgosedation. It is associated with a high degree of patient comfort and rapid recovery times, and has a potential cost benefit concerning nursing care and bed facilities.

Adult↗