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Poststress left ventricular ejection fraction is an independent predictor of major cardiac events in patients with coronary artery disease and impaired left ventricular function.

AIM: The aim of this study was to investigate the prognostic value of myocardial perfusion and function SPECT imaging in patients with coronary artery disease (CAD) and poor left ventricular (LV) function. METHODS: We studied 261 patients (231 men, age 66+/-10 years) with CAD and a resting LV ejection fraction (LVEF) <or= 40% assessed during myocardial gated SPECT. Perfusion defect extent was calculated using 4D-MSPECT software (Michigan University). Ischemia scoring was performed visually. Considered end points were: 1) major adverse cardiac events (MACE) (cardiac death, non-fatal myocardial infarction or late revascularization), 2) MACE or the need for hospitalization due to heart failure (MACE-HF) and 3) cardiac death or non-fatal myocardial infarction. RESULTS: During a median follow-up of 31 months, 52 patients (20%) died (35 cardiac deaths), 50 (19%) developed a MACE and 69 (26%) a MACE-HF. In a clinical model, diabetes and angina status were the only predictors of MACE (chi-squared=19.3; P<0.001). By multivariate analysis, poststress LVEF (chi-squared-gain of 6.4; P=0.008) and presence of ischemia (chi-squared-gain of 5.8; P=0.018) were predictive of MACE. Similarly, diabetes mellitus (chi-squared=12.1; P<0.001), poststress LVEF (chi-squared-gain of 5.5; P=0.019) and presence of ischemia (chi-squared-gain of 4.3; P=0.044) were independent predictors of MACE-HF. Diabetes mellitus (chi-squared=17.8; P<0.001), presence of angina complaints (chi-squared-gain of 6.8; P=0.028) and poststress LVEF (chi-squared-gain of 6.3; P=0.008) were independent predictors of cardiac death or non-fatal myocardial infarction. CONCLUSION: In patients with impaired LV function and CAD, poststress LVEF is an independent predictor of future cardiac events.

Aged↗

Surgical intensive care unit resource use in a specialty referral hospital: I. Predictors of early death and cost implications.

The rationing of medical care prioritizes the need for early predictors of death in the surgical intensive care unit (SICU). We prospectively studied 100 consecutive SICU admissions, looking for predictors of early death in the SICU and the cost implications of these findings. Serial APACHE II scores on days 1, 3, and 5 were subjected to multinomial logistic regression analysis to determine significant predictors of death in the SICU on day 1. Survivors had significantly lower (p less than 0.05) mean day-1 APACHE II scores than had nonsurvivors (13.6 vs 22.1). Half of the patients with scores greater than 18 died, and all patients with scores on day 1 of 25 or greater died. Significant predictors of death on SICU day 1 were APACHE II scores, Acute Physiology Score, Glasgow Coma Score, creatinine level, and Chronic Health Evaluation Score. Forty-one patients had been transferred from community hospitals as a results of acute illness; this population accounted for two thirds of the deaths in the SICU. Ten of 18 nonsurvivors were predicted on day 1, with these patients incurring a total cost of approximately $1 million. If therapy had been modified on days 5, 10, or 15, the potential cost savings would have been $340,000, $240,000, or $140,000, respectively. Integration of the results of this study into the management decision-making process and treatment guidelines may reduce the cost of care in the SICU.

Costs and Cost Analysis↗

Early predictors of adolescent aggression and adult violence.

The Cambridge Study in Delinquent Development is a prospective longitudinal survey of 411 London males from ages 8 years old to 32 years old. This article investigates the prediction of adolescent aggression (ages 12-14 years old), teenage violence (ages 16-18 years old), adult violence (age 32 years old), and convictions for violence. Generally, the best predictors were measures of economic deprivation, family criminality, poor child-rearing, school failure, hyperactivity-impulsivity-attention deficit, and antisocial child behavior. Similar predictors applied to all four measures of aggression and violence. It is concluded that aggression and violence are elements of a more general antisocial tendency, and that the predictors of aggression and violence are similar to the predictors of antisocial and criminal behavior in general.

Achievement↗

The clinical and renal biopsy predictors of long-term outcome in lupus nephritis: a study of 87 patients and review of the literature.

The prognostic markers in 87 consecutive patients with lupus nephritis who underwent renal biopsy are reported for five clinically relevant long-term outcomes--renal insufficiency, renal failure, death due to renal systemic lupus erythematosus, death due to non-renal SLE and death due to SLE, both renal and non-renal. We have demonstrated that a number of previously neglected or rarely studied predictors were important prognostic markers. These included the duration of renal disease before biopsy, overall severity of SLE, as well as the presence of vasculitis, hypertension or a comorbid ailment. Furthermore, the study confirms the predictive importance of serum creatinine, 24-h urinary excretion of protein, C3, and of the activity and chronicity indices on biopsy. However, overall a simple measure of tubulointerstitial disease was the best predictor obtained from biopsy. Prognostic models based on clinical data alone were developed for each of the five outcomes. The models amplify our clinical understanding of lupus nephritis. Markers of renal severity were most important in predicting renal outcomes such as renal insufficiency and renal failure. Prognostic factors less directly related to renal disease (comorbidity and vasculitis) were important predictors of fatality. A marker of immunologic disease activity (C3) was a valuable predictor for many of the outcomes. Thus markers of disease severity reflecting organ damage due to SLE and other comorbid conditions could be combined with markers of immunologic activity to predict a variety of outcomes of relevance to a clinician. When biopsy data obtained by light or electron microscopy were evaluated for their ability to add new predictive information to the clinical models, only a limited value for biopsy was noted. It is likely that this reflected the close correlational relationships between clinical and biopsy variables, the strong clinical models generated, and the inclusion in the clinical models of the previously neglected clinical variables, duration of renal disease before biopsy and the presence of vasculitis or comorbid disease.

Adolescent↗

Prevalence and predictors of smokeless tobacco use: Iowa's program against smoking.

Data from surveys of adolescents were analyzed so that we could determine the prevalence of smokeless tobacco use and identify and compare the concurrent correlates of its use and cigarette smoking. Panel data from seventh through eleventh and eighth through twelfth graders between 1980 and 1984 and cross-sectional data from seventh graders in 1980 and 1985 suggest that boys are more likely to use SLT than are girls and that the boys' use has increased with age and over time. Concurrent correlates of seventh-grade boys' and girls' SLT use and cigarette smoking were identified with discriminant analyses. Predictors of smokeless tobacco use were compared with those of weekly smoking for boys and girls separately. Predictors of use by boys were also compared with those by girls. Trying alcohol and the other form of tobacco were the only predictors that related to the use of either form by boys and girls. Differences among other predictors were noted and their implications for prevention are discussed.

Adolescent↗

Predictors of excessive blood use after coronary artery bypass grafting. A multivariate analysis.

One hundred fifty-nine consecutive patients who underwent coronary artery bypass grafting were studied to determine clinical and laboratory predictors of excessive postoperative packed red blood cell transfusion. Consideration of the distribution of packed red blood cells administered revealed that the patients could be divided into two groups: those patients who received 5 units of red blood cells or less (group I, n = 139) and those patients who received more than 5 units of packed red blood cells (group II, n = 20). The Mann-Whitney test or Fisher's exact test was used whenever appropriate to test differences between these two groups with respect to twelve patient variables. Patients in group II were found to have a significantly longer preoperative template bleeding time and decreased preoperative packed red blood cell volume (p less than 0.0008 for both variables). In addition, group II patients were significantly older (p = 0.026), were more likely to have had preoperative heparin therapy (p = 0.049), and contained a greater proportion of women (p = 0.0048). Of interest, variables that did not achieve statistical significance between groups were partial thromboplastin time, prothrombin time, platelet count, preoperative hematocrit level, urgency of operation, recent ingestion of aspirin, and recent heparin administration. All of the measured variables were used in a stepwise logistic regression analysis to identify the best predictors of the need for more than 5 units of packed red blood cells after operation. Of the variables examined, bleeding time (p less than 0.001; chi 2 improvement = 15.1) and red blood cell volume (p = 0.009; chi 2 improvement = 6.8) were the best predictors of excessive postoperative packed red blood cell use. On the basis of a 50% logistic probability level, the specificity and sensitivity of these two variables in predicting greater than a 5-unit transfusion requirement were 85% and 99%, respectively. A clinically useful nomogram based on this logistic model is presented. This nomogram suggests that a ratio of bleeding time to red blood cell volume of 0.0071 or greater is associated with a greater than 70% chance of requiring more than 5 units of packed red blood cells. We conclude that preoperative bleeding time and red blood cell volume are useful predictors of excessive postoperative blood transfusion. These results suggest that factors other than aspirin therapy may be associated with bleeding time prolongation leading to excessive postoperative transfusion.

Aged↗

Respiratory symptoms and FEV1 as predictors of hospitalization and medication in the following 12 years due to respiratory disease.

The predictive value of cough, mucus hypersecretion, breathlessness, chronic bronchitis and forced expiratory volume in one second (FEV1) for hospitalization and medication were examined in a random population sample of 876 men, 46-69 yrs of age. All of the men were examined in 1974 with interview and lung function tests. Information on hospitalization in the period 1977-1986 was obtained from the Danish National Patient Register, and information on drug usage was obtained from 567 men in a questionnaire survey ultimo 1985. FEV1 was a strong predictor of both hospitalization and medication. Respiratory symptoms were good predictors of hospitalization due to either respiratory disease in general (odds ratios 2.56-3.29), or chronic obstructive pulmonary disease (COPD), (odds ratios 4.16-5.75). They contained predictive values in addition to that provided by FEV1. Respiratory symptoms were good predictors of medication for airway obstruction, relative risks 3.56-4.70, and/or airway disease in general, relative risks 2.67-4.69. After controlling for FEV1, cough was still significantly associated with treatment for airway disease in general and both cough, mucus hypersecretion and chronic bronchitis were significantly associated with treatment for airway obstruction. We conclude that apart from FEV1, respiratory symptoms are independent predictors of hospitalization and medication due to respiratory disease.

Aged↗

Predictors of decline in CD4 lymphocytes in a cohort of homosexual men infected with human immunodeficiency virus.

Longitudinal data on four visits scheduled at 6 month intervals were available on a cohort of 1,827 homosexual men who were human immunodeficiency virus (HIV) seropositive at entry. To identify predictors of the rate of decline of CD4 T-lymphocytes, we used an autoregressive model that relates CD4 counts to predictor variables, while adjusting for previous CD4 counts. Significant predictors of steeper decline of CD4 counts were high CD8 count, low hemoglobin, low platelets, high serum IgA, high cytomegalovirus (CMV) antibody, and low HIV antibody. Using the fitted model, a subject with an initial deficit of 314 CD4 cells (median value of study sample) with respect to seronegative subjects and with average values in all other predictors is estimated to lose approximately 53 cells in a 6 month period (95% C.I. = 45-61 cells). Contrasting this estimate to the one obtained with similar methods in intravenous drug users, it is suggested that a faster rate of decline is present among i.v. drug users. This analysis provides evidence that several covariates in addition to previous number of CD4 counts have significant predictive power for estimating the decline in CD4 counts in HIV seropositive subjects.

AIDS Serodiagnosis↗

Predictors of reoperation after myocardial revascularization.

The first 1,000 patients undergoing primary isolated myocardial revascularization each year from 1971 to 1978 were analyzed to define the incidence of reoperation and to elucidate the determinants of reoperation and reoperation-free survival. Six hundred sixty-six patients (9.7%) underwent reoperation in a mean of 6.9 +/- 3.2 years. Cumulative percent reoperation was 2.7% at 5 years, 11.4% at 10 years, and 17.3% at 12 years. The annual incidence of reoperation was 1.1% at 5 years and increased to 3.9% at 12 years. Twenty-five patient descriptors were analyzed for predictors of reoperation. Young age was found to be the most important predictor of potential for reoperation. Other risk factors in descending order of significance were absence of an internal mammary artery graft, incomplete revascularization, New York Heart Association Functional Class III/IV, and single or double vessel disease. Absence of an internal mammary artery graft was an important predictor for all age groups. In the multivariate analyses for risk factors for reoperation-free survival, absence of an internal mammary artery graft was the most important predictor. Other factors of major significance were smoking, incomplete revascularization, and moderate/severe left ventricular impairment. Internal mammary artery grafting neutralizes hypertension, serum cholesterol level higher than 300 mg/dl, and smoking as risk factors for reoperation-free survival.

Adult↗

Predictors of physical activity one year after myocardial infarction.

A number of factors predicting habitual physical activity, duration of night's rest, return to work and exercise tolerance one year after acute myocardial infarction (AMI) are studied in fifty-five male patients. Except for exercise tolerance three months after AMI, the results of this prospective study suggest that psychologic factors are more important predictors of the four outcome variables than angina pectoris, infarction size and participation in a physical training program. The most important predictor appears to be the patient's subjective opinion of his physical capabilities, measured by the perceived exercise tolerance scale. The expectation of the eventual return to work three months after MI plays also a significant role as a predictor. Both are predictors of the exercise tolerance and return to work one year after AMI. These findings suggest that physical activity--defined as exercise tolerance, habitual physical activity and duration of night's rest--and return to work are closely related.

Attitude to Health↗

Dynamic muscle strength as a predictor of bone mineral density in elderly women.

Although muscle strength has been shown to predict bone mineral density (BMD) in older adults, the variance explained by isometric and isokinetic testing has been generally low (< 20%) and limited to only a few exercises and muscle groups. To elucidate the relationship of muscle strength to BMD at multiple sites, and to ascertain the most robust predictor of BMD using isotonic strength testing apparatus, we examined dynamic muscle strength and BMD in 40 healthy elderly women aged 65-82 years. BMD of the spine (L2-4), proximal femur (neck, trochanter, Ward's triangle), forearm (midradius), and whole body were measured by dual-energy X-ray absorptiometry. Dynamic strength (1-RM), utilizing isotonic weight-lifting equipment, was assessed for 10 standard upper and lower body exercises. In stepwise multiple regressions, leg press was the only independent predictor of spine (R2 = 0.11), neck and trochanter (R2 = 0.21 and 0.18), forearm (R2 = 0.21), and whole body BMD (R2 = 0.19), while bench press was an independent predictor of Ward's BMD (R2 = 0.12). The most robust predictor of regional and whole body BMD using isotonic equipment was the leg press, which may reflect overall skeletal health in this population. The portion of variance explained by dynamic muscle strength (11-21%) is similar to that reported when strength is assessed by isometric and isokinetic testing. The relationship of dynamic strength to BMD was not generally site-specific.

Absorptiometry, Photon↗

Psychosocial predictors of hypertension in black and white Africans.

OBJECTIVE: To test the hypothesis that psychosocial factors that are closely related to the behavioural stress process in developing countries have predictive value for the incidence of hypertension. DESIGN: A cohort of 528 African students (220 White, 308 Black), mean +/- SD age 22 +/- 3.2 years, were followed up for 4 years at the University of Zimbabwe. Baseline measures of selected psychosocial variables such as anxiety, anger, expression, active coping and family instability were made, together with biological and behavioural predictors of hypertension (initial blood pressure, heart rate, body mass, family history of hypertension or diabetes, alcohol intake, smoking and number of years of urbanization). Analyses were stratified by sex and ethnicity. RESULTS: In multivariate analysis Black students had significantly greater baseline anxiety levels and suppressed anger than White students, and Black students who went on to develop hypertension had significantly higher baseline parameters than those who remained normotensive. In multivariate regression analysis, including biological predictors, anxiety, suppressed anger and family instability remained significant independent predictors of hypertension in urbanized Black students. No psychosocial variable alone predicted hypertension in White students in multivariate analyses. CONCLUSIONS: Among young, urbanized Black students, besides the well-known genetic (family history of hypertension) and biological (initial blood pressure, heart rate, body mass index, smoking and alcohol intake) predictors of hypertension, psychosocial factors are predictive of the later incidence of hypertension. Behavioural non-pharmacological treatment for hypertension might be considered in African developing countries.

Adult↗

An analysis of potential physiological predictors of respiratory adequacy following cardiac surgery.

More than 50 potential physiological and clinical predictors of postoperative respiratory adequacy were examined in an attempt to identify those few variables which, singly or in combination, best predicted the outcome of the first trial of spontaneous respiration following cardiac surgery. This trial was initiated when patients seemed hemodynamically stable and relatively alert following surgery. Analysis of data from 124 patients identified the following useful predictors: forced vital capacity, total lung capacity, and maximal mid-expiratory flow rate from preoperative pulmonary function tests; resting cardiac index from preoperative cardiac catheterization; postoperative compliance and resistance measured by a computer-based monitoring system; postoperative vital capacity per kilogram, and maximum inspiratory force, measured at the bedside prior to the weaning trial. Stepwise linear discriminant analysis indicated that vital capacity per kilogram and maximum inspiratory force were the most useful predictors, the dividing line between successes and failures being represented by a vital capacity per kilogram of 15 ml. and a maximum inspiratory force of 28 cm. H2O. Mean values of successes were 18.3 +/- 7 ml. per kilogram and 30.7 +/- 9 cm. H2O and, for failures, 11.9 +/- 4 ml. per kilogram and 24.3 +/- 8.4 cm H2O. These physiological variables assess patient effort acting upon an abnormal pulmonary system. Measurements of passive pulmonary mechanics, cardiac function, and the measurement of arterial blood gases were suprisingly poor predictors.

Airway Resistance↗

[The short-term results and angiographic predictors of subacute thrombosis in the coronary implantation of the Palmaz-Schatz endoprosthesis].

INTRODUCTION AND OBJECTIVES: Intracoronary stenting has been proposed as an adjunct to balloon angioplasty in order to improve the immediate and long-term results. The purpose of this study was evaluate the short-term results, subacute closure rate and to try to identify angiographic predictors of subacute thrombotic after Palmaz-Schatz stent implantation. METHODS: Through a prospective registry, we have evaluated in 500 patients the safety and efficacy of Palmaz-Schatz stent implantation (580 in total) in coronary arteries and saphenous vein grafts. The identification of clinic and angiographic predictors of subacute closure have been evaluated with the assistance of a BMDP statistical software using an univariate and multivariate statistical analysis (logistic regression). The determination of diameter and stenosis has been achieved by electronic caliper. RESULTS: The stent was implanted successfully in 98.6% of the patients. There was no abrupt closure (< or = 1 day), however 36 patients (7.2%) developed subacute thrombotic closure (among 2nd-21st day after stenting). The major complications were: death 9 patients (1.8%), bypass surgery 7 patients (1.4%) and myocardial infarction 21 patients (4.2%). The predictors of subacute thrombotic closure through univariate statistical were: stenting for bail-out (S.T.: 27%; p < or = 0.0001), multiple stenting (S.T.: 24.1%; p < or = 0.0001), final diameter stent < or = 3.25 mm (S.T.: 12.6%; p < or = 0.013), and left ventricular ejection fraction < or = 45% (S.T.: 15.7%; p < or = 0.022). We showed with logistic regression that final diameter stent < or = 3.25 mm; p < or = 0.0030, left ventricular ejection fraction < or = 45%; p < or = 0.0012, stenting for bail-out; p < or = 0.0195 and multiple stenting; p < or = 0.0252, were predictors of subacute thrombotic closure. CONCLUSIONS: The Palmaz-Schatz coronary stenting will preferably realize in those arteries bigger than 3.25 mm and left ventricular ejection fraction > 45%, showing multiple stenting and stenting for bail-out greater subacute thrombotic closure rate.

Acute Disease↗

Response to treatment as a predictor of longterm outcome in patients with lupus nephritis.

OBJECTIVE: To evaluate response to therapy over one year as a predictor of several longterm outcomes in lupus nephritis. METHODS: Response to treatment was evaluated by comparing serum creatinine and 24 h urine protein excretion at initial renal biopsy to those obtained after one year of treatment. Response at one year was evaluated as a predictor of renal failure, death due to lupus nephritis, and total lupus mortality, using survival analysis. RESULTS: Eighty-five patients with lupus nephritis diagnosed between 1967 and 1983 and followed through 1990 were studied. Change in proteinuria was a powerful predictor of renal failure (p = 0.001) death due to lupus nephritis (p < 0.001) and overall lupus mortality (p = 0.001). In contrast to a recent study of patients selected for severe lupus nephritis, serum creatinine was not found to be of prognostic significance. CONCLUSION: Response of proteinuria to treatment over one year is a useful predictor of longterm outcomes in lupus nephritis.

Adolescent↗

Simple predictors to differentiate acute asthma from ARI in children: implications for refining case management in the ARI Control Programme.

There is a considerable overlap in the clinical presentation of acute asthma and ARI. According to the current ARI Control Programme recommendations, a child with cough and rapid breathing is overtreated for ARI (pneumonia) with antibiotics and undertreated for asthma with bronchodilators. The present study, therefore, evaluated simple predictors to differentiate these two conditions to refine the recommended case management. In a case control comparison, children between 6 to 60 months age who presented with cough and rapid breathing due to acute asthma (n = 100) and ARI (n = 100) were evaluated. Only 34% of asthmatics had an audible wheeze. Significant independent predictors on multiple logistic regression analysis were number of earlier similar attacks and fever (or temperature). The best predictor for asthma was two or more earlier similar episodes (sensitivity 84%, specificity 84%) followed by temperature < 37.6 degrees C (sensitivity 73% and specificity 84%). Absence of fever, audible wheeze and a family history of asthma had excellent specificities (98-100%) but low sensitivities (20-34%). It is concluded that simple clinical predictors can differentiate acute asthma and ARI. The recommended case management can, therefore, be refined by either: (i) Prescribing bronchodilators and no antibiotics with two or more earlier similar episodes of cough and rapid breathing; or (ii) To further minimize undertreatment for pneumonia, prescribing bronchodilators as above, but denying antibiotics in such cases only if there is audible wheeze or family history of asthma or no fever.

Acute Disease↗

Ventilatory lung function level as a predictor of survival among the elderly.

During a population survey in 1986/1987 among community-dwelling elderly in Cracow, aged 65 yrs and over, measurements of ventilatory lung function were carried out on 698 males and 1,211 females. The main objective of the study was to assess the importance of forced expiratory volume in one second (FEV1) as a predictor of survival experienced in this population group over a 6 year follow-up, in comparison with that of sociodemographic variables, smoking habit, chronic respiratory symptoms, hypertension, obesity and self-assessment of health. Statistical analysis of the relationship between mortality and chosen predictors has been performed with Cox proportional hazards statistical model. It was found that in addition to age, the FEV1 level was the most relevant and independent of age survival predictor among the elderly. In males, a reduction of FEV1 by 100 ml after allowing for age, showed a significantly higher risk of dying by 4%, (relative risk (RR) = 1.04; 95% confidence interval (CI) 1.01-1.06), and in females by 5% (RR = 1.05; 95% CI 1.05-1.09). Male current or ex-smokers displayed a higher mortality risk due to reduction of FEV1 (RR = 1.05; 95% CI 1.01-1.09) compared to lifetime nonsmokers (RR = 1.04; 95% CI 1.00-1.07); the corresponding RR values in women were 1.12 (95% CI 1.02-1.23) and 1.04 (95% CI 1.00-1.08), respectively. However, the differences found between the smokers and nonsmokers were not significant in either gender group. Other potential predictors considered, such as education, chronic respiratory symptoms, hypertension, self-assessment of health, or obesity, appeared to have been irrelevant in the multivariate analysis.

Age Factors↗

Clinical and laboratory predictors of invasive diarrhoea in children less than five years old.

Five hundred and thirty-three children < 5 years of age with acute watery diarrhoea were followed for appearance of blood in their stools to evaluate various clinical and laboratory predictors of dysentery. The statistical analysis was performed in two steps. Firstly, clinical and laboratory variables were evaluated as 'predictors' for isolation of invasive bacterial enteropathogens from stool culture. Secondly, all the variables, including isolation of invasive bacterial enteropathogens, were analyzed for predicting bloody diarrhoea. Presence of mucus (sensitivity = 57.4%, specificity = 83.1%, positive predictive value = 24.8%, negative predictive value = 95.3%, p = 0.0000) was the only significant clinical predictor of bloody diarrhoea. Polymorphonuclear leucocytes (PMN) > 10/hpf (sensitivity = 55.3%, specificity = 92.4%, positive predictive value = 41.3%, negative predictive value = 95.5%, p = 0.0000) and red blood cells, regardless of their number, (sensitivity = 78.7%, specificity = 93%, positive predictive value = 52.1%, negative predictive value = 97.8%, p = 0.0000) on light microscopy of fresh stool samples were two significant laboratory findings. Isolation of invasive bacterial enteropathogens was also a significant predictor of bloody diarrhoea (sensitivity = 19.1%, specificity = 89.5%, positive predictive value = 15%, negative predictive value = 92% p = 0.0077) but ranked lower than the other 3 variables. Our results indicated that it is the severity of invasion caused by offending enteropathogens, clinically manifesting as mucoid stools and/or presence of PMN or RBC, which may be a better indicator of the invasive process and subsequent development of dysentery rather than mere isolation of invasive enteropathogens from the stools.

Acute Disease↗