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Biomedical subjects

B A Finegan

Publications and source records attributed to B A Finegan.

At least 19 recordsLinked to original sources

The attitude of the general public towards preoperative assessment and risks associated with general anesthesia.

PURPOSE: To survey the general public's attitude towards preoperative assessment and commonly perceived fears about general anesthesia. METHODS: A province wide telephone survey was conducted in Alberta. General and regional anesthesia were defined, a scenario involving major knee surgery was described, and participants were asked to choose between regional and general anesthesia. Respondents used a seven-point scale to rate the importance of seeing an anesthesiologist preoperatively and were questioned about the timing of such a visit. Attitudes towards commonly perceived fears associated with anesthesia were also assessed. RESULTS: A total of 1,216 people were surveyed. Over 30% of respondents felt that it was very important to see an anesthesiologist preoperatively, with a total of over 60% attributing a high degree of importance to this. Fifty percent felt that this assessment should occur on the day prior to surgery. A preference for regional or general anesthesia was not expressed in the situation. Approximately 20% of respondents were very concerned about brain damage, waking up intraoperatively and memory loss. Twelve percent were concerned about dying intraoperatively. Nine percent expressed concern about postoperative pain, with 12% reporting being concerned about nausea and vomiting. CONCLUSIONS: The general public considers anesthetic assessment on the day prior to surgery an important part of preoperative preparation. Fears of brain damage, death and intraoperative awareness associated with general anesthesia remain prevalent, suggesting that preoperative education of patients should address these concerns. The general population was less concerned about realistic fears such as nausea, vomiting and postoperative discomfort.

Adult↗

Phentolamine prevents the adverse effects of adenosine on glycolysis and mechanical function in isolated working rat hearts subjected to antecedent ischemia.

Adenosine inhibits glycolysis from exogenous glucose, reduces proton production and enhances post-ischemic left ventricular minute work (LV work) following ischemia in isolated working rat hearts perfused with glucose and fatty acids. In hearts partially depleted of glycogen by antecedent ischemic stress (AIS)--two cycles of ischemia (10 min) and reperfusion (5 min)--adenosine stimulates rather than inhibits glycolysis, increases proton production and worsens recovery of post-ischemic LV work. We determined if the switch in adenosine effect on glycolysis and recovery of LV work following ischemia in hearts subject to AIS was due to the reduction in glycogen content per se or because of alpha-adrenoceptor stimulation. One series of hearts underwent a 35-min period of substrate-free Langendorff perfusion (substrate-free glycogen depletion; SFGD) and a second series of hearts was subjected to AIS. Both series of hearts had a similar glycogen content (approximately 70 micromol/g dry wt) prior to drug treatment. In SFGD hearts perfused aerobically, adenosine (500 microM) inhibited glycolysis from exogenous glucose and reduced proton production. In SFGD hearts reperfused after prolonged ischemia, adenosine exerted similar effects on glucose metabolism and enhanced recovery of post-ischemic LV work (87.2 +/- 2.2% of preischemic values) relative to untreated hearts (25.9 +/- 13.3% of preischemic values). In AIS hearts perfused aerobically or subject to ischemia and reperfusion, phentolamine (1 microM) given in combination with adenosine, prevented adenosine-induced stimulation of glycolysis from exogenous glucose and reduced calculated proton production from glucose. Recoveries of post-ischemic LV work in AIS hearts for untreated, adenosine, phentolamine and adenosine/phentolamine groups were 34.4 +/- 11.4%, 8.6 +/- 3.9%, 16.3 +/- 13.5% and 73.2 +/- 13.1% respectively, of preischemic values. Glycogen depletion in the absence of ischemia does not switch the effect of adenosine from inhibition to stimulation of glycolysis or alter the cardioprotective properties of adenosine in hearts subject to ischemia and reperfusion. The detrimental switch in the metabolic and cardioprotective effects of adenosine, in hearts subject to AIS, can be prevented by phentolamine, an alpha-adrenoceptor antagonist. These data support the concept that modulation of glucose metabolism is an important factor in the mechanical functional recovery of the post-ischemic heart.

Adenosine↗

Rocuronium anaphylaxis and multiple neuromuscular blocking drug sensitivities.

PURPOSE: To report a case of anaphylaxis to rocuronium and the sensitivities to multiple neuromuscular blocking drugs in a patient with no previous exposure to this group of drugs. We describe the current recommendations for both intraoperative and postoperative testing of these patients. CLINICAL FEATURES: A 36-yr-old man was admitted for repair of a ruptured Achilles tendon. Following induction of general anesthesia with fentanyl and propofol, 60 mg of rocuronium were given to facilitate tracheal intubation. He immediately became profoundly hypotensive with impalpable pulses, and blood pressure could not be recorded. Airway pressure increased markedly, and hand ventilation of the lungs became very difficult. His airway was secured and he was successfully resuscitated with 3 mg epinephrine and three litres crystalloid and colloid intravenous fluid therapy. His recovery in the intensive care unit was uneventful and the operation was performed four days later under spinal anesthesia. Subsequent skin prick testing, performed six weeks later, demonstrated strong positive weal and flare reactions to rocuronium, vecuronium and pancuronium, and some cross-reactivity with the benzylisoquinolinium group of muscle relaxants. CONCLUSION: Muscle relaxants are responsible for 61.6% of cases of anaphylaxis during general anesthesia. Cross-reactivity is common, as this group of drugs share a quaternary ammonium group. It is mandatory that patients be tested for both the agent responsible and cross-reactivity following an anaphylactic response. We suggest a protocol for investigation of suspected anaphylaxis.

Achilles Tendon↗

Deficiency in myocardial NO biosignalling after cardioplegic arrest: mechanisms and contribution to post-storage mechanical dysfunction.

1 In order to understand mechanisms that limit the safe ischaemic time of donor hearts, this study evaluated NO/cyclic GMP biosignalling in the recovery of function after cardioplegia and hypothermic storage. 2 Hearts removed from anaesthetized rats were either perfused in working mode (Fresh) or arrested (St. Thomas' II cardioplegia) and stored at 3 degrees C for 8 h (CPL) prior to working mode perfusion. LV work and indices of the production of NO (Ca2+-dependent and Ca2+-independent NOS), cyclic GMP (soluble guanylyl cyclase (sGC) and GTP) and superoxide (xanthine oxidase (XO) and xanthine dehydrogenase (XDH)) were measured. 3 Relative to Fresh hearts, CPL hearts were deficient in cyclic GMP and had poor function. Correction of cyclic GMP deficiency (SNP, 200 microM) improved LV work and LV compliance. SNP effects were prevented by inhibition of sGC (ODQ, 3 microM), and potentiated by inhibition of cyclic GMP-dependent phosphodiesterase (zaprinast, 20 microM). SNP (200 microM) had no effect on function of Fresh hearts. 4 NOS activities (pH = 7.2) were similar in CPL and Fresh hearts, but at end-ischaemic pH (6.3), Ca2+-dependent NOS activity was reduced. The sensitivity of sGC to SNP was greater, and activities of XO and XDH were higher, in CPL than in Fresh hearts. 5 The deficiency in NO biosignalling in CPL hearts may arise due to acidosis-induced inhibition of NOS activity, reduced availability of GTP and/or enhanced inactivation of NO by superoxide. These findings provide rationales for novel strategies to prevent the deficiency in NO biosignalling and so improve the function of the transplanted heart.

Adenosine Triphosphate↗

Flumazenil in drug overdose: randomized, placebo-controlled study to assess cost effectiveness.

OBJECTIVE: To investigate cost effectiveness of administration of flumazenil to patients presenting with suspected acute drug overdose. DESIGN: Double-blind, prospective, placebo-controlled randomized study. SETTING: University teaching hospital. PATIENTS: Forty-three adults presenting with suspected drug overdose and having a Glasgow Coma Scale (GCS) score of <13. Patients with known benzodiazepine/tricyclic ingestion were excluded. INTERVENTIONS: Intravenous administration of flumazenil (up to 2 mg) or placebo. MEASUREMENTS AND MAIN RESULTS: Individual patient costs were assessed and data aggregated for each treatment group. Major diagnostic and therapeutic interventions were recorded and between group comparisons performed. Clinical response to study drug administration was assessed by obtaining pre- and post-drug GCS scores and observation of the patient for at least 180 mins for signs of resedation. Aggregate cost or number of major diagnostic and therapeutic interventions were not different between groups. Patients randomized to the flumazenil group showed a marked increase in GCS score (7.4 to 11.8) compared with those in the placebo group (8.2 to 8.6). CONCLUSION: Use of flumazenil in intentional drug overdose of unknown etiology is not cost effective.

Adolescent↗

Cardioprotection by activation of NO/cGMP pathway after cardioplegic arrest and 8-hour storage.

BACKGROUND: We determined whether activation of the nitric oxide/cyclic guanosine monophosphate pathway by sodium nitroprusside (SNP) protects hearts subjected to cardioplegic arrest and prolonged hypothermic storage. METHODS: Isolated rat hearts arrested with St. Thomas' II cardioplegia and stored at 3 degrees +/- 1 degree C for 8 hours were reperfused at 37 degrees C in Langendorff (10 minutes) and working (60 minutes) modes. RESULTS: During reperfusion, left ventricular work was depressed in stored hearts relative to fresh hearts. When present during arrest, storage, and both reperfusion phases, SNP (200 mumol/L) improved work to values close to those in fresh hearts. When added only during the 10-minute period of Langendorff reperfusion, SNP also improved the subsequent recovery of work. This effect was antagonized by the soluble guanylyl cyclase inhibitor 1H-[1,2,4]oxadiazolo[4,3-a]quinoxalin-1-one (ODQ). Poststorage coronary perfusion was not increased by SNP. CONCLUSIONS: The ability of SNP to enhance recovery independent of changes in coronary perfusion and in an ODQ-sensitive manner suggests that SNP-induced protection is due to activation of the myocardial nitric oxide/cyclic guanisine monophosphate pathway. These results suggest that supplementing cardioplegic solutions with SNP, administering SNP during early reperfusion, or both may offer additional means to improve donor heart preservation.

Animals↗

Prophylactic oral dolasetron mesylate reduces nausea and vomiting after abdominal hysterectomy. The Canadian Dolasetron Study Group.

PURPOSE: The incidence of postoperative nausea and vomiting (PONV) varies from 50% to 75% after gynaecological surgery under general anaesthesia. This study evaluates the dose-response relationships, safety, and efficacy of the new 5-HT3 antagonist, dolasetron mesylate, in the prevention of PONV in women undergoing total abdominal hysterectomy (TAH). METHODS: Three hundred and seventy four women scheduled for TAH under general anaesthesia were studied at 13 Canadian centres. Patients received in a randomized, double-blind manner 25, 50, 100, or 200 mg dolasetron or placebo po one to two hours before induction of anaesthesia. The anesthetic protocol was standardized. Efficacy was evaluated for 24 hr after surgery by comparing the number of emetic episodes, administration of rescue medication, severity of nausea, and patient satisfaction. RESULTS: Analysis of complete response (no emetic episodes and no rescue for 24 hr) revealed a linear dose-response relationship across dolasetron groups (P < 0.002). Dolasetron 100 mg (P < 0.003) and 200 mg (P < 0.01) were superior to placebo. The percentage of patients with no emetic episodes increased from 29.3% (placebo) to 54.1 % (100 mg). Subgroup analysis revealed ASA status (I > II), previous history of PONV, previous history of motion sickness, and total morphine dose (> 55 mg associated with less PONV than < 55 mg) influenced the incidence of emetic symptoms, but did not alter the results of the primary analysis. CONCLUSION: Prophylactic dolasetron (100 mg and 200 mg) reduces the incidence of PONV in patients having total abdominal hysterectomy.

Adolescent↗

Inhibition of glycolysis and enhanced mechanical function of working rat hearts as a result of adenosine A1 receptor stimulation during reperfusion following ischaemia.

1. This study examined effects of adenosine and selective adenosine A1 and A2 receptor agonists on glucose metabolism in rat isolated working hearts perfused under aerobic conditions and during reperfusion after 35 min of global no-flow ischaemia. 2. Hearts were perfused with a modified Krebs-Henseleit buffer containing 1.25 mM Ca2+, 11 mM glucose, 1.2 mM palmitate and insulin (100 muu ml-1), and paced at 280 beats min-1. Rates of glycolysis and glucose oxidation were measured from the quantitative production of 3H2O and 14CO2, respectively, from [5-3H/U-14C]-glucose. 3. Under aerobic conditions, adenosine (100 microM) and the adenosine A1 receptor agonist, N6-cyclohexyladenosine (CHA, 0.05 microM), inhibited glycolysis but had no effect on either glucose oxidation or mechanical function (as assessed by heart rate systolic pressure product). The improved coupling of glycolysis to glucose oxidation reduced the calculated rate of proton production from glucose metabolism. The adenosine A1 receptor antagonist, 8-cyclopentyl-1,3-dipropylxanthine (DPCPX 0.3 microM) did not alter glycolysis or glucose oxidation per se but completely antagonized the adenosine- and CHA-induced inhibition of glycolysis and proton production. 4. During aerobic reperfusion following ischaemia, CHA (0.05 microM) again inhibited glycolysis and proton production from glucose metabolism and had no effect on glucose oxidation. CHA also significantly enhanced the recovery of mechanical function. In contrast, the selective adenosine A2a receptor agonist, CGS-21680 (1.0 microM), exerted no metabolic or mechanical effects. Similar profiles of action were seen if these agonists were present during ischaemia and throughout reperfusion or when they were present only during reperfusion. 5. DPCPX (0.3 microM), added at reperfusion, antagonized the CHA-induced improvement in mechanical function. It also significantly depressed the recovery of mechanical function per se during reperfusion. Both the metabolic and mechanical effects of adenosine (100 microM) were antagonized by the nonselective A1/A2 antagonist, 8-sulphophenyltheophylline (100 microM). 6. These data demonstrate that inhibition of glycolysis and improved recovery of mechanical function during reperfusion of rat isolated hearts are mediated by an adenosine A1 receptor mechanism. Improved coupling of glycolysis and glucose oxidation during reperfusion may contribute to the enhanced recovery of mechanical function by decreasing proton production from glucose metabolism and the potential for intracellular Ca2+ accumulation, which if not corrected leads to mechanical dysfunction of the postischaemic myocardium.

Adenosine↗

Antecedent ischemia reverses effects of adenosine on glycolysis and mechanical function of working hearts.

This study compared the effects of adenosine (Ado) on the coupling of glycolysis and glucose oxidation and on mechanical function in normal hearts and in hearts subjected to transient ischemia. Isolated working rat hearts were perfused with Krebs containing 1.2 mM palmitate and 100 microU/ml insulin. After 15 min of aerobic perfusion, hearts underwent either two cycles of 10 min of ischemia and 5 min of reperfusion (stressed) or 30 min of aerobic perfusion (control). After 45 min, hearts underwent either aerobic perfusion for 35 min (series A) or 30 min of ischemia and 30 min of reperfusion (series B). In series A, left ventricular minute work (LV work) was similar in control and stressed hearts and was not affected by Ado (500 microM) or N6-cyclohexyladenosine (CHA 0.5 microM). Ado reduced glycolysis by 49% in control hearts but increased glycolysis by 74% in stressed hearts. CHA inhibited glycolysis in both groups by 50 and 62%, respectively. In series B, LV work during reperfusion recovered to a similar extent in untreated control and stressed hearts. In control hearts, Ado reduced glycolysis by 50% while enhancing LV work to 81% of preischemic values. In stressed hearts, Ado increased glycolysis by 34% and depressed LV work to 9%, whereas CHA inhibited glycolysis by 53% and LV work to 91%. These data indicate that coupling of glycolysis to glucose oxidation is a key determinant of mechanical function of the postischemic myocardium. They also show that the metabolic and protective effects of Ado depend on the status of the heart before sustained ischemia.

Adenosine↗

Changing the admission process for elective surgery: an economic analysis.

This study compared the costs of an inpatient elective surgical admission process with an outpatient based same day admission programme in patients undergoing laparoscopic cholecystectomy. The effect of this process change on annual surgical volume and case flow (number of procedures performed per surgical bed) in the year before the initiation of same-day method (1989/90) and subsequent to the widespread use of the process (1992/93), was also assessed. Costs incurred by 53 patients who underwent preoperative anaesthetic and surgical assessment as outpatients and were admitted as an outpatient on the day of surgery (SD Group) were compared with those incurred by 11 patients who entered hospital on the day before surgery and underwent anaesthetic and other assessments as inpatients (IP Group). Nursing, radiology, laboratory, operating room, rehabilitation and clinic costs were obtained for each patient. The remaining costs were not amenable to individual attribution and were assigned to each group as a percentage of the allocated costs. The cost per case in the SD Group was $360 less than in the IP Group, reflecting decreased nursing costs incurred by the SD Group. Between the period 1989/90 and 1992/93, the number of surgical beds declined 15.7%; however, surgical volume decreased by only 5.4%. Total case flow improved by 12.2%, that for elective and non-elective surgery increasing by 14.1% and 9.5%, respectively. Elective surgery, where same day admission was used, showed the greatest improvement in case flow. We conclude that a same day admission process reduces cost and serves to enhance hospital productivity.

Adult↗

Magnesium sulfate prophylaxis after cardiac operations.

One hundred patients undergoing elective cardiac operations were randomized into placebo (n = 54) and magnesium (n = 46) groups. The magnesium group received six doses of 2.4 g (19.2 mEq) magnesium sulfate intravenously in the first 24 hours after the cardiac operation. The magnesium group had higher serum magnesium concentrations postoperatively (1.09 +/- 0.20 versus 0.75 +/- 0.13 mmol/L; p < 0.0001), postoperative day 1 (1.49 +/- 0.34 versus 0.70 +/- 0.12 mmol/L; p < 0.0001) and postoperative day 2 (0.96 +/- 0.19 versus 0.76 +/- 0.07 mmol/L; p < 0.0001). Patients in the magnesium group had a lower incidence of ventricular tachyarrythmias (VTs) (17.3% versus 51.9%; p = 0.0006), less need for treatment (6.5% versus 20.3%; p < 0.0001), fewer VT episodes/patient (0.3 +/- 0.8 versus 1.39 +/- 1.9; p < 0.0001), and a reduction in the severity of VTs as measured by the modified Lown grade (p = 0.0002). No differences were demonstrated with respect to supraventricular tachyarrythmias. The magnesium group had reduced absolute creatine kinase-MB levels (5.3 +/- 4.2 versus 28.4 +/- 28 IU/L; p = 0.001) as well as creatine kinase-MB fraction (0.01 +/- 0.02 versus 0.05 +/- 0.04; p = 0.001) on postoperative day 1. Serum magnesium concentrations were lower during VTs than during periods of sinus rhythm (0.75 +/- 0.75 versus 1.02 +/- 0.35 mmol/L; p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗

Evaluation of a long-range adaptive predictive controller for computerized drug delivery systems.

A closed-loop adaptive control system, based on the generalized predictive control law with a terminal matching condition, has been developed for computerized drug delivery. The control law is a minimization of the squares of prediction errors over a small future prediction horizon plus weighted square of the prediction error at steady-state. A control-relevant, long-range identification algorithm is used for on-line parameter estimation. Since the control and identification are mutually compatible, the system truly satisfies the approximate dual control criterion. The system has been applied to the control of mean arterial pressure (MAP) by automatic infusion of sodium nitroprusside in the presence of physical and physiological constraints. Experimental evaluation on six mongrel dogs, in an ethics-approved manner, included setpoint tracking and regulation of MAP in the presence of unpredictable disturbances. The system was found to be capable of inducing hypotension in an average of 2.44 +/- 0.31 min (mean +/- standard error of mean) after probing without any overshoots in mean arterial pressure. The nitroprusside infusion was also free of any ringing. When the subjects were not disturbed, 96.2% of mean arterial pressure remained within 5 mm Hg of the target pressure. A series of disturbances introduced in the presence and absence of closed-loop control affirms the robustness and effectiveness of this control system.

Algorithms↗

Ischemic preconditioning inhibits glycolysis and proton production in isolated working rat hearts.

The effect of ischemic preconditioning (IPC) on glycolysis, glucose oxidation, adenine nucleotide and nucleoside levels, and mechanical function was studied in isolated paced working rat hearts under aerobic conditions or when reperfused following sustained ischemia. IPC inhibited glycolysis in aerobic hearts (4.48 +/- 0.66 vs. 3.18 +/- 0.39 mumol.min-1.g dry wt-1) and calculated proton production attributable to exogenous glucose (7.79 +/- 1.31 vs. 4.73 +/- 0.81 mumol.min-1.g dry wt-1). In hearts subjected to ischemia and reperfusion, IPC decreased, relative to controls, glycogen content before the onset of ischemia (116.6 +/- 4.3 vs. 158.0 +/- 8.4 mumol/dry wt) and decreased consumption of glycogen during ischemia (54 +/- 6 vs. 76 +/- 7 mumol/dry wt). During reperfusion, glycolysis was lower in IPC hearts (2.45 +/- 0.16 vs. 4.4 +/- 0.46 mumol.min-1.g dry wt-1), as was calculated proton production (3.57 +/- 0.30 vs. 8.38 +/- 0.93 mumol.min-1.g dry wt-1). Glucose oxidation was similar in control and IPC hearts. Adenosine and ATP content of IPC hearts, relative to controls, were higher at the end of ischemia, being 0.86 +/- 0.08 vs. 0.34 +/- 0.15 mumol/g dry wt and 11.3 +/- 0.8 vs. 5.0 +/- 1.6 mumol/g dry wt, respectively. IPC enhanced recovery of ventricular work during reperfusion of ischemic hearts from 37 to 68%. These results indicate that IPC is associated with a reduction in glycogen content, inhibition of glycolysis during ischemia and reperfusion, and a decrease in proton production from glucose. These changes may, in part, explain the enhanced recovery of mechanical function observed in IPC hearts.

Adenosine Triphosphate↗

Comparison of selection of preoperative laboratory tests: the computer vs the anaesthetist.

HealthQuiz II (HQII) is a computerized history-taking device which can be used by patients before anaesthesia and surgery. HealthQuiz II provides a summary of symptoms, a modified ASA Classification, and a list of suggested laboratory tests. Developed at the University of Chicago, the device has not been evaluated in Canada. The purpose of this study was to compare preoperative evaluation and selection of laboratory tests by a group of Canadian anaesthetists using traditional methods versus using HealthQuiz II. Twenty-seven anaesthetists from three (Western) Canadian University teaching hospitals participated in the study. The subjects were male, aged between 30-50 yr, trained in Canada and practicing in Calgary, Edmonton and Vancouver. They were asked to self-evaluate and select laboratory tests and then to complete the HQII protocol, the day before a proposed mock operation. Results of this comparison showed that the ASA scores assigned by HQII were higher for 11 subjects and lower for two. Eight anaesthetists thought HQII asked questions which they omitted while five thought HQII overlooked items. Thirteen anaesthetists believed HQII would be a useful adjunct to their practice. Only ten anaesthetists requested any tests while HealthQuiz II suggested tests for 23 subjects, with an average of 1.9 tests/subject (anaesthetists) vs 5.4 tests/subject (HQII). The total cost of tests selected by anaesthetists was $272.15 in contrast with $1,513.20 for those suggested by HQII. We conclude that rationale for test selection may have contributed to the difference in number and costs of tests.

Adult↗

Plasma fatty acid levels in infants and adults after myocardial ischemia.

High levels of fatty acids are detrimental during reperfusion of ischemic hearts in part because of an inhibition of myocardial glucose use. We therefore measured plasma fatty acids during and after myocardial ischemia in both adult and pediatric patients. In adult patients undergoing thrombolytic therapy after an acute myocardial infarction, plasma fatty acids levels were elevated on admission to hospital (0.96 +/- 0.06 vs 0.40 +/- 0.01 mmol/L in healthy control subjects) and remained elevated throughout the initial 48 hours of hospitalization. In adult patients undergoing cardiac surgery, plasma fatty acids were markedly increased during surgery and at the time of the release of the aortic cross clamp (2.21 +/- 0.54 and 1.61 +/- 0.32 mmol/L, respectively). In children and infants (mean age 4.33 +/- 0.44 years) who had surgery to correct congenital heart defects, fatty acid levels during surgery increased to 3.27 +/- 0.26 mmol/L and remained elevated during immediate reperfusion (1.91 +/- 0.15 mmol/L) and for 24 hours after surgery (1.67 +/- 0.22 mmol/L). Because experimental studies have shown that high levels of fatty acids are detrimental to recovery of adult animal hearts, we determined the effect of high fatty acid levels on reperfusion recovery of isolated working hearts from 1-day-old rabbits perfused with 0.4 mmol/L palmitate (normal fat) or 1.2 mmol/L palmitate (high fat) and subjected to 50 minutes of global ischemia followed by aerobic reperfusion.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗