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Biomedical subjects

J Schipper

Publications and source records attributed to J Schipper.

At least 55 records · Page 3Linked to original sources
PubMed2004

[Neurophysiologic intraoperative monitoring to preserve cranial nerve function in base of skull surgery].

BACKGROUND: Neurophysiologic intraoperative monitoring (NIM) has gone through a renaissance since the advent of computer technology. Currently, both motor and sensory cranial nerves, including the IInd and VIIIth cranial nerves, can be intraoperatively controlled by means of small and mobile systems. PATIENTS AND METHODS: In order to estimate the value of NIM using the new generation of computer systems, we analyzed the records of 379 patients who underwent skull base surgery since 1996. These comprised NIM of the IInd, VIIth, VIIIth cranial nerves in most cases and of the IXth, Xth, XIth, and XIIth cranial nerves in selected cases. RESULTS: Whereas 72% of these cases demonstrated changes in the recorded intraoperative NIM signals, only 29% of them gave evidence of either clinical or electrophysiological neural function alterations during the postoperative follow-up. CONCLUSIONS: NIM is the only available system capable of providing the surgeon with instant intraoperative neural status-related feedback.

Computer Systems↗
PubMed2004

[Erythropoietin in patients with head and neck carcinomas?].

BACKGROUND: Various studies have demonstrated the prognostic significance of the pretherapeutic blood hemoglobin concentration for patients with head and neck cancer following surgery or primary definitive or adjuvant radio- or radiochemotherapy. It was the aim of this study to evaluate whether the prognosis of these patients might be improved when correcting decreased pretherapeutic hemoglobin values by administering erythropoietin. METHOD: In a prospective placebo-controlled double-blind study (Cochrane "evidence-based medicine" level Ib) the effect of erythropoietin was analyzed in patients with locally advanced head or neck tumours with low blood hemoglobin values (women: < 12 g/dL; men: < 13 dL) and a Karnofski value of > 60 following primary definite or adjuvant radiotherapy (up to 70 Gy). The time to local tumour progression and survival was evaluated. Kaplan-Maier estimates were applied and, the relative risk of well-known prognostic factors tested for with a Cox Proportional Hazards model. RESULTS: 157 patients of the Freiburg University ENT-clinic were recruited from 1997 to 2001. Study conduct was performed according to the GCP guidelines. A rapid increase of the blood hemoglobin value happened during the first five weeks of treatment under epoetin beta. Placebo patients experienced only minor changes of the hemoglobin value. Following adjuvant radiotherapy local tumour control probability at two years was 68 % +/- 7 % and 72 +/- 7 % for placebo and epoetin beta patients, respectively (p = 0.64). Patients who had undergone primary definite radiation experienced a local control probability of 36 % +/- 11 % in the placebo arm after two years, compared to epoetin beta with 23 % +/- 11 % (p = 0.05). CONCLUSION: Epoetin beta resulted in prompt and stable correction of blood hemoglobin values in anemic patients with advanced head or neck tumours, but tumour control and survival was impaired particularly in patients with a high tumour burden.

Anemia↗
PubMed2004

[Does computer-aided navigation of endonasal sinus surgery improve process quality and outcome quality?].

BACKGROUND: Ever since navigation technology was introduced into endonasal surgery, its impact on process and result of surgery has been debated. In this respect, factors of investment costs and additional costs for time exposure will be discussed as well. PATIENTS AND METHODS: In a retrospective analysis of quality assurance, the results of endonasal surgery by surgeons of different experience in 56 patients were evaluated. Preparation time, preoperative setup time as well as time of actual surgery were analysed and compared with possible indications for navigation. RESULTS: From our analysis a classification resulted dividing the indications for navigation into the following four different categories: redundant, reasonable, helpful, necessary. Navigation was redundant when it was dispensable and did not result in a clear improvement of process or outcome quality. Navigation has been proved reasonable when it helped to obtain additional information for improving process quality. It was considered helpful when the information obtained by navigation had an influence at least on the course and/or result of surgery. Navigation was necessary from the surgeon's point of view when the intervention in regard to the benefit-risk-ratio could not be justified without navigation, or only intraoperative slice imaging would allow surgery. CONCLUSION: Not only redundant, but also facultative and obligatory indications for navigation in endonasal surgery result from careful consideration of the risk-benefit-cost ratio. In standardized endonasal sinus surgery, like infundibulotomy or ethmoidectomy, however, navigation can be a hindrance to process quality and does not result in any advantage for outcome quality.

Adult↗
PubMed2004

[Tumour staged surgery of endolymphatic sac tumors (ELST)].

BACKGROUND: Endolymphatic sac tumours (ELST) have only been known as own tumour entities since 1984. ELST might occur solitarily and sporadically as well as hereditary connected to von Hippel-Lindau disease (VHL). This connection has been observed in 1992 for the first time and confirmed by molecular genetic analyses of the VHL gen. There is no agreement yet concerning diagnostics and therapy. METHODS: Our attempt of classifying this type of tumour is the first one. According to our own experience and to literature, we suggest the following classification: ELST type A is locally confined without erosions of the temporal bone nor infiltration of the subarachnoidal area; ELST type B with bony infiltration of the labyrinth block and clinical hearing loss, and ELST type C with additional infiltration of the sigmoid sinus and the vein of jugular bulb. Preoperative diagnostics are performed according to defined radiological criteria in CT and MRI scans including MR-angiography. RESULTS: In 6 patients, including two with a VHL syndrome, ELST was completely sanitized by stage-compatible surgery, using translabyrintine to infratemporal approaches, according to the tumour classification that we developed. The VII (th) nerve could be saved in all tumour stages, and in stage ELST type A the VIII (th) nerve as well. All patients remained without local recurrence in MRI check during the observation period of 4 to 38 months. CONCLUSION: Our stage-compatible surgery of ELST allows total tumor removal with minor morbidity. In contrast to the antero-, retrosigmoidal and suboccipital approaches, the tumour matrix can be safely removed via transmastoidal approach to exclude local recurrences.

Adult↗
PubMed2004

[Diagnosis and management of cervical paragangliomas: the Freiburg experience].

BACKGROUND: Paragangliomas of the head and neck represent rare tumors of neural crest origin that arise from chemoreceptors. They are highly vascular neoplasms that are benign in the majority of cases. There are controversial discussions concerning the different treatment options for cervical paragangliomas. PATIENTS: Between January 1992 and November 2003 a total of 13 patients with 15 cervical paragangliomas were treated at the Department of Otorhinolaryngology - Head and Neck Surgery, University of Freiburg. Our study includes eight female and five male patients with a mean age of 39.9 years (range: 20 - 79 years). There were 14 carotid body tumors and one vagal paraganglioma. RESULTS: 14 tumors were resected and one underwent primary radiation. In four patients we noted a total of 8 permanent, postoperative nerve deficits. During follow-up no recurrent tumors were seen. CONCLUSION: Complete surgical removal represents the therapy of choice for the majority of cervical paragangliomas. In cases of multiple head and neck paragangliomas or in patients with underlying diseases, primary radiation should be discussed as a treatment option.

Adult↗
PubMed2004

[Subtemporal approach according to house versus Wigand in intrameatal CPA tumors type A].

BACKGROUND: The subtemporal approach is indicated in intrameatal CPA tumors type A in order to preserve hearing. The exploration of the inner auditory canal for tumor exposure varies. It reaches from a locally limited uncovering of the bony inner auditory canal to a complete removal of the surrounding bony bed with the circular skeletization (360 degrees ) according to Wigand of the 7 (th) and 8 (th) nerve. Concerning the preservation of the function of the cranial nerve as well as an avoidable hyperelevation of the temporal cerebral lobe with a possible consecutive organic brain syndrome, both approaches have often been discussed controversially. METHOD: In a quality assurance analysis, we examined patients suffering from a unilateral, intrameatally limited CPA tumor type A in tumor stages 1 to 5. The functions of the 7 (th) and 8 (th) cranial nerves were assessed according to the consensus conference "Systems for reporting results in acoustic neuroma", Tokyo, November 2001, under consideration of the recommendations of the "American Academy of Otolaryngology, Head and Neck Surgery -- Committee on hearing and equilibrium guidelines for the evaluation of hearing preservation in acoustic neuroma", 1995, as well as indications for a possible organic brain syndrome. The results then were compared to current literature. RESULTS: 37 patients with an intrameatal confined CPA tumor after subtemporal tumor exstirpation were evaluated. In these patients, the inner auditory canal was only exposed in the area of the bony tectum (90 degrees - 120 degrees ) adjusted to the volume of the tumor, as described by House: 1 patient with tumor stage 1, 2 patients stage 2, 12 patients stage 3, 16 patients stage 4 and 6 patients with a tumor stage 5. The N. VII was anatomically preserved in 100 %. Immediately after surgery the function of N. VII was assessed in 32 % of the cases as stage I, 43 % stage II, 3 % stage IIIa, 14 % stage IIIb, 3 % stage IV, 0 % stage V, 5 % stage VI. All patients in stage VI had a restricted function of N. VII in stage II or IIIa already before surgery. N. VIII could be preserved anatomically in 78 % of the cases. 1 to 6 months postoperatively the hearing was at stage A in 10 % of the cases, at 25 % in stage B, 33 % in stage C, 16 % in stage D, 5 % in stage E and 11 % in stage F. One patient demonstrated signs of a possible organic brain syndrome postoperatively even after 12 months of latency (headache, unsteady walking, attention disorders). CONCLUSION: When comparing own data with the clinical results from literature, no differences can be found concerning the function of the 7 (th) and 8 (th) cranial nerves. There are no data concerning the incidence of a potential organic brain syndrome. The advantage of the House method is a noticeably reduced drilling time as well as possibly a reduced elevation of the temporal cerebral lobes. The Wigand method, however, allows a better overview and is needed for extrameatally growing tumors anyway.

Cranial Nerve Injuries↗
PubMed2004

[Etiology and therapy of the internal jugular vein thrombosis].

BACKGROUND: Thromboses of the upper limp and neck are rare in comparison with those of the lower extremities. Internal jugular vein thrombosis (IJVT) is a serious event with a potentially fatal outcome. Complications include pulmonary embolism, sepsis with septic emboli to different organs and tissues as well as intracranial propagation of the thrombus with cerebral edema. As any thrombosis, IJVT is precipitated by Virchow's triad: endothelial damage, alteration of blood flow and hypercoagulability. The history and examination in patients with an IJVT may be vague and misleading. Patients may present with a painful swelling of the neck but they may also be absolutely asymptomatic. Imaging procedures frequently used to diagnose an IJVT include sonography with color-coded duplex sonography, computed tomography, magnetic resonance imaging as well as magnetic resonance venography. Up to date, there is no standardized treatment regimen for patients with an IJVT. PATIENTS AND METHODS: This retrospective study includes all ten patients with an IJVT who were seen at our department between January 2000 and January 2004. There were six female and four male patients. The average age was 49.7 years, ranging from 28 to 79 years. RESULTS: In five cases, the thrombosis was associated with a malignant tumor. In four patients, it was caused by a deep neck space infection and in one case the IJVT was due to cervical, intravenous drug abuse. Two patients were found to be pregnant (one tumor patient and one patient with a deep neck space infection). In all cases, a ten day treatment regimen with intravenous antibiotics and anticoagulant therapy was initiated. Oral or subcutaneous anticoagulation was continued for six weeks to six months. No complications were seen in any patient. In three patients a revascularization of the affected vessel could be demonstrated with color-coded duplex sonography six months after the initial presentation. CONCLUSIONS: Thrombosis of the IJV is probably underdiagnosed. Since the clinical presentation may be vague or misleading, a high degree of suspicion is required to make the diagnosis. The potential complications such as pulmonary embolism or intracranial propagation of the thrombus may be fatal. Whenever the thrombosis is not caused by an inflammatory process, a malignant tumor should be excluded. We recommend a therapy with intravenous antibiotics as well as a systemic anticoagulation. Ligation or resection of the internal jugular vein is reserved for patients who develop complications despite adequate medical therapy.

Administration, Oral↗
PubMed2004

[Identification of two heterozygous mutations in the SLC26A4/PDS gene in a family with Pendred-syndrome].

BACKGROUND: Pendred-syndrome is an autosomal recessive disease that is classically characterised by sensorineural hearing loss and enlargement of the thyroid gland. The gene SLC26A4/PDS for the pendred-syndrome has been localised by linkage analysis on chromosome 7q31. This protein is expressed in the inner ear, thyroid gland, kidney and placenta. Functional analysis in Xenopus laevis oocytes revealed that it acts as an iodide/chloride and chloride/formate exchanger. METHOD: Each of the exons and flanking splice regions of the SLC26A4/PDS gene was analysed by direct sequencing. RESULTS: In the involved family two heterozygous mutations could be detected which results by combination in hearing loss and deafness. CONCLUSION: By evidences of familial background in hearing loss and thyroid disorder it is reasonable to analyse the PDS gene for mutation to have early the possibility for medical care of linguistic development through hearing aid or CI-implantation.

Child↗
PubMed2004

[Obliterated cochlea in Cogan's syndrome -- implications for cochlear implant surgery].

BACKGROUND: Acute, often bilateral deafness in Cogan's syndrome or other autoimmune diseases is caused by autoimmune mediated inflammatory attack on the membranous labyrinth. Auditory rehabilitation in case of bilateral deafness can be achieved by cochlear implant surgery. METHODS: A retrospective analysis of all patients suffering from Cogan's syndrome that had received a cochlear implant, was carried out. RESULTS: 6 of 295 adult patients (2.6 %) that had received a cochlear implant, had become deaf due to Cogan's syndrome. Partial obliteration or ossifikation was encountered in all cases and influenced surgical procedure. In one case a fibrous obliteration of the scala tympani was found 8 weeks after acute onset of complete deafness. CONCLUSIONS: The course of obliteration is unknown. With regard to our results a fibrous obliteration may occur as early as 8 weeks after complete deafness. This has to be considered in counseling of patients. Only early cochlear implant surgery facilitates best possible rehabilitation results.

Adult↗
PubMed2004

[Electrophysiologic examinations in low frequency hearing impairment: clinical and prognostic aspects].

INTRODUCTION: Low-frequency hearing impairment (LFHI) is mainly associated to endolymphatic hydrops and shows a high variety of possible outcomes. Electrophysiologic examinations are widely recommended in diagnostics of LFHI, wheras up to now no data exist about the prognostic value of these examinations in a conservative therapeutic regimen. METHODS: In a quality assessment, we retrospectively evaluated the records of 90 patients, and performed an audiometric follow-up for analysis of long-time hearing data. All patients had undergone diagnostic electrocochleographic examination (ECochG) and then had been treated with rheologic infusions, followed by dehydrating infusions in patients lacking complete remission. The results of both therapeutic strategies and of long-time results were correlated to electrophysiologic findings. RESULTS: The prognosis of LFHI is significantly reflected by pretherapeutic electrocochleographic data. All significant parameters were associated to compound action potential (CAP) whereas parameters associated to cochlear microphonics (CM) did not include any utilizable prognostic value. In patients with a good outcome, the latency of CAP complex was significantly shorter, and the width of CAP complex significantly smaller than in patients with poor hearing outcome after rheologic and after dehydrating therapy and in long time assessment. The relation of summating potential (SP) und CAP was significantly smaller when the outcome was sufficient or good for either therapy and in long time analysis. Steep CAP-input-output-curves were associated to insufficient outcome after rheologic therapy and in long time assessment, but not for dehydrating therapy. CONCLUSIONS: The results indicate that ECochG is of significant prognostic value concerning hearing outcome after conservative therapy in patients suffering from LFHI. It can help the physician to counsel the patient and perform an effective management of the disease. We conclude that ECochG should be performed before the onset of therapy, including collection of SP and CAP data whereas CM parameters may be omitted.

Action Potentials↗
PubMed2004

[Evaluation of the insertion-trauma of the Nucleus Contour Advance electrode-array in a human temporal bone model].

BACKGROUND: The development of intracochlear electrode arrays is aiming at a placement close to the modiolus with an insertion as atraumatic as possible. A new perimodiolar electrode model the Nucleus Contour Advance was to be evaluated regarding the possible intracochlear trauma. METHODS: The implantation of the Contour Advance electrode was performed in 11 frozen native temporal bones. Beneath a regular insertion in 5 temporal bones in 6 cases the insertion was carried out using the "advance-off-stylett" technique with a fixed stylett. The temporal bones were embedded in metacrylate based resin for histomorphological evaluation. The evaluation was performed regarding to the intracochlear placement close to the modiolus and the damage to intracochlear fine structures (basilar membrane, osseus spiral lamina). RESULTS: In 2 out of 11 cases we found a perforation from the scala tympani to the scala vestibuli independent of the insertion-technique. A severe intracochlear trauma was observed in one case with fracture of osseus spiral lamina using the AOS-technique. A close position to the modiolus could be achieved by insertion the scala tympani without perforation of the basilar membrane. CONCLUSIONS: The Nucleus Contour Advance electrode array showed minimal trauma in human temporal bones by using a standard insertion technique. By using the freehand AOS-technique a severe cochlear trauma is possible. Therefore further development in electrode design and the use of an insertion-tool is recommended.

Basilar Membrane↗
PubMed2003

Individual prefabricated titanium implants and titanium mesh in skull base reconstructive surgery. A report of cases.

Titanium implants can be shaped by traditional hand forming, press shaping, modular construction by welding, construction on full-size models shaped from CT coordinates and, most recently, by computer-assisted design and computer-assisted manufacturing (CAD/CAM) that consist in the direct prefabrication of individual implants by milling them out of a solid block of titanium. The aim of our study was to present a set of preliminary cases of an ongoing program of reconstructive procedures of the skull base using titanium implants. The subjects underwent ablative procedures of the skull base with reconstruction either by titanium mesh or individual prefabricated CAD/CAM implants. Six patients have been operated on successfully since 2000: two received prefabricated CAD/CAM titanium plates and four others underwent reconstruction with titanium mesh. The stability of CAD/CAM plates is superior to that of mesh, thus it is more useful in reconstructing large lesions of the frontal skull base and the temporal and occipital bones. Titanium mesh was successfully used for defects smaller than 100 cm(2) or where selected viscerocranial defects are complicated in design and less reproducible by CAD/CAM. The intraoperative design, shaping and adjustment characteristic of titanium mesh can be dispensed with when CAD/CAM implants are used. The 3-D data set used in the CAD/CAM process also operates in the navigated simulation and planning of the ablation contours, the latter being of great assistance in establishing the optimal future defect. As a disadvantage, CAD/CAM technology is more expensive than titanium mesh, and the process is time-consuming as it is carried out in advance of surgery.

Adult↗
PubMed2003

[Microsurgical resection of jugular foramen tumors with hearing preservation and without facial nerve palsy].

BACKGROUND: The juxtacondylar microsurgical approach is an adequate alternative to the classical infratemporal approach for the resection of tumors of the jugular foramen. PATIENTS AND METHODS: Retrospectively, we report on our experience with eight patients suffering from tumors of the jugular foramen with different etiologies, who were treated successfully via the juxtacondylar approach with interdisciplinary cooperation. RESULTS: The advantage of the juxtacondylar approach is that there is no need to expose and transpose the facial nerve. Additionally, reduction or translocation of the posterior wall of the auditory canal and removal of the ossicular chain are not necessary. CONCLUSIONS: Tumors of the jugular foramen can be safely removed without damaging the facial nerve or auditory capacity, with a comparatively much better overview over the vascular and neural structures of the jugular foramen. This more neurosurgically orientated skull base approach is not very well known in the ENT surgical literature.

Adult↗
PubMed2003

[Transvestibular closure with an autologous bone graft as surgical repair of a nasoseptal defect due to Le Fort-I osteotomy].

Defects of the nasal septum are a common complication after nasal surgery. Affected patients frequently suffer from bleeding, crusting and impaired nasal air flow. The surgical closure of septal defects remains a distinctive challenge. Though many different techniques have been described, the failure rate of this procedure remains high. In the case presented here, a large basal septum defect occurred after a prosthetic Le Fort-I osteotomy. The attempt to cover the distance between the bony nasal floor and the nasal septum with pedicled mucosal flaps failed due to extensive scar formation of the nasal mucosa. Therefore a nasal floor elevation by insertion of an autologous bone graft from the iliac crest was conducted. The bone graft was connected with the hard palate via two titanium screws. Other than with an autologous cartilage graft, no major resorption of the bone graft is to be expected. This indirect method for the closure of a basal nasal septum defect is new.

Alveolar Ridge Augmentation↗
PubMed2003

[The preconditioning and prelamination of pedicled and free microvascular anastomised flaps with the technique of vacuum assisted closure].

BACKGROUND: Since the technique of vacuum assisted closure has been clinically introduced, the possibilities in reconstructive head and neck surgery have greatly increased. Preconditioning and prelaminating allows a pedicled or free flap plasty to be epithelialized on both sides before the flap gets transferred to its future location. METHODS: We describe the technique of preconditioning and prelaminating of pedicled and free microvascular anastomised flap plasties and we report our experience with 5 cases. Our results are compared with data from the literature. RESULTS: The procedures concerned take only little time and the flap gets optimally prepared for its task in view of the postoperatively modified hemodynamics. By preconditioning, the flap to be lifted is prepared for the future centralised blood supply exclusively via the pedicle vessel without leaving the donor side. Thereby the skin island of such flaps can be increased in size over the natural angiosomes without an increased risk of necrotisation. CONCLUSIONS: By the technique of prelamination, skin or mucosa tissue may be applied onto both sides of the flap so that it can resist the biochemical and mechanical tasks which will be required after transposition. Especially for the reconstruction of defects in the upper aerodigestive tract this is a great advantage, since the inner side of the flap has to resist saliva which represents one of the most aggressive secretions in the human body.

Adult↗
PubMed2001

Transsphenoidal computer-navigation-assisted deflation of a balloon after endovascular occlusion of a direct carotid cavernous sinus fistula.

SUMMARY: A 49-year-old woman with a direct posttraumatic carotid cavernous fistula (CCF) was treated with detachable balloons via a transcarotid route. After the procedure, her intracranial bruit, conjunctival injection, and orbital congestion were cured, but the preexistent sixth nerve palsy deteriorated. CT showed one balloon positioned in the posterior portion of the right cavernous sinus and was regarded to be responsible for nerve compression. After surgical exposure by use of a transnasal-transsphenoidal approach under 3D navigation control, this balloon was deflated by puncture with a 22-gauge needle. The previously described symptoms resolved after balloon deflation. This report presents a rare complication of endovascular treatment of direct CCF and a new microsurgical approach to a balloon in a case of nerve compression.

Abducens Nerve Diseases↗
PubMed2000

Cataract-free interval and severity of cataract after total body irradiation and bone marrow transplantation: influence of treatment parameters.

PURPOSE: To determine prospectively the cataract-free interval (latency time) after total body irradiation (TBI) and bone marrow transplantation (BMT) and to assess accurately the final severity of the cataract. METHODS AND MATERIALS: Ninety-three of the patients who received TBI as a part of their conditioning regimen for BMT between 1982 and 1995 were followed with respect to cataract formation. Included were only patients who had a follow-up period of at least 23 months. TBI was applied in one fraction of 8 Gy or two fractions of 5 or 6 Gy. Cataract-free period was assessed and in 56 patients, who could be followed until stabilization of the cataract had occurred, final severity of the cataract was determined using a classification system. With respect to final severity, two groups were analyzed: subclinical low-grade cataract and high-grade cataract. Cataract-free period and final severity were determined with respect to type of transplantation, TBI dose, and posttransplant variables such as graft versus host disease (GVHD) and steroid treatment. RESULTS: Cataract incidence of the analyzed patients was 89%. Median time to develop a cataract was 58 months for autologous transplanted patients. For allogeneic transplanted patients treated or not treated with steroids, median times were 33 and 46 months, respectively. Final severity was not significantly different for autologous or allogeneic patients. In allogeneic patients, however, final severity was significantly different for patients who had or had not been treated with steroids for GVHD: 93% versus 35% high-grade cataract, respectively. Final severity was also different for patients receiving 1 x 8 or 2 x 5 Gy TBI, from patients receiving 2 x 6 Gy as conditioning therapy: 33% versus 79% high-grade cataract, respectively. The group of patients receiving 2 x 6 Gy comprised, however, more patients with steroid treatment for GVHD. So the high percentage of high-grade cataract in the 2 x 6 Gy group might also have been caused to a significant extent by steroid treatment. The percentage of patients with high-grade cataract was lower in allogeneic transplanted patients without steroid treatment for GVHD than in autologous transplanted patients: 35% versus 48%. An explanation for this could be pretransplant therapy containing high-dose steroids. CONCLUSIONS: After high-dose-rate TBI in one or two fractions, steroids for GVHD influence latency time of a cataract and are of great importance for the severity the cataract finally attains. Although a cataract will develop in all patients, a clinically important high-grade cataract is relatively infrequent in patients not treated with steroids. Pretransplant therapy might also influence final severity of cataract.

Adolescent↗