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Biomedical subjects

J Soler-Soler

Publications and source records attributed to J Soler-Soler.

At least 19 recordsLinked to original sources
PubMed2002

Reproducibility of sequential head-up tilt testing in patients with recent syncope, normal ECG and no structural heart disease.

AIMS: To assess the reproducibility of the response to sequential head-up tilt tests. METHODS AND RESULTS: A head-up tilt test was performed early after syncope in 127 patients with a normal ECG and no structural heart disease. Patients with a positive response (82 patients) were randomized to two (1 week and 2 weeks later) or one (2 weeks later) additional head-up tilt tests, and patients with a negative response (45 patients) were randomized to a second head-up tilt test 1 or 2 weeks after the first. The reproducibility of a positive response in the second head-up tilt test was 80% after 1 week and 53% after 2 weeks (P<0.01). Only 53% of the patients with a positive response to a first and second head-up tilt test had a positive response to a third (P=0.01). Intra-individual variation in the time to a positive response was wide. The reproducibility of the cardioinhibitory responses was very poor. Reproducibility of a negative response was 80%. CONCLUSIONS: In patients with recent syncope, the rate of positive responses decreases with sequential head-up tilt tests. Furthermore, the time to a positive response in different head-up tilt tests shows important intra-individual variations, and the reproducibility of the cardioinhibitory responses is very poor. In contrast, the reproducibility of the negative responses is high.

Adolescent↗
PubMed2001

Intravenous administration of the natriuretic peptide urodilatin at low doses during coronary reperfusion limits infarct size in anesthetized pigs.

OBJECTIVE: It has been shown that cGMP content is reduced in post-ischemic myocardium, and that stimulation of cGMP synthesis prevents cardiomyocyte hypercontracture and cell death in vitro. This study was aimed at determining whether administration of the natriuretic peptide urodilatin (URO) at the time of reperfusion could limit myocardial cell death secondary to transient coronary occlusion. METHODS: The relation between cGMP content in reperfused myocardium and the extent of cell death was investigated in isolated rat hearts (n=62) receiving different URO concentrations during initial reperfusion. The dose of intravenous URO necessary to obtain the targeted increase in cGMP in reperfused myocardium was investigated in ten pigs submitted to transient coronary occlusion (CO), and the effect of two selected doses of URO on infarct size was investigated in 22 pigs. RESULTS: cGMP was severely reduced in post-ischemic rat hearts. Addition of 0.01 microM URO during the first 15 min of reperfusion had no effect on myocardial cGMP content, functional recovery or LDH release in hearts submitted to 40 or 60 min of ischemia. At 0.05 microM, URO increased myocardial cGMP to 111% of values in normoxic hearts, improved functional recovery (P=0.01) and reduced peak LDH released by 40% (P=0.02). The beneficial effect of urodilatin was abolished by ANP receptor inhibition. At 1 microM, URO increased cGMP in reperfused myocardium to 363% of normoxic controls and had no beneficial effect. In pigs allocated to 47 min of CO and 5 min of reperfusion, cGMP was markedly reduced in reperfused myocardium. Intravenous URO at 10 ng/kg per min during the first 25 min of reperfusion normalized myocardial cGMP after 5 min of reflow (95% of control myocardium), and reduced infarct size by 40% (P=0.04). At 50 ng/kg per min, urodilatin increased myocardial cGMP in reperfused myocardium to 335% of control myocardium and failed to significantly reduce infarct size (46 vs. 66%, P=0.125). None of these doses had detectable hemodynamic effects. CONCLUSIONS: Intravenous low-dose URO at the time of reperfusion normalizes myocardial cGMP and limits necrosis. Large doses of URO increasing myocardial cGMP well over normal values may lack this beneficial effect.

Animals↗
PubMed2001

Q-wave evolution of a first acute myocardial infarction without significant ST segment elevation.

BACKGROUND: Some patients with acute myocardial infarction presenting without significant ST segment elevation develop a Q-wave infarction. It is unclear whether these patients can be identified from the admission electrocardiogram (ECG) and whether they differ in their in-hospital prognosis from those who retain a non-Q-wave myocardial infarction. METHODS: In 432 consecutive patients admitted to our centre with a first acute myocardial infarction without Q waves and with ST segment amplitudes < or =0.1 mV on admission, we assessed the frequency, the electrocardiographic predictors and the short-term implications of a Q-wave evolution. RESULTS: In 94 patients (22%), a Q-wave myocardial infarction evolved before hospital discharge (14 anterior, 26 inferior, six lateral, and 48 posterior). Minor anterior ST segment elevation was 36% sensitive and 95% specific in predicting anterior Q waves; minor inferior ST segment elevation, 42% and 89%, respectively, for inferior Q waves; and a maximal ST segment depression > or =0.2 mV in leads V2-V3 with upright T waves and without remote ST segment depression, 38% and 97%, respectively, for posterior R waves. Although patients with a Q-wave evolution had a greater creatinkinase MB peak than those retaining a non-Q-wave pattern (191+/-113 vs. 105+/-77 IU/l, respectively, P<0.001), they experienced a benign in-hospital course, with similar risk of severe complications after adjustment for the baseline clinical predictors than non-Q-wave patients. CONCLUSIONS: About one fifth of patients with a first acute myocardial infarction without a significant ST segment elevation develop a Q-wave infarction and the admission ECG can help identify them. This evolution, however, is not associated with a worse in-hospital outcome.

Biomarkers↗
PubMed2001

Survival following self-limited left ventricular free wall rupture during myocardial infarction. Management differences between patients with or without pseudoaneurysm formation.

The clinical, angiographic and therapeutic features of eight patients who developed a left ventricular pseudoaneurysm (PA) after an acute myocardial infarction (AMI) and those of 25 who did not develop this complication following a medically managed left ventricular free wall rupture (FWR) were compared. These 25 patients were treated with pericardiocentesis, extended rest and strict blood pressure control. Most patients with FWR or PA had a first AMI and absence of overt heart failure. Both groups had a comparable age, frequency of systemic hypertension and extent of coronary disease. Pericardial effusion (> or =10 mm) was documented in all patients with FWR and in two of the three with PA with this information. Twenty four patients with FWR were hospitalized within the first 48 h (96%) but only three of those with PA (37.5%, P<0.002). Moreover, in patients with PA, a FWR was not suspected during AMI and, as opposed to those with FWR, they did not undergo a strict blood pressure control or a restriction of physical activity following AMI. Also, beta blockers were administered to 15 patients with FWR (60%) but to only one with PA (11%, P<0.02). Our findings suggest that failure to recognise a self limited FWR during AMI and to provide adequate control of blood pressure and physical exercise during the acute phase and the early weeks postinfarction, are likely to favor development of PA.

Aged↗
PubMed2001

[Myocardial perfusion SPECT and isotopic ventriculography in obstructive and non-obstructive hypertrophic myocardiopathy].

OBJECTIVE: To evaluate the role of myocardial perfusion SPET and radionuclide ventriculography in patients with hypertrophic cardiomyopathy (HC). METHODS: Exercise myocardial perfusion SPET with 99mTc-tetrofosmin and radionuclide ventriculography were performed in a consecutive series of 101 patients (54 15 years, 50 women, 55 with dynamic obstruction) diagnosed of HC by echo. Follow-up from the diagnosis was 9,9 6,7 years (1 to 28 years). RESULTS: Thirty six percent of patients had perfusion defects (non reversible in 15 and reversible in 21). In non obstructive HC higher number of patients with non reversible defects (p = 0.01 was obseved and in patients with no reversible defects higher incidence of pathologic Q waves in ECG (p = 0.01), Higher ventricular volumes (p < 0.05), lower ejection fraction (p = 0,0001) and longer time to peak emptying velocity (p < 0.05). There were 4 cardiac deaths, 15 syncopes, 18 pacemakers and 6 myectomy. Ejection fraction was higher in patients with syncope (p = 0,034) and there was no isotopic variable predictive of mortality, pacemaker or myectomy. CONCLUSIONS: Neither SPET nor radionuclide ventriculography have a prognostic role in patients with HC, but patients with syncope have higher values of ejection fraction. Patients with non reversible defects have higher rate of pathologic Q waves in ECG, higher ventricular volumes and lower ejection fraction. This is indicative of evolution to dilated form of HC.

Adult↗
PubMed2001

Practical recommendations for the use of ACE inhibitors, beta-blockers and spironolactone in heart failure: putting guidelines into practice.

Surveys of prescribing in both hospitals and primary care have shown delays in translating improved survival data from clinical trials into clinical practice thereby denying patients the benefits of proven treatments, such as the angiotensin converting enzyme inhibitors. This may be due to unfamiliarity with clinical guidelines and concerns about adverse events. Recent trials have shown that substantial improvements in survival are associated with spironolactone and beta-blocker therapy. In order to accelerate the uptake of these treatments, and to ensure that all eligible patients should receive the most appropriate medications, a clear and concise set of clinical recommendations has been prepared by a group of clinicians with practical expertise in the management of heart failure. The objective of these recommendations is to provide practical guidance for non-specialists in order to support the implementation of evidenced-based therapy for heart failure. These practical recommendations are meant to supplement rather than replace existing guidelines.

Adrenergic beta-Antagonists↗
PubMed2001

Variations in diagnostic yield of head-up tilt test and electrophysiology in groups of patients with syncope of unknown origin.

AIMS: To assess the diagnostic yield of the head-up tilt test and electrophysiology in different groups of patients with syncope of unknown origin established according to simple clinical criteria. METHODS AND RESULTS: Six hundred consecutive patients with syncope of unknown origin submitted to a tilt test. Two hundred and forty seven of them also underwent electrophysiology. Patients were divided into groups according to age at the time of first syncope, ECG findings and the presence of organic heart disease. Positive responses to the tilt test were more common in patients who had suffered their first syncope at an age equal to or below 65 years (group I) than in older patients (group II) (47% vs 33%, P<0.05, OR 1.8, CI 1.2-2.78), and in patients with a normal ECG and without organic heart disease than in the other subgroups of patients (47% vs 37%, P<0.008, OR 1.6). The lowest rate of positive response was observed in older patients with an abnormal ECG and organic heart disease. Electrophysiology disclosed abnormal findings in group II more often than in group I (23% vs 7%, P<0.001, OR 3.7, CI 1.7-9.2). The diagnostic yield from electrophysiology was higher in patients with an abnormal ECG than in those with a normal ECG (22% vs 3.7%, P<0.0005, OR 7.1), and it was especially low in patients with a normal ECG and without organic heart disease (2.6%). CONCLUSION: The diagnostic yield of the tilt test and electrophysiology differs in groups of patients with syncope of unknown origin, established according to simple clinical criteria. These findings have a bearing on selecting the most appropriate test in a particular patient.

Adolescent↗
PubMed2001

Standard provocative manoeuvres in patients with and without left bundle branch block studied with myocardial SPECT.

BACKGROUND: The objective of this study was to determine the prevalence of anterior and septal defects in patients with left bundle branch block (LBBB), and to assess the diagnostic accuracy of myocardial single photon emission computed tomography (SPECT) with technetium compounds in patients with and without LBBB using standard provocative manoeuvres. METHODS: Five hundred and nine consecutive patients (456 without LBBB and 53 with LBBB) without previous infarction who had a coronary angiography performed within <3 months of the scintigraphic study were retrospectively evaluated. The same stress procedures were followed in all patients. (1) Only exercise when it was sufficient; and (2) exercise + simultaneous administration of dypiridamole if exercise was insufficient. Only reversible defects were considered positive and > or =50% of coronary stenosis was considered significant. RESULTS: Prevalence of reversible anterior and septal defects was low (33% and 12%, respectively) in patients with LBBB. Although lower values of global sensitivity (81%) and specificity (73%) were obtained in these patients, there were no significant differences with respect to the patients without LBBB (89% and 86%, respectively). Specificity values for the diagnosis of stenosis of left anterior descending (78%), left circumflex (96%) and right coronary artery (74%) in patients with LBBB were lower, but without significant statistical differences with respect patients without LBBB (90%, 96% and 82%, respectively). CONCLUSIONS: Myocardial SPECT with technetium compounds, using standard provocation manoeuvres, can be used in patients with LBBB with only a mild decrease in diagnostic accuracy as compared to patients without LBBB.

Aged↗
PubMed2001

Long term results of mechanical prostheses for treatment of active infective endocarditis.

OBJECTIVE: To analyse the long term results of mechanical prostheses for treating active infective endocarditis. DESIGN: Prospective cohort study of a consecutive series of patients diagnosed with infective endocarditis and operated on in the active phase of the infection for insertion of a mechanical prosthesis. SETTING: Tertiary referral centre in a metropolitan area. RESULTS: Between 1975 and 1997, 637 cases of infective endocarditis were diagnosed in the centre. Of these, 436 were left sided (with overall mortality of 20.3%). Surgical treatment in the active phase of the infection was needed in 141 patients (72% native, 28% prosthetic infective endocarditis). Mechanical prostheses were used in 131 patients. Operative mortality was 30.5% (40 patients). Ninety one survivors were followed up prospectively for (mean (SD)) 5.4 (4.5) years. Thirteen patients developed prosthetic valve dysfunction. Nine patients suffered reinfection: four of these (4%) were early and five were late. The median time from surgery for late reinfection was 1.4 years. During follow up, 12 patients died. Excluding operative mortality, actuarial survival was 86.6% at five years and 83.7% at 10 years; actuarial survival free from death, reoperation, and reinfection was 73.1% at five years and 59.8% at 10 years. CONCLUSIONS: In patients surviving acute infective endocarditis and receiving mechanical prostheses, the rate of early reinfection compares well with reported results of homografts. In addition, prosthesis dysfunction rate is low and long term survival is good. These data should prove useful for comparison with long term studies, when available, using other types of valve surgery in active infective endocarditis.

Acute Disease↗
PubMed2001

Persistence of gap junction communication during myocardial ischemia.

During myocardial ischemia, severe ATP depletion induces rigor contracture followed by intracellular Ca2+ concentration ([Ca2+]i) rise and progressive impairment of gap junction (GJ)-mediated electrical coupling. Our objective was to investigate whether chemical coupling through GJ allows propagation of rigor in cardiomyocytes and whether it persists after rigor development. In end-to-end connected adult rat cardiomyocytes submitted to simulated ischemia the interval between rigor onset was 3.7 +/- 0.7 s, and subsequent [Ca2+]i rise was virtually identical in both cells, whereas in nonconnected cell pairs the interval was 71 +/- 12 s and the rate of [Ca2+]i rise was highly variable. The GJ blocker 18alpha-glycyrrhetinic acid increased the interval between rigor onset and the differences in [Ca(2+)]i between connected cells. Transfer of Lucifer yellow demonstrated GJ permeability 10 min after rigor onset in connected cell pairs, and 30 min after rigor onset in isolated rat hearts submitted to nonflow ischemia but was abolished after 2 h of ischemia. GJ-mediated communication allows propagation of rigor in ischemic myocytes and persists after rigor development despite acidosis and increased [Ca2+]i.

Animals↗
PubMed2001

Relationship between the location of the most severe myocardial perfusion defects, the most severe coronary artery stenosis, and the site of subsequent myocardial infarction.

UNLABELLED: This study evaluated the relationship between the location of the most severe myocardial perfusion defects, the most severe coronary artery stenosis, and the site of subsequent acute myocardial infarction (AMI). METHODS: Of 3,180 patients who were admitted with a diagnosis of AMI, we identified 44 patients who had undergone previous myocardial perfusion SPECT. Thirty-one of them also had previous coronary angiography. The relationship between the location of the myocardial perfusion defects, the coronary artery stenosis, and the site of subsequent AMI was studied in these patients. RESULTS: The concordance between the location of the most severe reversible defects detected by SPECT and the site of subsequent AMI was 71% (kappa = 0.499). The concordance between the most severe stenosis detected by coronary angiography and the site of subsequent AMI was 64% (kappa = 0.451). However, kappa values for SPECT and coronary angiography were good when the interval between these investigations and subsequent AMI was <3 mo (0.724 and 0.661, respectively), for moderate to severe perfusion defects (0.719), and for 90%-99% coronary stenosis (0.626). CONCLUSION: The culprit lesion is not always the one that is manifested by the most severe reversible perfusion defect or the most critical coronary artery stenosis. Myocardial SPECT and coronary angiography can predict the location of a future AMI in 71% and 64% of patients, respectively. The percentage is higher when the interval between investigations and subsequent AMI is <3 mo, for moderate to severe perfusion defects, and for 90%-99% coronary stenosis.

Aged↗
PubMed2001

Frequency and clinical significance of myocardial ischemia detected early after coronary stent implantation.

UNLABELLED: A high number (30%-50%) of reversible defects have been detected early after coronary balloon angioplasty. Inadequate luminal enlargement despite a good angiographic appearance has been suggested as a possible mechanism of these perfusion abnormalities, and some reports have shown better coronary flow reserve after coronary stent implantation than after balloon dilatation. The primary objective of this study was to evaluate the frequency of early ischemic defects detected by maximal exercise (plus dipyridamole) with (99m)Tc-tetrofosmin SPECT after successful coronary angioplasty with stent implantation. A secondary objective was to determine the prognostic value of these early ischemic defects. METHODS: Thirty patients without previous myocardial infarction who successfully underwent 1-vessel coronary angioplasty with stent implantation were studied. Maximal-exercise (99m)Tc-tetrofosmin myocardial SPECT, with simultaneous dipyridamole if exercise was suboptimal, was performed at 6 +/- 1 d (mean +/- SD) after percutaneous transluminal coronary angioplasty. At 8 +/- 3 mo, all patients were followed up clinically, and 77% of them underwent follow-up angiography. RESULTS: The percentage of stenosis decreased from 68.5% +/- 12.6% of luminal diameter to 9.3% +/- 8.8% after stent implantation, and minimal luminal diameter increased from 0.89 +/- 0.36 mm to 2.85 +/- 0.45 mm. Mild-to-moderate reversible myocardial defects in the territory of the dilated artery were detected in 5 patients (17%), with no angiographic or procedural differences occurring between them and patients without ischemic defects. At follow-up, the target lesion revascularization rates depending on the presence or absence of early ischemic defects were 40% and 8%, respectively (P = 0.18). Angiographic restenosis occurred in 3 of 4 patients who had early ischemic defects and underwent follow-up angiography and in 3 of 19 patients who had no early ischemic defects and underwent follow-up angiography (restenosis rate, 75% and 16%, respectively; P < 0.05). CONCLUSION: Coronary angioplasty with stent implantation is associated with a 17% rate of ischemic defects early after the procedure. Patients with early myocardial perfusion defects after coronary stent implantation had a high rate of restenosis.

Angioplasty, Balloon, Coronary↗
PubMed2000

Clinical clues to the causes of large pericardial effusions.

PURPOSE: To examine whether the size of the effusion, the presence of tamponade, and inflammatory signs are useful in determining the causes of moderate or severe pericardial effusions. SUBJECTS AND METHODS: All echocardiograms performed at a general hospital between January 1990 and April 1996 were screened for pericardial effusion. Patients with moderate (echo-free space of 10 to 20 mm during diastole) or severe (echo-free space >20 mm) effusions were studied. RESULTS: We identified 322 patients (166 [52%] men, mean [+/- SD] age 56 +/- 17 years [range 15 to 88 years]), 132 (41%) with moderate and 190 (59%) with severe pericardial effusion. The most frequent etiologic diagnoses were acute idiopathic pericarditis (n = 66 [20%]), iatrogenic effusions (n = 50 [16%]), cancer (n = 43 [13%]), and chronic idiopathic pericardial effusion (n = 29 [9%]). In 192 (60%) of the patients, the cause of the effusion was a known medical condition. In the 130 other patients, inflammatory signs were associated with acute idiopathic pericarditis (likelihood ratio = 5. 4, P < 0.001), severe effusions without inflammatory signs or tamponade were associated with chronic idiopathic pericardial effusion (likelihood ratio = 20, P < 0.001), and tamponade without inflammatory signs was associated with malignant effusions (likelihood ratio = 2.9, P < 0.01). CONCLUSIONS: In many patients, pericardial effusions are due to a known underlying disease or condition. In patients without underlying diseases, inflammatory signs, the size of effusion, and the presence or absence of cardiac tamponade can be helpful in establishing cause.

Acute Disease↗
PubMed2000

Dipyridamole administration at the end of an insufficient exercise Tc-99m MIBI SPECT improves detection of multivessel coronary artery disease in patients with previous myocardial infarction.

To demonstrate that the administration of dipyridamole at the end of an insufficient maximal subjective exercise test can improve the diagnostic accuracy of single-photon emission computed tomography in patients with previous myocardial infarction, 209 consecutive patients were studied with technetium-99m methoxyisobutyl isonitrile single-photon emission computed tomography and coronary angiography. Patients were divided in 3 groups: group 1, 107 patients with sufficient exercise testing; group 2, 55 patients with insufficient exercise testing; group 3, 47 patients with insufficient exercise testing in whom intravenous dipyridamole (0.56 mg/kg over 4 minutes) was administered at the end of exercise. In groups 1 and 3 the sensitivity values for the diagnosis of multivessel disease were significantly higher (80% and 76%, respectively) than those in group 2 (59% [p = 0.009 and p = 0.02, respectively]). Specificity and predictive values were not different among the 3 groups. Thus, in patients with previous infarction in whom adequate levels of exercise could not be achieved, dipyridamole administration at the end of exercise significantly increased the sensitivity for diagnosing multivessel disease.

Cardiac Catheterization↗
PubMed2000

Urodilatin limits acute reperfusion injury in the isolated rat heart.

OBJECTIVES: Hypercontracture is an important mechanism of myocyte death during reperfusion. cGMP modulates the sensitivity of contractile myofilaments to Ca2+, and increasing cGMP concentration during the last minutes of anoxia prevents reoxygenation-induced hypercontracture in isolated cardiomyocytes. The purpose of this study was to determine whether stimulation of particulate guanylyl cyclase with the natriuretic peptide urodilatin, given at the time of reperfusion, reduces myocardial necrosis in the rat heart submitted to transient ischemia. METHODS: Isolated rat hearts (n = 38) were submitted to either 40 or 60 min of no-flow ischemia and 2 h of reperfusion, and were allocated to receive or not receive 0.05 microM urodilatin during the first 15 min of reperfusion or non-reperfusion treatment. RESULTS: A marked reduction in myocardial cGMP concentration was observed in control hearts during reperfusion after 40 or 60 min of ischemia. Urodilatin significantly attenuated cGMP depletion during initial reperfusion, markedly improved contractile recovery after 40 min of ischemia (P < 0.0309), and reduced reperfusion-induced increase in left ventricular end-diastolic pressure (P = 0.0139), LDH release (P = 0.0263), and contraction band necrosis (P = 0.0179) after 60 min of ischemia. The beneficial effect of urodilatin was reproduced by the membrane permeable cGMP analog 8-Bromo-cGMP. CONCLUSIONS: These results indicate that reduced cGMP concentration may impair myocyte survival during reperfusion. Stimulation of particulate guanylyl cyclase may appear as a new strategy to prevent immediate lethal reperfusion injury.

Analysis of Variance↗
PubMed2000

Strategy for optimal aortic regurgitation quantification by Doppler echocardiography: agreement among different methods.

BACKGROUND: Although different Doppler methods have been validated for aortic regurgitation quantification, the benefit of combining information from different methods has not been defined. METHODS: Our study included 2 phases. In the initial phase (60 patients), Doppler parameters (jet width, short-axis jet area, apical jet area, regurgitant fraction from pulmonary and mitral flow, and deceleration slope) were correlated with angiography; range values for each severity grade were defined and intraobserver and interobserver and intermachine variability were studied. In the validation phase (158 patients), defined value ranges were prospectively tested and a strategy based on considering as the definitive severity grade that in which the two best methods agreed was tested. RESULTS: Jet width had the best correlation with angiography (r = 0.91), and its ratio with the left ventricular outflow diameter did not improve the correlation (r = 0.85) and decreased reproducibility. Apical jet area and regurgitant fraction from pulmonary flow permitted acceptable quantification (r = 0.87 and 0.86, respectively) but with worse reproducibility. The other methods were not assessable in 20% to 30% of studies. Concordance with angiography decreased in jet width when the jet was eccentric (90% vs 77%, P <.01), in apical jet area when mitral valve disease was present (84% vs 65%, P <.02), and in short-axis jet area and regurgitant fraction from pulmonary flow with concomitant aortic stenosis (77% vs 44%, P <.002 and 77% vs 53%, P <.02, respectively). Agreement with angiography was very high (94 [95%] of 99) when severity grade coincided in both jet width and apical jet area. In 59 cases without concordance, regurgitant fraction from pulmonary flow was used as a third method. Overall, this strategy permitted concordance with angiography in 146 patients (92%). CONCLUSIONS: Jet width is the best predictor in aortic regurgitation quantification by Doppler echocardiography. However, better results were obtained when a strategy based on concordance between jet width and another Doppler method was established, particularly when the jet was eccentric.

Adult↗