Biomedical subjects

S H Duda

Publications and source records attributed to S H Duda.

At least 37 records · Page 2Linked to original sources

PubMed2001

[Endovascular therapy of renal artery stenosis: technical results with the Palmaz-Corinthian stent].

OBJECTIVE: To evaluate the technical performance and delivery characteristics of the Palmaz-Corinthian stent for endovascular therapy of atherosclerotic renovascular disease. METHODS: 61 patients underwent implantation of 76 Palmaz-Corinthian (PC) stents in 72 arteries. 50 original PC and 26 PC stents with the modified IQ-design were employed. The indications comprised primary stenting of ostial (n = 49) or truncal (n = 1) stenosis or occlusion (n = 3), and selective stenting following complicated (dissection, n = 4) or unsuccessful (n = 8) angioplasty. The remaining stents were placed in patients with recurrent stenosis (n = 5) or acute aortic dissection (n = 2) involving the renal artery. Mean severity and length of stenosis were 81.3% and 9.8 mm, respectively. 39 lesions were rated eccentric or calcified. Data on technical success, complication rate, delivery characteristics and ease of placement compared to standard renal stents were retrieved from a prospective multicenter registry. RESULTS: Stent delivery was successful in all patients, major complications were not reported. Stent placement was suboptimal in 7 of 72 cases: 4 stents were located too distally in the renal artery, necessitating proximal coaxial overstenting in 2 cases. The distal part of the stenosis was incompletely covered and the orifice of a segmental branch inappropriately overstented in one case each. One stent was dislodged from the balloon, resulting in stent protrusion in the aortic lumen. Significant residual stenosis after stenting was not observed. Overall stent deliverability, trackability and potential repositioning inside the stenosis were rated positive, radio-opacity was rated superior for the IQ design. CONCLUSION: Technical performance and delivery characteristics of the Palmaz-Corinthian stent have been significantly improved compared to the Palmaz design, allowing mostly correct placement in renal artery stenoses with a low complication rate.

Angiography, Digital Subtraction↗

PubMed2001

[CT-guided therapy of osteoid osteoma by drill trepanation of the nidus. Clinical follow-up results].

PURPOSE: Evaluation of technical success and follow-up of patients with osteoid osteoma. MATERIAL AND METHODS: 9 patients (3 w, 6 m) with a mean age of 22.3 years suffering from an osteoid osteoma localized in the femur were treated with a combination therapy based on drill trepanation of the nidus and subsequent installation of 1-2 ml ethanol (96%). The treatment was done under CT-guidance in general anaesthesia. RESULTS: During the follow-up period of 20.6 months (10 to 39 months) one relapse occurred within 3 months. This was treated with the same percutaneous method. CONCLUSIONS: Percutaneous removal of intracortical osteoid osteomas under CT-guidance had success in this study, was technical easy, and a had low relapse rate. In addition the duration of hospitalisation is shorten. Meanwhile other studies have used additive ablation with radiofrequency. A second study has been started in our department using a thermoablative procedure. In a comparison between surgical and radiological methods, the rates of relapse are similar (9% vs. 23% surgically). The CT-guided removal of intracortical osteoid osteomas should be the procedure of first choice.

Adolescent↗

PubMed2001

[2D-phase contrast flow evaluation and contrast-enhanced MR angiography for perioperative assessment of internal mammary artery grafts].

PURPOSE: To evaluate LV functional parameters, graft flow and patency in patients with IMA grafts using a combined MR protocol with phase-contrast technique and contrast enhanced MR angiography. MATERIAL AND METHODS: Using a 1.5 T MR system 27 patients with 27 left internal mammary artery (LIMA) and 41 venous grafts were examined before and 6 months after CABG surgery. A T(1)w-TSE sequence (slice thickness 5 mm) was applied for morphological imaging. LV function (EF, CO) was evaluated on cine images (segmented FLASH 2D, TR(eff) 11 ms, TE 4.8 ms, flip angle 25 degrees ). A phase-contrast FLASH 2D (TR 24 ms, TE 5 ms, flip angle 20 degrees ) sequence was applied for aortic and IMA flow measurements. Postoperatively, a contrast enhanced FLASH 3D MR angiography (TR 3.8 ms, TE 1.4 ms, flip angle 30 degrees ) with 25 ml Gd-DTPA was performed to assess bypass patency. RESULTS: In patients with reduced LV function (ejection fraction < 50 %) an improvement of the ejection fraction from 38.4 +/- 10.3 % to 49.8 +/- 15.3 % (p < 0.05) was found postoperatively. LIMA grafts were occluded in 1/27 patients, while 6/41 venous grafts were occluded. Distal LIMA anastomoses were demonstrated in 33 % by MRA. Flow of LIMA decreased from 21.2 +/- 11 ml/min/m(2) preoperatively to 14.4 +/- 9.6 ml/min/m(2) postoperatively (p < 0.01). CONCLUSION: MR imaging allows accurate combined assessment of LV function, bypass patency and flow. The protocol of this study may be applicable for perioperative follow-up studies in patients after CABG surgery.

Aged↗

PubMed2001

[MR-venography using manual flow augmentation in an open low field MR system].

OBJECTIVE: To evaluate the feasibility of signal enhancement in the deep veins by means of manual compression of the calf (flow augmentation) as a new approach to MR venography in open configuration, low-field systems. METHODS: 10 healthy volunteers underwent MR venography of the calf unconstrained and during short localized manual compression. Gradient recalled echo sequences (FLASH, FISP) with repeated single slice acquisition and first-order gradient motion refocussing were tested in four protocols with and without arterial presaturation slabs (scan time 2.2 - 5.0 s per slice). The effect on flow enhancement was rated by means of a signal score. Interventional accessories, particularly an in-room LCD screen, were required for interactive application of compression manoeuvres. RESULTS: Sequences with arterial presaturation slabs were superior to those without regardless of the longer acquisition times. Careful targeting of compression to the mid-time of data acquisition was crucial to obtain marked flow acceleration. Enhancement was best in the case of proximally applied calf compression. Signal improvement was consistently achieved in the proximal parts of the posterior tibial and peroneal veins, but was only seen in 4/10 volunteers in the distal part of the anterior tibial vein. CONCLUSION: Flow augmentation by means of manual calf compression is a simple and effective complementary approach to MR venography in open configuration, low field MR systems.

Adult↗

PubMed2001

Local intra-arterial drug delivery for prevention of restenosis: comparison of the efficiency of delivery of different radiopharmaceuticals through a porous catheter.

RATIONALE AND OBJECTIVES: Several radiopharmaceuticals were administered through a porous balloon catheter to compare the absolute amount deposited and the retention in the vessel wall. The reported efficiency of local drug delivery ranges from 0.001% to 0.1%, with poor retention after 24 hours. METHODS: An endothelin derivative (n = 6), pertechnetate (n = 6), hexamethylpropylene amineoxime (HMPAO) (n = 5), ethyl cysteinate dimer (ECD) (n = 5), and tin colloid (n = 5) were labeled with 185 MBq/mL 99m-technetium. After balloon denudation of the infrarenal aorta in 27 New Zealand White rabbits, 100 microL of each agent was administered through a porous balloon at a pressure of 4 bar. Dynamic and static whole-body scintigrams were obtained for 24 hours. The infrarenal aorta was excised and the activity calculated in a gamma counter. RESULTS: Apart from their retention in the region of local administration, the radiopharmaceuticals showed different distribution patterns. The highest regional tracer retention was observed with HMPAO. After administration of HMPAO, a significant difference between regional (vessel wall plus surrounding tissue: 14.5% of injected dose [ID]/24 hours) and local (vessel wall: 1.8% ID/24 hours) delivery was found. In contrast, ECD was eliminated quickly (local retention after 24 hours = 0% ID). The retention efficiencies were HMPAO > endothelin derivative > tin colloid > pertechnetate > ECD. CONCLUSIONS: The different physicochemical and pharmacokinetic properties of radiopharmaceuticals resulted in different delivery efficiencies after local application.

Animals↗

PubMed2001

Peripheral artery occlusion: treatment with abciximab plus urokinase versus with urokinase alone--a randomized pilot trial (the PROMPT Study). Platelet Receptor Antibodies in Order to Manage Peripheral Artery Thrombosis.

PURPOSE: To evaluate the combination of a platelet glycoprotein IIb/IIIa complex receptor inhibitor and urokinase for treatment of recent (<or=6 weeks) arterial occlusion of the legs. MATERIALS AND METHODS: Seventy patients with lower extremity arterial occlusion of less than 6 weeks duration were randomly separated into two treatment groups: urokinase plus abciximab or urokinase plus placebo. Primary end points were the rate of major complications at 30 days after randomization and the rates of amputation-free survival and survival without open surgery or major amputation at follow-up of 90 days. Two readers unaware of the patients' treatment group assignments analyzed digital subtraction angiograms as they related to the study end points, with a final consensus reading. RESULTS: Thrombolysis relative to clot length was faster in the urokinase-plus-abciximab group (odds ratio, 0.52; 95% CI: 0.35, 0.76; P < .001). There were no procedure-related deaths or intracranial hemorrhages, but the rate of nonfatal major bleeding was higher with urokinase plus abciximab (four of 50 patients) than with urokinase alone (none of 20 patients; P = .32). At 90 days, amputation-free survival was 96% (48 of 50 patients) in the urokinase-plus-abciximab group compared with 80% (16 of 20 patients) in the urokinase alone group. The hazard ratio for the two Kaplan-Meier curves was 0.42 (95% CI: 0.16, 0.96; P = .04). CONCLUSION: In patients with lower extremity arterial occlusion who were undergoing urokinase thrombolysis, adjunctive abciximab treatment resulted in faster thrombus dissolution and improved amputation-free survival, despite an increase in major bleeding.

Abciximab↗

PubMed2001

A new device for percutaneous suture-mediated closure of arterial puncture sites using exteriorized needles: initial experience.

PURPOSE: To assess the feasibility and initial clinical results of Closer (Perclose, Redwood City, California), a new device for percutaneous suture-mediated closure of arterial puncture sites. METHODS: Vascular interventions were performed using 6 and 7 French sheaths in 22 consecutive patients. All patients underwent suture-mediated percutaneous closure with the new device. Patients were followed by physical examination the day after the procedure. RESULTS: Immediate hemostasis was achieved in 20/22 patients (91%). In 3 out of 5 antegrade closures, only one suture was captured. In two cases, this was managed by reinsertion of a second device. In another patient, hemostasis was not achieved by the device due to knot entrapment. No major complications were observed. The overall rate of minor complications was 9% (2/22) due to hematomas without the need for blood transfusions. CONCLUSION: Percutaneous suture with this new device is an acceptably safe and effective method to achieve immediate hemostasis of the arterial access site after interventional procedures with minimized manipulation of the puncture track.

Adult↗

PubMed2000

In vitro evaluation of teratogenic effects by time-varying MR gradient fields on fetal human fibroblasts.

The purpose of this study was to evaluate the influence on fetal cell growth in vitro of rapidly changing magnetic gradient fields such as those produced by the gradient coils of a typical magnetic resonance (MR) imager. The static magnetic field and the radiofrequency pulses were disabled during all measurements. Human fetal fibroblasts were placed within a specially designed MR-compatible incubation system inside the magnet. Trapezoid-shaped waveforms of 500 and 75 Hz base frequency and an amplitude of 2 mT were applied for 2-24 hours. Proliferation of the cells was monitored for 3 weeks after exposure. Cell cycle analysis was performed until 24 hours after exposure to detect alterations in cell division. Tests were performed under two different conditions of growth to detect increased as well as decreased proliferation effects. None of these tests showed differences in proliferation and cell cycle distribution between exposed and nonexposed cells.

Abnormalities, Radiation-Induced↗

PubMed2000

[Benign bile duct stenoses. Treatment with flexible metal wire stent or silicone prostheses (Yamakava) in nonresectable stenoses or high surgical risk cases].

INTRODUCTION: High benign biliary stenoses, which can occur as a complication of disease or surgery, may be difficult to correct by open surgery and may also carry a high risk. An alternative to surgery is the percutaneous implantation of a flexible metallic stent or silicon prosthesis at the affected site. METHODS: Twelve patients with benign biliary stenoses have been operated on in our department since March 1992, and the therapeutic success was reviewed in this study. RESULTS: Six received a Palmaz stent and six a silicon prosthesis, with a follow-up after completion of treatment of more than 7 years and more than 3 years, respectively. Fifty percent of the patients with a stent experienced no problems and 66% of the stents remained patent (including one requiring operative intervention to restore patency). No further surgery was necessary in any of the patients with a silicon prosthesis. CONCLUSION: When the advantages and disadvantages of the various procedures are considered, long-term splinting with a wide-lumened silicon prosthesis (Yamakava) appears to be a promising alternative to surgery for the treatment of benign biliary stenosis.

Adult↗

PubMed2000

Massive pulmonary embolism: percutaneous emergency treatment by pigtail rotation catheter.

OBJECTIVES: This study was designed to assess the feasibility, efficacy and safety of mechanical fragmentation of pulmonary emboli using a new rotational pigtail catheter system. BACKGROUND: Acute massive pulmonary embolism associated with right ventricular dysfunction is frequently lethal, despite high-dose thrombolytic therapy. Adjunctive catheter fragmentation may prevent a fatal outcome. METHODS: In 20 patients (age 58.9+/-10.5 years) with severe hemodynamic impairment, massive pulmonary emboli were fragmented by mechanical action of the rotating pigtail. Fifteen patients received thrombolysis after embolus fragmentation or no thrombolysis at all (noninterference group). RESULTS: Prefragmentation pulmonary arterial occlusion was 68.6 +/- 11.3% for both lungs. Pulmonary placement and navigation of the fragmentation catheter was easy and rapid. Fragmentation time was 17+/-8 min. The noninterference group showed a decrease pre- to postfragmentation of shock index from 1.28+/-0.53 to 0.95+/-0.38 (p = 0.011), mean pulmonary artery pressure from 31+/-5.7 to 28+/-7.5 mm Hg (p = 0.02) and a recanalization by fragmentation of 32.9+/-11.8% (mean angiographic score per treated lung from 7.4 to 5.0). Overall mortality was 20%. CONCLUSIONS: Fragmentation by pigtail rotation catheter provided for a rapid and safe improvement of the hemodynamic situation and an average recanalization of about one-third of the pulmonary embolic occlusion. The method appears useful especially in high-risk patients threatened by right ventricular failure, to accelerate thrombolysis, and as a minimal-invasive alternative to surgical embolectomy.

Aged↗

PubMed2000

Physical properties of endovascular stents: an experimental comparison.

PURPOSE: Different endovascular stent types (AVE Bridge, AVE Bridge X, Memotherm, Palmaz Large, Palmaz Medium, Palmaz-Schatz Long-Medium, Perflex, S.MA.R.T., Symphony, and Wall-stent) of 4 cm length and 8 mm diameter were subjected to standardized physical tests. MATERIALS AND METHODS: The metal mass of each stent was assessed by weighing. The balloon-expandable stents were pneumatically tested for hoop strength. In self-expanding stents, radial resistive force and chronic outward force were determined with use of a loop test. Stent delivery system pushability was assessed in a crossover model. Stent radiopacity was analyzed quantitatively. RESULTS: The hoop strength of the balloon-expandable stents ranged from 15.8 N/cm (Perflex) to 28.9 N/cm (AVE Bridge X). The stent weight increased with greater hoop strength (Perflex, 0.046 g/cm vs. AVE Bridge X, 0.061 g(cm). The self-expanding stents had a radial resistive force between 0.39 N/cm (Wallstent) and 1.7 N/cm (Smart). The flexible balloon-expandable stents showed pushability values between 0.13/N (AVE Bridge) and 0.20/N (Perflex). The self-expanding stents had flexibilities between 0.13/N (Memotherm) and 0.24/N (Symphony). Radiopacity assessed with use of a phantom simulating the iliac region ranged from 92 (Palmaz Large) to 115 (AVE Bridge) on a 256-point gray scale (0 = black, 256 = white). CONCLUSIONS: There is no stent with ideal physical properties. However, depending on the characteristics of the arterial lesion to be treated, the most appropriate stent can be chosen.

Alloys↗

PubMed2000

[Animal experiment studies on the effectiveness of permanent occlusion of the hepatic artery in transarterial chemoembolization].

PURPOSE: To evaluate the effect of permanent occlusion of the hepatic artery on the efficacy of transarterial chemoembolization (TACE) in an animal model. MATERIAL AND METHODS: 12 days after inoculation of the Morris hepatoma 3924 A in 15 male ACI rats, TACE with Mitomycin C (0.25 mg/kgBW) + Lipiodol (0.2 ml/kgBW) without (n = 5) and with permanent occlusion of the hepatic artery (n = 5) was performed. Control group consisted of 5 rats. Tumor volume was determined by MRI (1.0 T, T1 [TR/TE, 400/14 ms]) before and 12 days after therapy. RESULTS: Compared to the control group, TACE without and with permanent occlusion of the hepatic artery showed a significant reduced tumor growth after 12 days (p = 0.017 and p = 0.005). However, permanent occlusion did not improve the retarding effect on tumor growth (p = 0.9). CONCLUSION: The effectiveness of TACE in an animal model using a cytostatic-/lipiodol-emulsion is not improved by permanent occlusion of the hepatic artery.

Animals↗

PubMed2000

[Pulsed spray lysis with reteplase in peripheral arterial occlusions--technique and initial results].

PURPOSE: Urokinase followed by rt-PA are the most frequently used drugs approved for thrombolysis in peripheral arteries in the USA and Europe. We wanted to test the safety and efficacy of low-dose reteplase administered by pulsed spray technique. MATERIALS AND METHODS: 10 patients with acute or subacute occlusion of a peripheral artery (n = 8) or graft (n = 2) were treated (history 8 +/- 17 days; occlusion length 4-60 cm, mean 23 cm). Reteplase was administered as an intra-arterial (i.a.) bolus (0.5 U/10 cm of occlusion length) followed by pulsed spray lysis (1 U/h for the first 2 h, then 0.5 U/h). The catheter was placed into the occlusion. In addition the patients received heparin (i.a.) and aspirin (oral). The site of puncture was closed with a percutaneous suturing system prior to discontinuation of heparin treatment. RESULTS: A total dose of 3.3 +/- 1.2 U reteplase was administered. The primary success rate was 7/10. Two distal embolizations and two bleeding complications were observed (one minor bleeding at the site of puncture and one rupture of the suture which had to be treated surgically). CONCLUSION: With regard to our limited data, low-dose i.a. reteplase seems to be safe and effective. Two bleeding complications were observed which both occurred at the site of puncture. Discontinuation of heparin treatment prior to sheath removal is recommended. Fibrinolysis with reteplase may be an alternative to urokinase or rt-PA.

Aged↗

PubMed2000

[Percutaneous radiofrequency ablation of hepatic neoplasms using a "cluster" electrode--first clinical results].

PURPOSE: To evaluate feasibility, safety and efficacy of percutaneous radiofrequency ablation (RFA) of hepatic neoplasms using a clustered electrode. MATERIAL AND METHODS: Percutaneous, CT-guided RFA using a clustered electrode was performed in 12 patients with a total of 15 hepatic neoplasms (2.0-6.0 cm in diameter). RESULTS: A total of 17 percutaneous RFA was performed. The mean total procedure time was 2.0 h (1.5-2.5 h). Placement of the clustered electrode within the neoplasms using a inter- or subcostal approach under local anesthesia was possible in all cases. Complications related to percutaneous treatment and technical problems were not encountered. Diameter of the ablated areas ranged between 3.0-7.0 cm. Technical success was observed in 13 of 15 neoplasms (86.6%). During a mean follow-up of 7.25 months (range 3-12 months) 8 of 12 neoplasms showed a complete necrosis. CONCLUSION: Percutaneous RFA using a clustered electrode is a feasible, safe and effective procedure for the treatment of hepatic neoplasms up to 6 cm in size.

Adult↗

PubMed2000

Human fetal lung fibroblasts: in vitro study of repetitive magnetic field exposure at 0.2, 1.0, and 1.5 T.

PURPOSE: To evaluate whether repetitive exposure to magnetic fields of 0.2, 1.0, and 1.5 T affect the growth of human fetal lung fibroblasts (HFLFs). MATERIALS AND METHODS: Cultured HFLFs were exposed to static magnetic fields of 0.2, 1.0, and 1.5 T for 1 h/d for 5 consecutive days. Control groups were kept under identical environmental conditions, apart from the magnetic field, during the experiments. Cell cycle analysis for synchronously and nonsynchronously growing cells was performed. Population doublings (PDs) were calculated. To rule out midterm effects, proliferation kinetics of the cells were analyzed for 21 days. RESULTS: Cell cycle analysis of synchronized and nonsynchronized cells did not reveal statistically significant differences between the exposed and control cells. The PDs did not indicate any growth modulation during exposure. Proliferation kinetics did not provide any hint of midterm growth modulation effects of repetitive magnetic field exposure. CONCLUSION: Repetitive magnetic field exposure does not exert any growth-modulating effect on overall cell growth and cell cycle distribution of cultured HFLFs. Midterm effects due to magnetic field exposure were not found.

Cell Cycle↗

PubMed2000

[Corticosteroid injections of the sacroiliac joint during magnetic resonance: preliminary results].

PURPOSE: The aim of this study was to evaluate the advantages of MRguided injections of corticosteroids into the sacroiliac joints (SIJ) in patients suffering from refractory sacroiliitis despite appropriate oral therapy. MATERIALS AND METHODS: At a lowfield open MR, we performed twentyfour infiltrations in 12 patients suffering from persistent buttock pain. Clinical followup and laboratory findings were evaluated every 4 up to 6 weeks. A subjective rating using a dolorimetry scale (0= no pain, up to=10 for most severe pain) was assessed prior to intervention and at three months followup. Morphological changes of the SIJ were examined on a 1.5 Tesla imager before and three months after steroid injections. RESULTS: Adequate positioning of the needle was obtained in all but one case due to a software defect. Clinical improvement was observed in 10 patients with a mean painfree period of 9.6 months. Dolorimetry index decreased from 7.6 +/- 1.5 to 2.9 +/- 1.5. Nonsteroidal antiinflammatory drugs could be discontinued in 4 patients and reduced in 4 others. CONCLUSION: We therefore conclude that MRguided injection of the SIJ is feasible and could be preferred to more conventional methods when technical equipment is available.

Adult↗

PubMed1999

Long-term effects of repetitive exposure to a static magnetic field (1.5 T) on proliferation of human fetal lung fibroblasts.

The aim of the study was to assess the effects of repetitive exposures to a static magnetic field (1.5 T) on human fetal lung fibroblast (HFL) proliferation. HFL were exposed three times a week for 1 hr to a static magnetic field for 3 weeks. Cells were subcultured every week. Population doublings (PD) and cumulative population doublings (CPD) were calculated weekly. Colony formation assays, bromodeoxyuridine enzyme-linked immunosorbent assay, and cell cycle analysis were performed weekly. After the third week, proliferation kinetics were assessed. Over a period of 3 weeks no statistically significant differences between the PD and CPD of exposed and control cells could be detected. Clonogenic activity, DNA synthesis, cell cycle, and proliferation kinetics were not altered by magnetic field exposure. The data do not provide evidence that repetitive exposures to a static magnetic field (1.5 T) exert effects on HFL proliferation.

Cell Division↗

PubMed1999

[Cardiac MRI for determining functional left ventricular parameters].

PURPOSE: To prove the accuracy of MR methods in the determination of left ventricular (LV) functional parameters and anatomy. MATERIALS AND METHODS: At 1.5 T, 20 healthy volunteers and 22 patients with aortic valvular disease (stenosis n = 15, regurgitation n = 7) were examined. Functional parameters like cardiac output, ejection fraction, end-diastolic volume, aortic flow maximum, and time interval from the R-wave to maximum flow were obtained using a velocity encoding 2D FLASH sequence (TR 24 ms, TE 5 ms, venc 250 cm/sec) and segmented breath-hold cine FLASH 2D technique (TR 100 ms, TE 4.8 ms, flip angle 25 degrees, temporal resolution 50 ms). Invasive measurements (Fick principle) served as gold standard, intra- and interobserver variability were determined. RESULTS: Differences of functional parameters between normal volunteers and patients were detectable at a high level of significance (p < 0.0001). For cardiac output a superior correlation with the gold standard was found using flow measurements (r = 0.66, p < 0.0007) compared to volumetric calculations from cine studies (r = 0.47, p < 0.02). Interobserver variability was 2.5 +/- 2.7%/4.5 +/- 6.9% (flow quantification/calculations from cine studies), intraobserver variability was 1.7 +/- 1.6%/3.3 +/- 2.2%. CONCLUSIONS: MRI is an appropriate tool for determining LV functional parameters and anatomy. Differences between normal volunteers and patients with aortic valvular disease can be detected reliably. Flow measurements turned out to be more accurate than calculations from cine images. Therefore, flow quantification techniques should be preferred for clinical use.

Adult↗