Biomedical subjects

T Stijnen

Publications and source records attributed to T Stijnen.

At least 109 records · Page 6Linked to original sources

PubMed1994

Effect of dietary fish oil on blood levels of free fatty acids, ketone bodies and triacylglycerol in humans.

Although the reduction of serum triacylglycerol concentrations by dietary fish oil is a well-known effect, the exact mechanism of this effect has not been previously studied in human subjects. Therefore, the aim of this study was (i) to examine the effect of short-term fish oil supplementation on blood concentrations of ketone bodies, free fatty acids and triacylglycerol in healthy humans and (ii) to verify whether the observed relationships between these variables would be consistent with reduced lipolysis and/or enhanced hepatic fatty acid oxidation after fish oil supplementation. Twenty subjects (21-23 years, normal liver function tests) were randomly divided into two groups to supplement their usual diet with either 30 g/d of fish oil (n = 11) or olive oil (n = 9). Venous blood samples were drawn after an overnight fast, before and after 1, 3 and 7 d of fish oil/olive oil supplementation. Blood concentrations of triacylglycerol and free fatty acids decreased consistently after fish oil supplementation; the reduction was already significant after one day of fish oil (P < 0.001 for triacylglycerol and P = 0.01 for free fatty acids). In contrast, neither of these blood values changed after olive oil supplementation (P > 0.10). No significant changes in glucose, insulin or ketone body levels were observed in either group after supplementation. After fish oil, but not after olive oil supplementation, the ratio of blood ketone body levels to free fatty acid levels increased significantly (P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1994

Hourly fetal urinary production rate and blood velocity waveforms in the fetal renal artery relative to fetal heart rate pattern and fetal eye movements in normal pregnancies at 30-32 weeks of gestation.

In 14 normal pregnancies at 30-32 weeks of gestation, bloodflow velocity waveforms in the fetal renal artery and fetal micturition were studied in relation to fetal heart rate pattern (FHRP) and fetal eye movements. PI in the fetal renal artery was significantly lower in the presence of FHRP-B and eye movements separately and in combination compared with FHRP-A and absent eye movements separately and in combination. Fetal urinary output was higher in the absence of fetal eye movements. There was an inverse relationship between renal artery PI and fetal heart rate. However, since mean fetal heart rate in the various state variables was not essentially different, no standardization for heart rate was necessary. No correlation existed between renal artery PI and fetal urinary production rate. It can be concluded that in the normal fetus at 30-32 weeks of gestation, renal artery PI demonstrates a significant reduction in the presence of FHRP-B and fetal eye movements separately and in combination, suggesting reduced downstream impedance at renal level. However, the decrease in fetal micturition in the presence of fetal eye movements, suggests that reduced urinary output is determined by changes in fetal central nervous system activity rather than by changes in fetal renal perfusion.

Adult↗

PubMed1994

Inferior vena cava flow velocity waveforms relative to fetal behavioural states and sample site in normal term pregnancy.

Reproducibility and behavioural state dependency of flow velocity waveforms from the proximal and distal part of the fetal inferior vena cava were studied in a total of 27 normal pregnancies at 36-39 weeks of gestation. Within patient coefficients of variation in fetal inferior vena cava waveform recording were markedly higher for the proximal part compared with the distal part. This is also reflected by lower reliability values as a measure of the relative proportion of within patient and between patient variance components. No statistically significant changes in flow velocity values could be detected at proximal and distal level of the fetal inferior vena cava relative to fetal behavioural states. A marked difference in flow velocity values was, however, observed between the two measuring sites with the highest velocities at proximal level. Since a considerable variation in fetal inferior vena cava flow recording was established, a possible behavioural state related modulation may have been obscured by these waveform variabilities.

Analysis of Variance↗

PubMed1994

Forces acting on the maxillary incisor teeth during laryngoscopy using the Macintosh laryngoscope.

We determined the forces on the maxillary incisors during routine laryngoscopy in 65 adult patients. The forces were measured by a strain gauge based sensor positioned between the handle and the blade of the laryngoscope. The mean maximal force acting on the maxillary incisors was 49 N. In patients without maxillary incisors, the force acting on the gums was significantly lower at 21 N (p < 0.001). These results suggest that, despite traditional advice to the contrary, a levering movement of the laryngoscope, using the maxillary incisors (or gums) as a fulcrum, is common practice. Biomechanical analysis revealed that, although levering is not the preferred movement, it is an efficient way of bringing the glottis into view. These results may have implications for future laryngoscope design.

Adult↗

PubMed1994

Endogenous and stimulated GH secretion, urinary GH excretion, and plasma IGF-I and IGF-II levels in prepubertal children with short stature after intrauterine growth retardation. The Dutch Working Group on Growth Hormone.

OBJECTIVE: The pathophysiological mechanisms underlying the failure of catch up-growth in children with short stature after intrauterine growth retardation (IUGR) remain obscure. Since GH secretion disturbances might play a role in the growth retardation of these children we have investigated various aspects of the GH/IGF axis. DESIGN: Cross-sectional study in one group of patients. PATIENTS: Forty prepubertal children (15 girls/25 boys; mean age (range) 7.5 years (3.4-10.8)) with short stature (height below the third centile) after IUGR, defined as a birth length below the third centile for gestational age, were studied. MEASUREMENTS: GH secretion was determined by a 24-hour plasma GH profile (sampling every 20 minutes) and, on a separate occasion, by a standard arginine provocation test (ATT). Plasma IGF-I and IGF-II levels were measured at the start of the GH profile. Urine was collected to measure urinary GH levels. Plasma and urinary GH were determined by double antibody RIA. IGF-I and IGF-II were determined by specific RIA after acid chromatography. The 24-hour GH profiles were analysed using Pulsar. RESULTS: Endogenous GH secretion was similar for boys and girls. Boys had significantly lower mean GH levels compared to healthy controls. Forty per cent of the children met our criteria for a normal 24-hour GH profile (group A; n = 16) and 60% (n = 24) did not. We subdivided these 24 children into two groups: group B (n = 14) (children with either mean GH levels less than controls but with at least one spontaneous GH peak above 20 mU/l and children with normal mean GH levels but with no GH peak above 20 mU/l (subnormal 24-hour GH profile)) and group C (n = 10) (children with mean GH levels less than controls and no GH peak above 20 mU/l (low 24-hour GH profile)). The GH secretory abnormalities were due to a decrease in pulse amplitude, not in pulse frequency. Mean (SD) maximal GH response during ATT was 22.3 (12.1) mU/l. Nineteen children (47.5%) had a maximal GH value < 20 mU/l. Moderate, but significant, correlations were found between several 24-hour GH profile characteristics and the maximal GH response during ATT (r = 0.31-0.35; P < 0.05). Mean (SD) overnight urinary GH excretion was 3.8 (2.1) and 4.4 (3.5) microU/night for boys and girls, respectively. Compared to healthy schoolchildren, overnight urinary GH was lower in boys, but not in girls. Mean (SD) IGF-I and IGF-II SDS levels for chronological age were -0.88 (1.40) and -0.64 (1.48), respectively. Plasma IGF-I and IGF-II levels were significantly reduced compared to controls. Height SDSCA or height velocity SDSCA did not correlate with either spontaneous or stimulated GH secretion, urinary GH excretion or plasma IGF-I or IGF-II levels. CONCLUSIONS: Our study indicates that 50-60% of children with short stature after intrauterine growth retardation have 24-hour GH profile abnormalities and/or subnormal responses to arginine provocation, while mean plasma IGF-I and IGF-II levels are significantly reduced, indicating GH insufficiency. Urinary GH excretion is lower in boys, but not in girls. The precise mechanism of the failure to catch up growth needs further elucidation. It seems justified to start clinical trials in order to investigate whether treatment with exogenous GH might be beneficial for these children.

Arginine↗

PubMed1994

Forces applied during laryngoscopy in children. Are volatile anaesthetics essential for suxamethonium induced muscle rigidity?

Increased masticatory muscle tone after administration of suxamethonium has been demonstrated in children when combined with volatile anaesthetics. Whether volatiles are a prerequisite for this phenomenon is not known. In this study upper airway muscle tone, including the tone of the masticatory muscles, was determined in 54 children (age range 2-15 years), anaesthetized with propofol, fentanyl and nitrous oxide and avoiding any use of volatiles. The children were either relaxed with suxamethonium (n = 26) or vecuronium (n = 28). The forces applied during laryngoscopy were used to quantify upper airway muscle tone and were significantly greater in the suxamethonium group than in the vecuronium group: maximally applied force was 25 N versus 21 N (P = 0.008), and mean applied force was 16 N versus 13 N (P = 0.006), respectively. The results of this study indicate that upper airway muscle tone increases after administration of suxamethonium in children independent of the presence of volatile anaesthetics. Moreover, increased muscle tone had no effect on the difficulty of laryngoscopy or the intubation conditions. Increased masseter muscle rigidity after suxamethonium could be due to the very unique characteristics of this muscle.

Adolescent↗

PubMed1994

Behavioural state dependency of renal artery and descending aorta velocimetry and micturition in the normal term fetus.

OBJECTIVE: To examine the behavioural state dependency of renal artery and descending aorta pulsatility index and hourly fetal urinary production rate (HFUPR) in the normal term fetus. DESIGN: An observational study. SUBJECTS: Twenty-three healthy women with a normal singleton pregnancy between 36 and 40 weeks gestation. MAIN OUTCOME MEASURES: Renal artery and descending aorta pulsatility indices were established using pulsed Doppler ultrasound. HFUPR (ml) was estimated using real-time ultrasound. Fetal behavioural states 1F (quiet sleep) and 2F (active sleep) were determined from combined recordings of fetal heart rate, eye movements and body movements. RESULTS: An inverse correlation between pulsatility index and fetal heart pattern was established for both the renal artery (r = 0.60; SD = 0.22; P = 0.0001) and the descending aorta (r = 0.73; SD = 0.16; P = 0.0001). The difference in mean pulsatility index between states 1F and 2F adjusted for fetal heart pattern was 0.09 (SD 0.23) for the renal artery (P = 0.02) and 0.26 (SD 0.19) for the descending aorta (P = 0.0001). Mean HFUPR was significantly higher (44.8%, P = 0.01) in state 1F (96 ml) compared with state 2F (54 ml). During the urinary filling phase, a poor correlation existed between renal artery pulsatility index and HFUPR (r = 0.04) and between descending aorta pulsatility index and HFUPR (r = 0.01). CONCLUSIONS: In the normal term fetus renal artery and descending aorta pulsatility indices are reduced during fetal behavioural state 2F, suggesting reduced downstream impedance at the fetal trunk and in particular at renal level. This behavioural state is, however, also associated with reduced micturition. No correlation exists between renal artery and descending aorta pulsatility indices and fetal urinary output.

Adult↗

PubMed1994

Ductus venosus flow velocity waveforms in relation to fetal behavioural states.

OBJECTIVES: To establish the reproducibility of flow velocity waveforms in the human ductus venosus and to assess the influence of fetal behavioural states on these waveforms in normal term fetuses. DESIGN: Reproducibility of Doppler waveform recording and analysis was studied in 10 normal pregnancies. The relation between ductus venosus flow velocities and behavioural states was investigated in 19 other term fetuses. Time-averaged, peak systolic, peak diastolic velocity, peak systolic/diastolic ratio and period time were calculated in both cross sectional studies. SETTING: Outpatient clinic, department of obstetrics (prenatal diagnosis section), Academic Hospital, Rotterdam--Dijkzigt. SUBJECTS: Twenty-nine women with normal singleton pregnancies at 36 to 39 weeks of gestation, resulting in uncomplicated births of healthy infants. RESULTS: Within-patient coefficients of variation, ductus venosus waveform recordings were approximately 8 to 10% except for the peak systolic/diastolic ratio (4.3%). A decrease of approximately 30% was established for peak systolic, peak diastolic velocity and time-averaged velocity during behavioural state 1F (quiet sleep) as compared with state 2F (active sleep). CONCLUSIONS: Flow velocity waveform recording in the ductus venosus demonstrates acceptable reproducibility. Fetal behavioural state-dependent changes were observed, suggesting a redistribution of umbilical venous blood through the ductus venosus shunt during the quiet sleep state.

Adult↗

PubMed1994

Diffusing capacity dependent on lung volume and age in normal subjects.

In this study we determined reference values of total diffusing capacity of carbon monoxide (DLCO) and DLCO per liter alveolar volume (DLCO/VA) at total lung capacity (TLC) and at lung volumes below TLC in sitting position. In 55 healthy nonsmoking volunteers (20-85 yr old), we determined reference values at TLC level in which age was the only parameter. In a subgroup (n = 16) these references did not change by correction for normal variability in hemoglobin concentration. In all volunteers DLCO decreased and DLCO/VA increased with decreasing VA. The increase in DLCO/VA was linear and less in older subjects. We derived equations to calculate reference values of DLCO/VA for lung volumes at and below TLC with two methods: 1) "random coefficients linear" model, which calculates the reference values directly, and 2) a conversion method, which calculates DLCO/VA for lower VA levels from reference values at TLC. An advantage of the conversion method is the suitability of DLCO/VA reference values at TLC of other populations. A disadvantage is the greater standard deviation of these reference values compared with those obtained by the random coefficients linear method. DLCO can be found by multiplying DLCO/VA with VA.

Adult↗

PubMed1994

Oxidative epithelial damage produces hyperresponsiveness of human peripheral airways.

The epithelium probably modulates airway smooth muscle responsiveness by producing relaxing factors, by inactivating agonists, or by acting as a physical barrier. In isolated airway strips, however, only a limited modulatory role of the epithelium has been found, and this may well be due to shortcomings of this airway model. The present study compares the modulatory role of the airway epithelium in human airway tubes and strips. In addition, since oxygen radicals may contribute to epithelial damage in asthma, oxidative damage to the airway epithelium was induced with luminally applied hydrogen peroxide (H2O2), and changes in responsiveness to the agonists histamine, methacholine, and salbutamol were measured. To examine whether intact epithelium acts as a barrier to histamine, the histamine concentration in the organ bath was measured in tubes with intact and damaged epithelium stimulated from the mucosal side. In airway strips, no differences in responsiveness were found between intact and epithelium-denuded airways for any of the three agonists. In contrast, the sensitivity of airway tubes to both histamine and methacholine was significantly lower with mucosal stimulation than with serosal stimulation (-log EC50: 4.87 and 4.92 versus 5.87 and 5.45 for histamine and methacholine, respectively, p < 0.001). No difference was found between the sensitivity to salbutamol of mucosally and serosally stimulated airways (-log EC50: 6.19 and 6.20, respectively). The modulation of the sensitivity to contractile agonists by the epithelium increased with increasing airway size, and was abolished after treatment with H2O2.(ABSTRACT TRUNCATED AT 250 WORDS)

Albuterol↗

PubMed1994

Final height and its predictive factors after renal transplantation in childhood.

A retrospective study is reported assessing final height (FH) and its predictive factors in 52 patients (31 male, 21 female) who underwent renal transplantation (RTx) before the age of 15 y. They received prednisone daily or on alternate days as well as azathioprine. The study period covered 20 y. FH remained below the third height percentile [height standard deviation score for chronologic age (hSDSCA) < -1.88] for most of these patients (77% males, 71% females). Median (range) FH was 165.0 (143.0-176.8) cm in males and 153.0 (135.0-168.4) cm in females. Median difference between FH and target height was 15.0 and 15.4 cm for males and females, respectively. For both sexes, the median hSDSCA was already below -1.88 at the start of the first hemodialysis, after which it decreased significantly until the first RTx. After RTx, there was no significant improvement of hSDSCA. The predictive factors for FH were determined by evaluating various factors simultaneous in a multiple regression analysis. This analysis provided a regression equation for predicting FH. A higher hSDSCA at the time of the first RTx and alternate-day versus daily prednisone therapy both had a significantly positive influence on FH, whereas a longer duration of reduced GFR (< 50 mL/min/1.73 m2) had a significantly negative effect on FH. Other factors such as age or bone age at first RTx, primary renal disease, duration of initial dialysis, repeat RTx, and the cumulative dose of prednisone did not influence FH significantly. In conclusion, 71-77% of patients that received their first renal transplant before the age of 15 ended up with severely short adult stature. Optimization of the hSDSCA at first RTx appears very important. Long-term administration of prednisone on alternate days would then result in optimal FH, particularly if the GFR remains above 50 mL/min/1.73 m2.

Adolescent↗

PubMed1994

Double blind trial comparing the effects of two doses of growth hormone in prepubertal patients with chronic renal insufficiency.

Growth retardation is a major problem for children with chronic renal insufficiency (CRI). Recent studies have convincingly shown that recombinant human GH accelerates growth significantly, but the optimal GH dose with regard to long term growth response and safety has not yet been established. GH therapy was given to 23 prepubertal children (18 boys and 5 girls; mean +/- SD age, 7.1 +/- 3.6 yr; range, 1.6-14.1) with CRI and severe growth retardation in a double blind, dose-response trial. Patients were randomly assigned to either 2 or 4 IU GH/m2.day for 2.5 yr. During the first 6 months, there were comparable and significant increases in height velocity SD score for chronological age with both doses (P < 0.001). However, during the ensuing 2 yr, the higher GH dose induced a significantly greater improvement in height velocity SD score for chronological age than 2 IU GH. Catch-up growth was only sustained for 2.5 yr with 4 IU. In contrast, catch-up growth ceased after 6 months with 2 IU. Neither 2 nor 4 IU GH resulted in accelerated bone maturation during 2.5 yr of therapy. There was a significant increase in plasma insulin-like growth factor-I (IGF-I) levels with either dose, but significantly more so with 4 IU. Plasma IGF-II levels only increased significantly with 4 IU. The pretreatment elevation of IGF-binding protein-1 (IGFBP-1) levels decreased by 50% during the first study year with the higher GH dose, whereas there was no decrease with 2 IU. The elevated pretreatment IGFBP-3 levels increased comparably and significantly with either GH dose. Interestingly, only 4 IU resulted in a significantly greater increase in IGF-I than in IGFBP-3 levels. Regardless of GH dose, there was an insignificant decrease in fructosamine levels, whereas lipid and parathyroid concentrations remained constant. Renal function deterioration did not accelerate. GH therapy with 4 IU/m2.day induced and maintained catch-up growth during 2.5 yr in children with CRI without evidence of adverse effects. Bone maturation did not accelerate. This suggests that this higher GH dose may be beneficial for children with severe growth retardation secondary to CRI.

Adolescent↗

PubMed1993

A bivariate approach to meta-analysis.

The usual meta-analysis of a sequence of randomized clinical trials only considers the difference between two treatments and produces a point estimate and a confidence interval for a parameter that measures this difference. The usual parameter is the log(odds ratio) linked to Mantel-Haenszel methodology. Inference is made either under the assumption of homogeneity or in a random effects model that takes account of heterogeneity between trials. This paper has two goals. The first is to present a likelihood based method for the estimation of the parameters in the random effects model, which avoids the use of approximating Normal distributions. The second goal is to extend this method to a bivariate random effects model, in which the effects in both groups are supposed random. In this way inference can be made about the relationship between improvement and baseline effect. The method is demonstrated by a meta-analysis dataset of Collins and Langman.

Analysis of Variance↗

PubMed1993

Relative risk, risk difference and rate difference models for sparse stratified data: a pseudo likelihood approach.

We consider a relative risk and a risk difference model for binomial data, and a rate difference model for Poisson (person year) data. It is assumed that the data are stratified in a large number of small strata. If each stratum has its own parameter in the model, then, due to the large number of parameters, straightforward maximum likelihood leads to inconsistent estimates of the relevant parameters. By contrast to the logistic model, conditioning on the number of events per stratum does not help in eliminating the stratum nuisance parameters. We propose a pseudo likelihood method to overcome these consistency problems. The resulting pseudo maximum likelihood estimates can easily be computed with standard statistical software. Our approach gives a more general framework for the Mantel-Haenszel type estimators proposed in the literature. In the special case of a series of 2 x 2 tables, for the risk and rate difference models, our approach yields exactly these ad hoc Mantel-Haenszel estimators, while for the relative risk model it gives a close approximation of the Mantel-Haenszel relative risk estimator. For the regression models corresponding to the association measures relative risk, risk difference and rate difference, our method provides analogues of conditional logistic regression, which were not previously available.

Analysis of Variance↗

PubMed1993

There are no rest-activity dependent changes in fetal ductus arteriosus flow velocity patterns at 27-29 weeks of gestation.

Blood flow velocity waveforms recorded in the fetal ductus arteriosus were related to fetal heart rate pattern (FHRP) in 13 normal pregnancies at 27-29 weeks of gestation. Recording time was always 65 min or more. In three women no low fetal heart rate (FHRP-A) variability was present, in the remaining 10 women high fetal heart rate (FHRP-B) variability was established in 80% of the recording time. There was no statistically significant difference between FHRP-A and FHRP-B pattern for all ductal flow velocity parameters, indicating rest-activity state independency in late second and early third trimester pregnancy.

Activity Cycles↗

PubMed1993

Influence of radiologically and cytologically assessed distant metastases on the survival of patients with esophageal and gastroesophageal junction carcinoma. The Rotterdam Esophageal Tumor Study Group.

BACKGROUND: Distant metastasis in carcinoma of the esophagus and gastroesophageal junction is associated with a poor survival after resection. To improve the selection of patients for surgical and nonsurgical treatment, this study determined the influence on survival of distant metastases, as assessed on radiologic studies or proven on cytologic studies. METHODS: During the period 1989-1990, 135 patients were referred to the institution in this study. On ultrasonographic or computed tomographic studies, distant metastases were suspected in 62 patients and were absent in 73 patients. In 33 patients, metastases were proven cytologically; 32 of these patients subsequently were excluded from surgery. Twelve other patients were unfit for surgery because of their general condition. The remaining 91 patients had surgery; 77 patients had transhiatal esophagectomy, and the tumor was unresectable in 14 patients. RESULTS: The 2-year survival rate for all patients in whom distant metastases were suspected on radiologic studies was 11.2%, and it was 44.3% for patients without metastases on these studies (P < 0.001). For patients with cytologically proven metastases, the 2-year survival rate (3%) was lower than for patients in whom distant metastases were suspected on radiologic studies but not cytologically confirmed (21.1%) (P < 0.001). There was no statistically significant difference in survival between this last group of patients and those without metastases identified by radiologic studies (P = 0.87). After resection, the 2-year survival rate decreased from 53.9% to 0% when distant metastases were present on histopathologic studies of the resected specimen (P = 0.04), and there was no significant difference in survival between patients with distant metastases suspected or absent on preoperative radiologic studies (P = 0.47). CONCLUSIONS: Surgery should be avoided in patients with cytologically proven distant metastases because the expected survival rate is low and surgery does not seem to be a life-prolonging procedure in these patients; however, patients should not be excluded from surgery on the basis of metastases identified by radiologic studies alone.

Adult↗

PubMed1993

Doppler flow velocity waveforms in late first- and early second-trimester fetuses: reproducibility of waveform recordings.

The objective of the study was to assess the reproducibility of Doppler flow measurements of the fetal umbilical vein and artery, descending and ascending aorta, mitral and tricuspid valve, pulmonary artery, inferior vena cava and ductus venosus in early pregnancy. In a cross-sectional study, Doppler measurements were obtained in a total of 54 women at 11-16 weeks of gestation, at 2-5 different vascular sites, on 3-5 different occasions, at 5-min time intervals. The total variance in the various flow velocity parameters was partitioned in a between-subject and within-subject component by analysis of variance, and, from these calculations, coefficients of variation in waveform recording were calculated. Flow velocity waveform recording was characterized by coefficients of variation in the range 2.2-5.7% except for the acceleration time (18.6-24.5%) and percentage reverse flow (8.8%). In conclusion, our data suggest that fetal flow velocity waveforms in early pregnancy demonstrate good reproducibility in the individual subject, while all parameters depict larger variabilities for between-subject values. Acceleration time turned out to be poorly reproducible. If a single flow velocity waveform measurement is used for the future evaluation of clinical conditions in early pregnancy, one has to consider that normal values will display a rather wide range.

Journal Article↗

PubMed1993

Relationship between fetal pulmonary trunk and ductus arteriosus flow velocity waveforms in early normal pregnancy.

To establish the relationship between flow velocity waveform patterns from the fetal pulmonary trunk and ductus arteriosus in normal late first- and second-trimester pregnancies, Doppler ultrasound examinations in these vessels were performed in 133 healthy women between 9 and 25 weeks of gestation. Differentiation between pulmonary and ductal blood flow was possible as from 12 weeks onwards resulting in a study population of 78 women. A linear gestational age-dependent increase in peak systolic velocity was found for both the pulmonary trunk and the ductus arteriosus. Ductal peak systolic velocity rose significantly faster with gestational age than pulmonary peak systolic velocity. This may be determined by differences in morphology and effective lumen between these two vessels.

Adult↗