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Valvular heart disease: assessment of valve morphology and quantification using MR.

For clinical evaluation and decision-making in patients with valvular heart disease, the diagnostic armamentarium expands steadily. This evolution makes it difficult to choose the most appropriate approach for a specific valvular lesion. It may also reflect our uncertainty of what are the findings that best predict clinical outcome of patients, e.g. after surgery. Accordingly, for each type of valvular lesion, some pathopysiological considerations are stated in order to derive the most important measures that would allow optimal guidance of patients. Based on these considerations the value of an MR study is discussed for each valvular lesion. Newest advances in MR technology allow for highly accurate measurements of regurgitant volumes and hence, MR may be the method of choice for a quantitative evaluation of regurgitant valves. For assessment of stenosis severity, measurement of transvalvular pressure gradient is an appropriate measure and MR may not confer benefits over echocardiography, provided the ultrasound window is adequate (and stroke volume is in the normal range). With respect to surgical treatment, valvular morphology is of pivotal importance, particularly for the mitral valve, and echocardiography still appears to be the first line method. Little data relate lesion severity and/or morphology to clinical outcome. Conversely, the extent of cardiac adaptation to pressure- and/or volume-overload, i.e. ventricular remodeling, is a strong predictor of outcome, and is therefore most important for final judgement of the patient. For assessment of left and right ventricular remodeling, echocardiography typically provides all the necessary information. However, in special cases with discrepant findings, with inadequate ultrasound window, or in the preoperative work-up, MR may provide important information regarding cardiac adaptation to valvular lesion.

Aortic Valve Insufficiency↗

Interlaboratory study of a NACE method for the determination of R-timolol content in S-timolol maleate: assessment of uncertainty.

Analyses of statistical variance were applied to evaluate the precision and practicality of a CD-based NACE assay for R-timolol after enantiomeric separation of R- and S-timolol. Data were collected in an interlaboratory study by 11 participating laboratories located in Europe and North America. General qualitative method performance was examined using suitability descriptors (i.e. resolution, selectivity, migration times and S/N), while precision was determined by quantification of variances in the determination of R-timolol at four different impurity levels in S-timolol maleate samples. The interlaboratory trials were designed in accordance with the ISO guideline 5725-2. This allowed estimating for each sample, the different variances, i.e. between-laboratory (s2(Laboratories)), between-day (s2(Days)) and between-replicate (s2(Replicates)). The variances of repeatability (s2r) and reproducibility (s2R) were then calculated. The estimated uncertainty, derived from the precision estimates, seems to be concentration-dependent above a given threshold. This example of R-timolol illustrates how a laboratory can evaluate uncertainty in general.

Adrenergic beta-Antagonists↗

Determination of five macrolide antibiotic residues in eggs using liquid chromatography/electrospray ionization tandem mass spectrometry.

A method using liquid chromatography electrospray ionization tandem mass spectrometry (LC/ESI-MS/MS) for the determination of trace levels of five macrolide antibiotics (spiramycin, tilmicosin, oleandomycin, erythromycin, and tylosin) in eggs is presented. Data acquisition under MS/MS was achieved by applying multiple reaction monitoring (MRM) of two or three fragment ion transitions to provide a high degree of sensitivity and specificity for both quantification and confirmation. Matrix-matched standard calibration curves were used to achieve the best accuracy of the method. A fully nested experimental design was used to study the measurement uncertainty arising from intermediate precision and trueness or proportional bias. The overall recoveries, that is, those determined by the nested experiments, of spiramycin, tilmicosin, oleandomycin, erythromycin, and tylosin at fortified levels of 60, 100, 200, and 300 microg/kg were 96.8, 98.2, 98.3, 98.8, and 95.4%, respectively. The LC/ESI-MS/MS method detection limits (S/N > or = 3:1) of five macrolides were <1.0 microg/kg.

Anti-Bacterial Agents↗

Hemodynamic comparison of dopexamine and nitroprusside at high and low doses in patients with coronary artery disease and impaired left ventricular function.

Pure vasodilator drugs are currently the preferred agents for treatment of acute and chronic heart failure of all grades of severity. In contrast, the role of drugs that combine vasodilation with inotropic action remains highly controversial despite their several advantageous physiological actions and long therapeutic history in heart failure. We hypothesize that this uncertainty might be due first to subtle unfavorable hemodynamic effects not detectable by the relatively crude hemodynamic methods by which these agents are usually analyzed, particularly with regard to the quantification of afterload, and secondly to the narrow therapeutic range of these drugs, such that the dose administered is critical. We tested this hypothesis by comparing several refined hemodynamic measurements of dopexamine, an inotropic vasodilator, with a pure arteriovenous dilator (sodium nitroprusside, SNP) on left ventricular (LV) systolic and diastolic function, large arterial behavior, and coupling of the left ventricle to the arterial system at two dose levels in 35 patients with ischemic heart disease. The study protocol was a fixed order of 15-min infusions of saline, dopexamine 1 microg/kg/min, and dopexamine 3 + ++microg/kg/min, or saline, SNP 1 microg/kg/min, and SNP 3 microg/kg/min. Detailed hemodynamic observations were made at the end of each 15-min infusion period. Both drugs produced equivalent arterial vasodilation, as measured by the decrease in systemic vascular resistance index (SVRI), but dopexamine resulted in a significantly greater increase in cardiac index (CI). Myocardial contractility, assessed by several load-independent indexes, increased with dopexamine, as anticipated with an inotropic drug, but did not alter with SNP. Arterial compliance, a measure of the distensibility of large conduit arteries, was increased by SNP but not by dopexamine. Arterial wave reflection was increased by dopexamine, especially at high doses, but reduced by SNP. Increased arterial compliance and reduced wave reflection reduce LV afterload. SNP reduced preload, whereas dopexamine had no effect on this aspect of ventricular function. Vasodilator drugs and those which combine vasodilator and inotropy increase cardiac output (CO) and reduce SVR. Therapy with inotropic vasodilators has no effect on preload and does not reduce the dynamic components of ventricular afterload, although it does reduce its static components. These effects are dose dependent; there is less perturbation of afterload at lower doses. In contrast, vasodilator therapy reduces preload and both static and dynamic parts of afterload.

Coronary Disease↗

Parthenolide is the component of tanacetum parthenium that inhibits nitroglycerin-induced Fos activation: studies in an animal model of migraine.

Tanacetum parthenium (TP) is a member of the Asteracee family long used empirically as a herbal remedy for migraine. So far, however, clinical trials have failed to prove consistently the effectiveness of TP extracts in preventing migraine attacks, probably as a consequence of the uncertainty as regards the active principle. In this study, the biological effects of different TP extracts and purified parthenolide were tested in an animal model of migraine based on the quantification of neuronal activation induced by nitroglycerin. The extract enriched in parthenolide significantly reduced nitroglycerin-induced Fos expression in the nucleus trigeminalis caudalis. Purified parthenolide inhibited nitroglycerin-induced neuronal activation in additional brain nuclei and, significantly, the activity of nuclear factor-kappaB. These findings strongly suggest that parthenolide is the component responsible for the biological activity of TP as regards its antimigraine effect and provide important information for future controlled clinical trials.

Animals↗

Hormesis--implications for risk assessment caloric intake (body weight) as an exemplar.

Hormesis can be considered as a parameter which has a non-monotonic relationship with some endpoint. Since caloric intake is such a parameter, and the impact of this parameter on risk assessment has been fairly well characterized, it can provide clues as to how to integrate the information from a hormetic parameter into risk assessments for toxicants. Based on the work with caloric intake, one could: (a) define a biomarker for hormetic effect; (b) integrate specific information on when in the animals lifespan the parameter is active to influence parameters such as survival; (c) evaluate component effects of the overall hormetic response; and (d) address the consequences of a non-monotonic relationship between the hormetic parameter and endpoints critical for risk assessment. These impacts on risk assessments have been characterized for chronic tests, but are also true for short-term tests. A priority is the characterization of the dose-response curves for hormetic parameters. This quantification will be critical in utilizing them in risk assessment. With this information, one could better quantitatively address the changes one expects to result from the hormetic parameter, and limit the uncertainty and variability which occurs in toxicity testing.

Aging↗

Differential laser absorption spectrometry for global profiling of tropospheric carbon dioxide: selection of optimum sounding frequencies for high-precision measurements.

We discuss the spectroscopic requirements for a laser absorption spectrometer (LAS) approach to high-precision carbon dioxide (CO2) measurements in the troposphere. Global-scale, high-precision CO2 measurements are highly desirable in an effort to improve understanding and quantification of the CO2 sources and sinks and their impact on global climate. We present differential absorption sounding characteristics for selected LAS transmitter laser wavelengths, emphasizing the effects of atmospheric temperature profile uncertainties. Candidate wavelengths for lower-troposphere measurements are identified in the CO2 bands centered near 1.57, 1.60, and 2.06 microm.

Journal Article↗

Dose-response relationships for chronic exposure to 2,3,7,8-tetrachlorodibenzo-p-dioxin in a rat tumor promotion model: quantification and immunolocalization of CYP1A1 and CYP1A2 in the liver.

The mechanisms responsible for the braod spectrum of effects of 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) are not entirely clear but seem to involve an initial interaction with the Ah receptor. A major uncertainty in risk assessment for TCDD is the lack of adequate dose-response relationships following chronic exposure to TCDD. Induction of cytochrome P-450 enzymes (CYP1A1 and CYP1A2) is one of the most sensitive responses to TCDD and its structural analogues. We have used a two-stage model for hepatocarcinogenesis in female Sprague-Dawley rats to evaluate dose-response relationships for induction of CYP1A1 and CYP1A2 in diethylnitrosamine-initiated as well as in noninitiated rats. After initiation with a single dose of diethylnitrosamine, TCDD was administered biweekly by p.o. gavage at doses equivalent to 3.5, 10.7, 35.7, and 125 ng/kg/day for 30 weeks. CYP1A1 and CYP1A2 concentrations were quantified in hepatic microsomes by radioimmunoassay and localized in hepatic tissue slices by immunohistochemical techniques. Radioimmunoassay data revealed a maximum induction of 200-fold for CYP1A1 and 10-fold for CYP1A2 and there were no statistically significant differences between initiated and noninitiated rats. Induction at the lowest dose (3.5 ng/kg/day) was 20-fold for CYP1A1 and 3-fold for CYP1A2. Mathematical analysis indicates that the best fit of the induction data are inconsistent with a threshold for this response. There was a linear relationship between administered dose and TCDD liver concentration over the entire dose range of the study. This indicates that induction of CYP1A2 does not significantly alter the distribution of TCDD in our chronic dosing regimen. Immunolocalization of CYP1A1 and CYP1A2 revealed the same localization and induction pattern for both isozymes in the cytoplasm of hepatocytes. However, the hepatic distribution pattern was not uniform with the most intense staining observed around central veins. These studies help to clarify dose-response relationships for dioxin-mediated effects and demonstrate different sensitivity of hepatocytes to the effects of TCDD.

Animals↗

Accidents and Decision Making under Uncertainty: A Comparison of Four Models.

Heinrich's (1931) classical study implies that most industrial accidents can be characterized as a probabilistic result of human error. The present research quantifies Heinrich's observation and compares four descriptive models of decision making in the abstracted setting. The suggested quantification utilizes signal detection theory (Green & Swets, 1966). It shows that Heinrich's observation can be described as a probabilistic signal detection task. In a controlled experiment, 90 decision makers participated in 600 trials of six safety games. Each safety game was a numerical example of the probabilistic SDT abstraction of Heinrich's proposition. Three games were designed under a frame of gain to represent perception of safe choice as costless, while the other three were designed under a frame of loss to represent perception of safe choice as costly. Probabilistic penalty for Miss was given at three different levels (1, .5, .1). The results showed that decisions tended initially to be risky and that experience led to safer behavior. As the probability of being penalized was lowered decisions became riskier and the learning process was impaired. The results support the cutoff reinforcement learning model suggested by Erev et al. (1995). The hill-climbing learning model (Busemeyer & Myung, 1992) was partially supported. Theoretical and practical implications are discussed. Copyright 1998 Academic Press.

Journal Article↗

Estimation of cardiac event risk by MDCT.

Coronary calcifications are specific markers for coronary atherosclerosis. The amount of coronary calcium is related to the likelihood of vulnerable plaques. Vulnerable plaques may rupture and may result in sudden coronary thrombus formation, occlusion, ischemia and ventricular fibrillation and finally cardiac death. Therefore, it is reasonable to believe that the risk of cardiac events can be assessed by the quantification of the extent of coronary calcium. However, until now, the predictive value of coronary calcium and the advantage over conventional risk factors has not yet been proven by any prospective cohort study. In practice uncertainty exists in the group of patients with an intermediate risk for cardiac events. In this particular cohort it is likely that the assessment of coronary atherosclerosis may help in the decision to initiate or discard a specific therapy. For this purpose it has been suggested to replace the Framingham age score by a score corrected by the amount of coronary calcium. Follow-up investigations may be helpful in the short term to determine the efficiency of different therapeutical options. To determine a significant progression of the amount of coronary calcium, the absolute mass should be determined in a period of 1 year.

Age Factors↗

Effects of inland nitrogen transport and attenuation modeling on coastal nitrogen load abatement.

Modeling of the spatial distribution of nitrogen transport and attenuation from various inland sources and along different hydrological pathways to coastal waters is needed for relevant decisions on effective allocation of measures for coastal nitrogen load abatement. We identify, classify, and quantify uncertainties associated with main discrepancies between spatial process representations in different catchment-scale nitrogen transport-attenuation models. The results show important model differences, indicating scientific disagreement on the realistic spatial process understanding, representation, and quantification in nitrogen transport-attenuation modeling. By further developing solutions for economic optimization of spatially differentiated nitrogen source abatement in coastal catchments, we find this disagreement to considerably affect the economic efficiency of coastal nitrogen load reduction. It may also lead to stakeholder mistrust and conflict and needs to be recognized and handled in environmental policy.

Algorithms↗

Estimation and correction of matrix effects in gas chromatographic pesticide multiresidue analytical methods with a nitrogen-phosphorus detector.

The assessment of matrix effects in the quantification of organophosphorus pesticides in fruit and vegetables by GC-NPD, were studied applying ANCOVA. Calibration curves prepared in solvent were compared with calibration curves prepared in a blank matrix extract for eight different commodities, establishing whether the matrix induces systematic or proportional errors in the quantification of the pesticides. In such cases correction functions were obtained and validated by quantifying spiked samples using solvent calibrations and applying the correction functions to the data obtained. The results were compared with those obtained by quantification using matrix-matching calibrations and with those from 100% recovery experiments. It was found that the matrix effects can be avoided using the correction functions. Finally the contribution of the correction functions to the uncertainty of the results was estimated as well as their stability during a four month period.

Calibration↗

Determination of diethanolamine or N-methyldiethanolamine in high ammonium concentration matrices by capillary electrophoresis with indirect UV detection: application to the analysis of refinery process waters.

Alkanolamines such as diethanolamine (DEA) and N-methyldiethanolamine (MDEA) are used in desulfurization processes in crude oil refineries. These compounds may be found in process waters following an accidental contamination. The analysis of alkanolamines in refinery process waters is very difficult due to the high ammonium concentration of the samples. This paper describes a method for the determination of DEA in high ammonium concentration refinery process waters by using capillary electrophoresis (CE) with indirect UV detection. The same method can be used for the determination of MDEA. Best results were achieved with a background electrolyte (BGE) comprising 10 mM histidine adjusted to pH 5.0 with acetic acid. The development of this electrolyte and the analytical performances are discussed. The quantification was performed by using internal standardization, by which triethanolamine (TEA) was used as internal standard. A matrix effect due to the high ammonium content has been highlighted and standard addition was therefore used. The developed method was characterized in terms of repeatability of migration times and corrected peak areas, linearity, and accuracy. Limits of detection (LODs) and quantification (LOQs) obtained were 0.2 and 0.7 ppm, respectively. The CE method was applied to the determination of DEA or MDEA in refinery process waters spiked with known amounts of analytes and it gave excellent results, since uncertainties obtained were 8 and 5%, respectively.

Electrolytes↗

Quantitative analysis of electron energy-loss spectra from ultrathin-sectioned biological material. II. The application of bio-standards for quantitative analysis.

Electron energy-loss spectroscopy (EELS) has been used to determine elemental concentrations in biological specimens, consisting of ultrathin-sectioned cells and tissues. Chelex100-based Ca- and Fe Bio-standards are used for elemental quantification to establish iron and calcium concentrations. These Bio-standards, as well as the biological materials, are treated in a standard EM procedure such that 'known' and 'unknown' sites are located in one cross-section. Uncertainties and variabilities present in the equations for calculating the concentration in the 'unknown' site (determined by comparing simplex-fitted EEL spectra from Bio-standards with those from tissue) are outlined in two examples. Using an H+ Bio-standard, the matrix composition of such biological cell material is analysed, leading to values which approach each other closely. Quantitative EELS, using Chelex100-based Bio-standards, is advocated.

Animals↗

Linking environmental effects to health impacts: a computer modelling approach for air pollution.

UNLABELLED: STUDY OBJECTIVE AND SETTING: To develop a computer model, using a geographical information system (GIS), to quantify potential health effects of air pollution from a new energy from waste facility on the surrounding urban population. DESIGN: Health impacts were included where evidence of causality is sufficiently convincing. The evidence for no threshold means that annual average increases in concentration can be used to model changes in outcome. The study combined the "contours" of additional pollutant concentrations for the new source generated by a dispersion model with a population database within a GIS, which is set up to calculate the product of the concentration increase with numbers of people exposed within each enumeration district exposure response coefficients, and the background rates of mortality and hospital admissions for several causes. MAIN RESULTS: The magnitude of health effects might result from the increased PM10 exposure is small-about 0.03 deaths each year in a population of 3 500 000, with 0.04 extra hospital admissions for respiratory disease. Long term exposure might bring forward 1.8-7.8 deaths in 30 years. CONCLUSIONS: This computer model is a feasible approach to estimating impacts on human health from environmental effects but sensitivity analyses are recommended. RELEVANCE TO CLINICAL OR PROFESSIONAL PRACTICE: The availability of GIS and dispersion models on personal computers enables quantification of health effects resulting from the additional air pollution new industrial development might cause. This approach could also be used in environmental impact assessment. Care must be taken in presenting results to emphasise methodological limitations and uncertainties in the numbers.

Adolescent↗

Quantitative precision of an automated, fluorescence-based image cytometer.

Digital image-based cytometry of clinical specimens labeled with fluorescent, disease-specific markers holds promise for becoming an important diagnostic and prognostic technique because the technique can make a diverse range of quantitative biochemical, morphologic, densitometric and contextual measurements on intact specimens. It has been previously shown by us, using an image cytometer (IC) consisting entirely of commercially available components, that the nuclei of individual cells in slide-supported specimens can be detected automatically using a fluorescent DNA stain and image analysis software. The purpose of this study was to determine the precision of the IC for quantifying the integrated fluorescence intensity and area of fluorescent standard beads and nuclei. Integrated intensities could be quantified to between 2.3% and 3.5% precision using a 40x objective lens and between 1.6% and 2.3% using a 20x objective. The main contribution to this uncertainty was 2% inaccuracy in determining the variations in sensitivity over the imaging area. Areas could be quantified to between 0.91% and 2.1% using a 40x objective and between 2.8% and 3.2% using a 20x objective. Significant quantification errors were introduced if the objects were not in focus or were touching each other. Overall, however, these results demonstrated that image cytometry of fluorescence-stained specimens can yield quantitative results with sufficient precision for determining DNA ploidy distributions and for making other measurements on clinical specimens.

3T3 Cells↗

Should SPET attenuation correction be more widely employed in routine clinical practice? Against.

The development of reliable and accurate devices for the correction of nonuniform soft tissue attenuation is essential for the future clinical use of SPET myocardial perfusion imaging. In addition to abolishing false-positive defects, which is the chief goal, such corrected SPET images may allow for improved detection of coronary artery disease and perhaps ultimately for true quantification of regional myocardial blood flow. Although progress has been made, most existing attenuation correction devices are not yet ready for prime time. To date the literature shows as many positive results as negative results. There is considerable uncertainty, confusion, and skepticism about the true reliability and value of currently available attenuation correction packages. Although commonly referred to as "attenuation correction devices," these packages are in fact much more complex systems and contain novel mechanical designs, novel image acquisition and image reconstruction algorithms, scatter correction, and depth-dependent resolution compensation, in addition to attenuation correction. Each of these variables needs to be better understood and tested prior to clinical implementation. Although the general concepts are shared, there are as may different approaches to attenuation correction as there are vendors. In order to minimize the confusion of potential buyers about such complex systems, it is desirable that, before attenuation correction is implemented in routine clinical practice, each attenuation correction device is rigorously tested using a standardized testing protocol. Potential buyers of equipment should be able to compare the results of testing with various devices against predefined criteria in order to make an educated decision. Such standards have as yet not been developed. At the present time it is unclear whether attenuation correction of cardiac SPET will remain the emperor's new clothes or will develop into a fashionable Armani suit. Until further progress has been made, one cannot recommend attenuation correction devices for routine clinical practice.

Artifacts↗

Lessons from the organization of a proficiency testing program in food microbiology by interlaboratory comparison: analytical methods in use, impact of methods on bacterial counts and measurement uncertainty of bacterial counts.

The proficiency testing program in food microbiology RAEMA (Réseau d'Analyses et d'Echanges en Microbiologie des Aliments), created in 1988, currently includes 450 participating laboratories. This interlaboratory comparison establishes proficiency in detection of Salmonella and Listeria monocytogenes, as well as enumeration of aerobic micro-organisms, Enterobacteriaceae, coliforms, beta-glucuronidase-positive Escherichia coli, anaerobic sulfito-reducing bacteria, Clostridium perfringens, coagulase-positive staphylococci, and L. monocytogenes. Twice a year, five units samples are sent to participants to assess their precision and trueness for enumeration and detection of micro-organisms. Most of participating laboratories use standard or validated alternative methods, they were 50-70% in 1994 and, for 5 years, they are 95%. An increasing use of alternative methods was also observed. This phenomenon is all the more significant as standard methods are laborious and time consuming; thus, 50% of the laboratories use alternative methods for the detection of Salmonella and L. monocytogenes. More and more laboratories use ready-to-use media and although the percentage is variable according to the microflora, we can consider that, today, 50-60% of the laboratories participating to the proficiency program only use ready-to-use media. The internal quality assurance programs lead also to an increasing use of media quality controls. The impact of analytical methods on bacterial counts was assessed by grouping together the results obtained by participating laboratories during the 10 last testing schemes from 1999 to 2003. The identified significant factors influencing enumeration results are variable from one microflora to another. Some of them significantly influence many microflora: the plating method (spiral plating or not) is influential for aerobic micro-organisms, Enterobacteriaceae, coliforms, and staphylococci, the type of culture medium and the medium manufacturer is influential for aerobic micro-organisms, Enterobacteriaceae, coliforms, E. coli, anaerobic sulfito-reducing bacteria, staphylococci, and L. monocytogenes. Others are specific of some micro-organisms: the resuscitation broth for L. monocytogenes, the mode of medium preparation for staphylococci and the incubation temperature for C. perfringens. These effects lead generally to small differences of about 0.1 log10 cfu g(-1), except for the enumeration of anaerobic sulfito-reducing bacteria, where the difference reaches 0.7 log10 cfu g(-1). These results, although difficult to extrapolate to all actual situations, which associate numerous food constituents and physiological states of bacteria to detect or numerate, allow nevertheless the quantification of interlaboratory variations linked to the methods in use. The analysis of bacterial counts obtained by the laboratories participating to the RAEMA proficiency testing program allowed also to validate a formula to calculate the repeatability of bacterial counts and to estimate the between-laboratory uncertainties for the majority of micro-organisms enumerated in food microbiology. The repeatability uncertainty is only indirectly affected by the method in use but depends essentially on the number of counted colonies. On the other hand, the between-laboratory uncertainty varies with the enumeration method in use, this variability is relatively small for the enumerations calling for methods without colony confirmation, i.e. for the enumeration of aerobic micro-organisms, Enterobacteriaceae, 'total' and thermotolerant coliforms, beta-glucuronidase-positive E. coli and coagulase-positive staphylococci with the technique using the rabbit-plasma fibrinogen agar. For these methods, the average between-laboratory standard deviation is 0.17 log10 cfu g(-1). The between-laboratory uncertainty is, on the contrary, larger for more complex techniques. For the enumeration of coagulase-positive staphylococci with the Baird-Parker agar, the between-laboratory standard deviation is equal to 0.23 log10 cfu g(-1), it is equal to 0.28 log10 cfu g(-1) for the enumeration of L. monocytogenes, to 0.34 log10 cfu g(-1) for the enumeration of C. perfringens, and to 0.47 log10 cfu g(-1) for the enumeration of anaerobic sulfito-reducing bacteria.

Bacteria↗