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Evaluation of a model for short-term clinical testing of cariogenicity.

Conventional mirror and probe examination and laser fluorescence were used to score caries-like alterations on the buccal surfaces of posterior teeth in 60 panelists, allotted to one of three groups. All subjects refrained from oral hygiene for five days. In one group each subject consumed 12 sucrose candies daily between meals and in the second group each subject similarly consumed 12 palatinose (isomaltulose) candies. The third group served as a control. At the end of the experimental period the tooth surfaces reexamined. Conventional and laser fluorescence scoring techniques showed an increase in the number of caries-like alterations for all groups, but there were no significant differences between the groups. For all groups, the laser method gave significantly greater scores throughout. The findings imply that certain aspects of the early development of enamel caries in subjects regularly using fluorides must be considered in the design of a short-term cariogenicity test. It is concluded that sensitive quantitative methods for the registration of caries are necessary in such tests.

Adolescent↗

Prenatal cocaine exposure adversely affects development of the primate cerebral cortex.

This study was conducted to determine whether prenatal exposure to cocaine interferes with the development of the primate cerebral cortex. For this purpose, pregnant rhesus monkeys received cocaine orally (20 mg/kg/day in fruit or candy treats), twice a day from the 40th-102nd days of pregnancy (E40-E102), which is a period of corticogenesis in this species. The control group of pregnant animals received fruit or candy treats only. On E64 and E65, all animals received intravenous injections of [3H]thymidine. Monkeys were allowed to deliver at term. The offspring were sacrificed at age 2 months, and their brains were processed for histology and autoradiography. The analysis of cresyl violet-stained sections showed that prenatal treatment with cocaine significantly altered lamination of the primate cerebral cortex, in some cases completely blending distinction between individual layers. In addition, autoradiographic analysis revealed that in the control animals, [3H]thymidine labeling concentrated in cortical layers V and/or IV depending on the cytoarchitectonic area observed. In contrast, drug-treated animals displayed labeled cells in the white matter and cortical layer VI in addition to layers V and IV, suggesting inability of cortical cells to reach proper cortical layers. The number of labeled cells was also much lower in these animals. Finally, immunocytochemical studies with antisera directed toward glial fibrillary acidic protein showed that prenatal exposure to cocaine had dramatic effect on the glial fibers normally observed in the upper cortical layers. In many cortical regions of cocaine-treated animals, we observed practically no such fibers. This study demonstrates that cocaine administered during pregnancy can significantly affect the development of the primate cerebral cortex.

Animals↗

Factors influencing development of caries teeth.

A cross sectional study was conducted on the children of 146 randomly selected urban families of Abha, Saudi Arabia, to find out the common factors associated with caries teeth. The factors considered for association were per capita monthly income, sources of drinking water, consumption of soft drinks, daily brushing of teeth, daily consumption of candy, and the education levels of mothers. All children up to 12 years of age were examined by visiting their families. The results showed that the per capita monthly income, sources of drinking water and habit of drinking soft drinks had no significant relation with the prevalence rates of caries teeth in children. But the habit of nonbrushing of teeth daily, daily consumption of candies, and low or no education of mothers had significant association with the presence of caries teeth. Adequate health education of children about the ill effects of these practices and raising the educational levels of mothers and prospective mothers may contribute towards achieving dental health by the year 2000 as targetted by the World Health Organization.

Child↗

Absorption rate of methylxanthines following capsules, cola and chocolate.

OBJECTIVE: To compare caffeine and theobromine absorption after oral administration of capsules, cola beverage and chocolate candy. METHODS: Three males and four females who abstained from methylxanthines received five methylxanthine-containing treatments: caffeine in capsules (72 mg), administered twice; theobromine in capsules (370 mg); cola beverage (72 mg caffeine) and chocolate candy (72 mg caffeine and 370 mg theobromine). Plasma methylxanthine levels were assayed from samples collected before and 0.25, 0.50, 0.75, 1.0, 1.5, 2.0, and 3.0 h after caffeine capsule and cola treatments and, additionally, at 4.0 and 6.0 h after theobromine capsule and chocolate treatments. RESULTS: Caffeine plasma concentrations increased rapidly and peaked at approximately 30 min following both capsule treatments 1 (Cmax: 1.93 micrograms.ml-1); and 2 (Cmax: 2.05 micrograms.ml-1). Relative to capsules, caffeine absorption from cola and chocolate was delayed and produced lower maximum caffeine plasma concentrations which peaked 1.5-2.0 h after treatment (For cola, Cmax: 1.57 micrograms.ml-1); and for chocolate, Cmax: 1.50 micrograms.ml-1. Theobromine plasma concentrations peaked approximately 3 h after capsule administration (Cmax: 6.72 micrograms.ml-1). Relative to capsules, theobromine absorption from chocolate was more rapid and produced higher maximum theobromine plasma concentrations which peaked approximately 2 h after treatment (Cmax: 8.05 micrograms.ml-1). CONCLUSIONS: The results suggest that a usual dietary portion of the cola or chocolate used in this study would produce behaviorally discriminable plasma levels of caffeine in most subjects and of theobromine in at least one subject.

Absorption↗

High-performance liquid chromatographic separation of carminic acid, alpha- and beta-bixin, and alpha- and beta-norbixin, and the determination of carminic acid in foods.

During a study of natural food colours, a simple and reliable high-performance liquid chromatography system was developed for use with cochineal and annato. An isocratic mobile phase, consisting of methanol and 6% aqueous acetic acid, resolved bixin and norbixin, while a gradient system was used to separate carminic acid and the annato compounds. The carminic acid contents of cochineal extract, carmine and carmine hydrosoluble were determined using an isocratic mobile phase (40:60, v/v). The detection limit for carminic acid in the various products was approximately 100 ng/g. Carminic acid was determined quantitatively in fruit beverages, yogurt and candies. It was demonstrated that, because of decomposition, carminic acid was not suitable for use in candies when manufacturing temperatures above 100 degrees C were required. Most membrane filters are not suitable for use with cochineal solutions, but a cellulose membrane filter did not adsorb carminic acid and was used successfully to remove impurities from water-based cochineal products and food extracts containing carminic acid.

Carmine↗

Endorphinergic modulation of neural reward systems indicated by behavioral changes.

Experiments were performed in rats expecting and/or having received rewards to see if naloxone-antagonizable changes occur in behavior. It was found that rats expecting to receive candy display a naloxone-blockable increase in nociceptive thresholds and a naloxone-sensitive increase in rearing. Similarly, water-deprived rats expecting to receive water show a naloxone-blockable increase in rearing, whereas thirsty animals not expecting water show no changes in nociception or activity. Naloxone was also found to reduce the consumption of a highly palatable food and to diminish the performance of rats trained to wait in one place to receive candy. The latter indicates that the naloxone effect upon goal seeking is not dependent upon a decrease in general activity. Experiments in highly morphine-tolerant rats maintained on relatively constant morphine concentrations showed that these rats drink chocolate milk in the same way as placebo-treated animals. The same rats were found to fail to decrease their intake to the same extent as placebo-controls when water is substituted for the first time for chocolate milk given regularly every day. This points to the possibility that a negative action of endorphins, that is a decrease in release, decreasing consumption, upon a reduction in the palatability of an expected food, might be absent in highly tolerant animals. It is suggested that endogenous opiate(s) regulate mood as defined by the level of goal-seeking behavior, sensitivity to noxious stimuli and general activity.

Analgesics↗

Is unconscious identity priming lexical or sublexical?

We examined unconscious priming in a stem-completion task with both identity and form-related primes. Participants were given exclusion instructions to avoid completing a stem (e.g., ca---) with a briefly flashed masked word (e.g., candy). In Experiment 1, priming of around 7% occurred for both identity (e.g., candy) and form-based (e.g., windy) primes at a 33 ms exposure duration. When examining only trials in which the participants failed to identify the prime, this effect increased to 12% for identity primes, but remained the same for form-based primes. In Experiment 2, priming without prime identification was 9% for identity primes, 4% for homophone primes, and 3% for orthographic control primes. Although identity priming was greater than form priming in both experiments, regression analyses revealed that orthographic and phonological overlap alone between the flashed primes and targets could completely account for unconscious identity priming. Hence, we conclude that masked words may only activate their sublexical orthographic and phonological representations and not their lexical representations.

Fixation, Ocular↗

Changes in food group consumption patterns from childhood to young adulthood: the Bogalusa Heart Study.

OBJECTIVE: The objective of this study was to assess changes in food group consumption patterns from childhood to young adulthood. DESIGN: Twenty-four-hour dietary recalls were collected on a longitudinal sample of young adults. SUBJECTS/SETTING: Dietary intake data were collected on 246 young adults (70% European American, 30% African American) aged 19 to 28 years who participated in a previous cross-sectional survey when they were 10-year-olds. STATISTICAL ANALYSES: Descriptive statistics and linear mixed models adjusting for study time (age), sex, and ethnicity. RESULTS: In childhood, consumption of fruits/fruit juice and mixed meats ( P </=.05), desserts, candy, and milk ( P </=.0001) were greater than in young adulthood. Young adulthood consumption was greater for sweetened beverages, poultry and seafood ( P </=.001), salty snacks ( P </=.05), and beef ( P </=.01) compared to childhood. Milk consumption decreased, but the decrease was greater among males ( P </=.0001). Sweetened beverage consumption increased, but the increase was greater for European Americans ( P </=.0001). Candy consumption decreased, but the decrease was greater for African Americans ( P </=.05). CONCLUSIONS: Changes occur in food group consumption patterns from childhood to young adulthood. Overall, there was a decrease in diet quality during this age transition. Understanding eating habits of children early in life is important for planning effective intervention strategies.

Adolescent↗

Effects of estradiol and aging on fine manual performance in female rhesus monkeys.

Aging is characterized by a progressive deterioration of motor function related to dysfunctions of the nigrostriatal system. Because estrogen has been reported to protect dopaminergic neurons and to improve the motor deficits associated with Parkinson's disease, we hypothesized that it would partially reverse the age-related decline of motor function in normal aging. We tested the effects of estrogen treatment and withdrawal on fine motor performance in five aged (21-24 years old) and five young (6-9 years old) ovariectomized female rhesus monkeys. The tests required the monkeys to use each hand to retrieve a Life Saver candy from metal rods bent in shapes of different complexity. Monkeys were tested twice a week for 8 consecutive weeks, during treatment with placebo or ethinyl estradiol (EE(2)) in alternating 14-day blocks. Each behavioral test was videotaped and subsequently scored for the duration and the success of the first trial on each shape. Both groups of monkeys improved rapidly with practice in speed and success of retrieval. The older monkeys were slower but as successful as the young monkeys in retrieving the candy. The left hand was faster than the right hand for both the aged and young females. We failed to detect any effect of EE(2) treatment on speed or success of retrieval in either group. These results confirm the slowing of fine motor performance with aging in female rhesus monkeys. They also indicate that estradiol, at least as administered in this study, does not benefit fine manual performance.

Aging↗

Temporal characteristics of capsaicin desensitization and stimulus-induced recovery in the oral cavity.

It was recently discovered that capsaicin desensitization of the tongue can be temporarily reversed during recurrent stimulation ("stimulus-induced recovery," SIR). The effects of concentration and the temporal pattern of stimulation on desensitization and SIR were studied in four experiments. In Experiment 1, three different concentrations of capsaicin (3.3, 33, or 330 microM) were delivered to the tongue in blocks of twelve stimuli at the rate of one per minute (treatment block) followed by a block of 20 exposures to 33 microM capsaicin (test block). The 33- and 330-microM treatments both caused significant desensitization, but by the end of the test block recovery was substantial only for the 33-microM condition. Experiment 2 provided a second test of the effect of concentration while also exploring whether intermittent stimulation was a requirement for SIR, i.e., stimuli were refreshed on the tongue every six minutes rather than every 60 s. SIR occurred but was pronounced only when the concentration of the test stimulus equaled or exceeded that of the treatment stimulus. In the third experiment we delivered capsaicin in a candy formulation to examine SIR under conditions in which stimulation was not interrupted at all. Although desensitization was evident during the first few minutes of succeeding exposures to the candy, peak irritation was unchanged throughout nine exposures over 3 days. In the final experiment, we returned to intermittent stimulation to examine the effect of lengthening ISI on SIR. The results showed that SIR remained virtually complete until ISI was lengthened to 60 s. We conclude that SIR is a robust phenomenon that is maximized by rapid exposure to capsaicin in a concentration at least as high as that of the desensitizing stimulus. The implications of these findings for hypotheses about the mechanism of SIR, its function in endogenous chemonociception, and for clinical use of capsaicin as a topical analgesic are discussed.

Adult↗

Ten year trends in the dietary habits of Danish men and women. Cohort and cross-sectional data.

OBJECTIVE: To describe 10 year trends and individual changes in food habits of Danish men and women in relation to dietary recommendations using data from both a cohort and a repeated cross-sectional study, and to examine whether the two sampling methods give similar results. DESIGN: Baseline data were collected in 1982-1984 and respectively repeated measurements for cohort and cross-sectional changes in food habits. SETTING: The County of Copenhagen, Denmark. SUBJECTS: Men and women aged 30-70y in 1982-1984, 1986-1988 and 1992-1994. The trend analyses included 3785 subjects for cohort and 7316 for cross-sectional study, respectively. Longitudinal changes were studied among 2430 individuals with food data from all three examinations. METHODS: Food intakes were estimated using a short food frequency questionnaire. RESULTS: During the study period both men and women reported a decreased intake frequency of animal and vegetable fats, milk, eggs, meat products, white bread and potatoes, while they had increased intakes of low-fat margarine, fruit, raw vegetables, coarse breads, oatmeal, pasta, rice, cakes and candy. In both men and women the decrease in the consumption frequency of, white bread and potatoes, and the increase in pasta, and candy, were higher in the younger than in the older age group. In contrast, the increased consumption frequency of coarse breads, and oatmeal were most pronounced in the older age groups. For most foods the cohort and the repeated cross-sectional surveys gave similar results. CONCLUSIONS: From 1982 through 1994 the food habits of middle-aged Danish men and women changed in the direction of a more healthy diet as recommended by health authorities. With the limitation of a possible reporting bias both the cohort and repeated cross-sectional study designs may be used for monitoring changes in food intake.

Adult↗

Projection sites of medial preoptic area and ventral bed nucleus of the stria terminalis neurons that express Fos during maternal behavior in female rats.

Medial preoptic area (MPOA) and ventral bed nucleus of the stria terminalis (VBST) neurons are involved in maternal behavior, but the neural sites to which the maternally relevant neurons project have not been determined. Since MPOA and VBST neurons express Fos during maternal behavior, we used a double-labeling immunocytochemical procedure to detect both Fos and a retrograde tracer, wheat germ agglutinin (WGA), in order to determine where these Fos neurons project. On Day 4 postpartum, fully maternal females were separated from their litters. On Day 5, WGA was iontophoretically injected into one of the following regions known to receive MPOA and/or VBST input: Lateral septum, medial hypothalamus at the level of the ventromedial nucleus, lateral habenula, ventral tegmental area, retrorubral field, or periaqueductal gray. On Day 7, females received a 2-h test with either pups or candy, after which they were perfused and their brains were processed for the detection of Fos and WGA. As expected, females tested with pups had more Fos-containing neurons in the MPOA and VBST than did females tested with candy. After WGA injections into several brain sites, the number of double-labeled cells observed in the MPOA and VBST was greater for the maternal females when compared to the non-maternal females. Therefore, these results pinpointed neural circuits that were activated during maternal behavior. For the maternal females, Fos-containing neurons in the MPOA projected most strongly to the medial hypothalamus at the level of the ventromedial nucleus and to the lateral septum, while Fos-containing neurons in the VBST projected most strongly to the retrorubral field, ventral tegmental area, and medial hypothalamus. Although relatively few MPOA and VBST neurons which expressed Fos during maternal behavior projected to the periaqueductal gray, these Fos-expressing neurons made up a relatively large proportion of the MPOA and VBST projection to the periaqueductal gray. This study suggests that MPOA and VBST efferents project to a variety of regions to promote full maternal responsiveness.

Animals↗

Food, alcohol and cigarette availability and consumption in Almaty, Kazakstan: results and appraisal of a rapid assessment.

OBJECTIVES: (1) To develop a useful tool to measure food, alcohol and tobacco items; (2) to document the availability of these items in Almaty, Kazakstan; (3) to describe the relationship between consumption and availability; and (4) to identify possible relationships between availability and health outcomes in the city and region. DESIGN: A survey of 648 vendors in Almaty, Kazakstan was conducted over one month from December 1999 to January 2000. Vendors identified which items they sold from a list of 61 food, alcohol and tobacco items. SETTING: Vendors were approached in three of the six regions of Almaty, Kazakstan. Regions canvassed included Auzov, one of the three 'sleeping regions'; Medeo, one of the two downtown regions; and Turksib, a more suburban/rural area of the city. RESULTS: There was a significant correlation between alcohol and cigarette consumption and availability. The relative availability of items was numerically and spatially consistent throughout the city. Fruits and vegetables occurred infrequently (<20% of sites) and in relative isolation from the rest of the system, while candy and cigarettes occurred with a higher relative frequency (75-80% of sites). Maps of vendors showed clusters around geographical features such as major roads and intersections. CONCLUSIONS: Combining a checklist and mapping tools provides a model of consumer item availability that can help identify priorities for public health and urban planning professionals. The wide availability of cigarettes, alcohol, candy, coffee and tea, and limited availability of fruits, vegetables and whole grains, is likely to support increasing rates of chronic disease in Almaty.

Alcohol Drinking↗

American-sign-language statements and delay of gratification in hearing-impaired and nonhandicapped children.

Hearing-impaired children were individually administered a task in which possession of accumulating candy rewards was made contingent upon the child's decision to stop any further accumulation of the candy. Hearing-impaired children, who under instruction periodically made American Sign Language (ASL) statements about the goodness of the reward, waited significantly longer before terminating the waiting period than did hearing-impaired children instructed to sign statements about the act of waiting and somewhat longer than did hearing-impaired children instructed to sign a neutral statement. Since the pattern of delay was unlike that reported in earlier investigations when nonhandicapped children verbalized similar statements and since variation in mode of communication did not influence delay in nonhandicapped children in the present investigation, the results were interpreted in terms of differences in cognitive controlling mechanisms between nonhandicapped and hearing-impaired children.

Attention↗

Sour taste preferences of children relate to preference for novel and intense stimuli.

Previous research has suggested that some children have a preference for sour tastes. The origin of this preference remains unclear. We investigated whether preference for sour tastes is related to a difference in rated sour intensity due to physiological properties of saliva, or to an overall preference for intense and new stimuli. Eighty-nine children 7-12 years old carried out a rank-order procedure for preference and category scale for perceived intensity for four gelatins (i.e. 0.0 M, 0.02 M, 0.08 M, 0.25 M added citric acid) and four yellow cards that differed in brightness. In addition, we measured their willingness to try a novel candy and their flow and buffering capacity of their saliva. Fifty-eight percent of the children tested preferred one of the two most sour gelatins. These children had a higher preference for the brightest color (P < 0.05) and were more likely to try the candy with the unknown flavor (P < 0.001) than children who did not prefer the most sour gelatins. Preference for sour taste was not related with differences in rated sour intensity, however those who preferred sour taste had a higher salivary flow (P < 0.05). These findings show that a substantial proportion of young children have a preference for extreme sour taste. This appears to be related to the willingness to try unknown foods and preference for intense visual stimuli. Further research is needed to investigate how these findings can be implemented in the promotion of sour-tasting food such as fruit.

Child↗

Transmucosal administration of midazolam for premedication of pediatric patients. Comparison of the nasal and sublingual routes.

BACKGROUND: Nasal transmucosal midazolam is effective for premedication of pediatric patients; however, 61-74% of these patients cry at nasal drug administration. Sublingual benzodiazepines, including midazolam, are effective in adults. The current blinded randomized study compared acceptance of and behavioral responses to transmucosal midazolam administered via the intranasal and sublingual routes. METHODS: Ninety-three patients aged 0.5-10 yr were stratified by age: 30 infants and toddlers, 0.5-2 yr; 39 preschoolers, 2.1-5 yr; and 24 school age, 5.1-10 yr. They were randomized to receive 0.2 mg/kg of midazolam in the nose or under the tongue without or with additional flavoring. For the group receiving sublingual flavored midazolam, the syringe tip was dipped in candy flavor and sugar. Duration of crying and compliance with instructions for sublingual drug administration were recorded. Hemoglobin oxygen saturation by pulse oximetry and sedation score were recorded by three observers before drug administration, at 2.5-min intervals for 10 min, at separation from parents, and during induction with halothane in O2. RESULTS: Children accepted midazolam administered via the sublingual route better than that given intranasally. In children not crying before drug administration, the frequency and duration of crying was greater following intranasal compared with sublingual administration (71% vs. 18% (P < 0.0001) and 48 +/- 56 vs. 25 +/- 49 s (P = 0.004), respectively). Lack of total compliance with instructions for sublingual administration did not alter drug effect, and there were no differences between the three study groups in maximum sedation, response to separation from parents, and behavior at induction of anesthesia; 80% displayed adequate or excellent behavior. Finally, the addition of candy flavor did not improve acceptance of or compliance with sublingual midazolam administration. CONCLUSIONS: Sublingual administration of midazolam is as effective as, and better accepted than, intranasal midazolam as a preanesthetic sedative in children.

Administration, Intranasal↗

A second look at the relation between colorectal adenomas and consumption of foods containing partially hydrogenated oils.

The trans fatty acids in partially hydrogenated vegetable oil may cause colorectal neoplasia by interfering with cell membrane function or eicosanoid metabolism. This possibility provided a rationale for looking at the relation between colorectal adenomas and consumption of foods containing partially hydrogenated vegetable oils in 234 cases and 407 controls recruited from referrals for colonoscopy at University of North Carolina Hospitals in Chapel Hill, between 1988 and 1990. Foods containing partially hydrogenated vegetable oils were divided into four groups: sweetened baked goods, chocolate candy, oils and condiments, and french fries and chips. We observed no evidence of increased adenoma prevalence associated with consumption of fries and chips (200+ vs 0 kcals/day: odds ratio (OR) = 0.70; 95% confidence limits (CL) = 0.27, 1.8) or chocolate candy (50+ vs 0 kcals/day: OR = 0.49; 95% CL = 0.23, 1.1). We did, however, find evidence of increased adenoma prevalence associated with consumption of sweetened baked goods (400+ vs < 100 kcals/day: OR = 1.9; 95% CL = 0.95, 3.8) and oils and condiments (200+ vs < 100 kcals/day: OR = 2.4; 95% CL = 1.3, 4.2).

Adenomatous Polyps↗

Learning by doing: teaching critical appraisal of randomized trials by performing an in-class randomized trial.

OBJECTIVE: Our medical students often encounter difficulty because many have trouble appreciating the relative merits and limitations of clinical research design. In order to remedy these deficits, we developed a novel in-class simulated randomized trial in which students were blinded to their treatment assignment. Specifically, our goals for the session were to demonstrate the importance of randomization of subject populations, to define and use basic terminology such as relative risk reduction along with absolute risk reduction, and to demonstrate the strengths and pitfalls of analysis of subsets of subjects. DESCRIPTION: We proposed the study of a hypothetical new drug, "Flunkimmune," which was claimed to prevent students from failing tests. Students received a random assignment to either the "Flunkimmune" or the placebo group. Students then received an opaque plastic egg appropriate for their randomization. We had prepared the eggs a-priori to each contain a piece of candy, and some to contain a blue dot. The flavor of the candy signified whether a particular student was in the treatment or control group. After all students had received their eggs, we "unblinded" the study by having the students open their eggs and learn to which treatment they had received. We then used an audience response system to construct a demographics table commonly known as Table 1 for the randomized trial-based characteristics of the students' choosing (e.g., "drinks Diet cola," "over six feet tall," "birth weight under seven pounds"). We asked the class to critique their own Table 1 and to comment on the adequacy of the randomization. Students were then informed that the presence of the blue dot signified a "failing" grade on a hypothetical exam to test the efficacy of "Flunkimmune." The eggs had been loaded so that the treatment group had a relative risk reduction of failure rates of 50% compared with the control group and an absolute risk reduction of 20%. This result prompted a debate among students about the relative merits of absolute or relative risk reduction in reporting the results of the study. Students also performed subgroup analyses by determining the failure rates for treatment and control students seated in particular aisles of the lecture hall. This enhanced discussion about the processes of bias and confounding inherent in subgroup analyses. DISCUSSION: This experiential teaching method allowed students to participate directly in a simulated randomized controlled trial, thereby facilitating understanding of this type of study. Students reported that the experience was enjoyable and stimulated active engagement with critical appraisal of randomized trials. Students' subsequent homework assignments, in which they were asked to critically appraise a randomized trial, demonstrated a depth of understanding not previously encountered at this level. We plan to develop and rigorously evaluate additional experiential activities that expose students to the role of the research investigator.

Education, Medical, Undergraduate↗