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PubMed1992

Acute tubular necrosis: diagnosis, treatment, and nursing implications.

Acute tubular necrosis (ATN) is the most common cause of acute renal failure. Early recognition of patients who are at risk for ATN can prevent or improve the course of ATN. Acute renal failure is classified as prerenal, intrinsic, or postrenal disease. ATN is classified as a type of intrinsic renal disease. The clinical course of ATN is divided into the renal failure phase, diuretic phase, and recovery phase, with each phase having distinct symptoms and laboratory findings. Diagnosis of ATN often is complicated and confusing; understanding of laboratory findings can facilitate the critical care nurse's ability to assess those at risk for ATN. The care and treatment of the patient with ATN is complicated, and specific treatments are discussed in detail. The critical care nurse can play a vital role in identifying the patient at risk, preventing the development of ATN in those at risk, and providing appropriate care for those who develop ATN.

Humans↗
PubMed1991

[Urinary tissue-type plasminogen activator (tPA) in renal transplant patients].

We have previously suggested that an appearance of FDP D-dimer fragment into the urine predicts the reversibility of acute renal transplant rejection. In the present study, we observed urinary tissue-type plasminogen activator (tPA), which is a fibrinolytic enzyme and produces D-dimer, in 51 renal transplantation patients. Urinary tPA values are generally higher in transplantation patients except on chronic rejection than in healthy controls. High values just before onset of rejection (increase of serum creatinine value), deterioration at onset phase and gradual elevation from peak phase toward recovery phase were observed in urinary tPA of 6 reversible acute rejection episodes. Urinary D-dimer values changed following urinary tPA values in serial observation of 2 cases. In conclusion, immunological reaction accompanying by functional and organic renal impediments may result in loss of fibrinolytic activity, decrease in urinary tPA and D-dimer. This findings suggest theoretically that the supplemental tPA administration prevents the progression of rejection reaction.

Fibrin Fibrinogen Degradation Products↗
PubMed1987

Quantitative and morphologic changes of Langerhans' cells after ultraviolet A irradiation of human epidermis.

Three different surface markers (OKT6, HLA-DR, and adenosinetriphosphatase) were compared to identify Langerhans' cells, and the changes in number and morphology of these cells were studied at different intervals after irradiation of human skin by a 2.5-fold minimal erythema dose of ultraviolet A. Morphologic alteration and decreased surface-marker reactivity became evident on day 2 and were most pronounced on day 3 or day 4 (injury phase). The recovery phase started between day 4 and 1 week and was complete by 3 weeks. HLA-DR+/OKT6- (DR+T6-) cells were present at all time intervals. The ratio of these cells to the sum of DR+T6- and DR+T6+ cells was 0.3% before irradiation, reached a peak of 65.4% at day 4, and decreased to 0.6% by 3 weeks.

Adenosine Triphosphatases↗
PubMed1986

Rehabilitation of the adult with head trauma.

The changes incurred as a result of brain injury are often devastating. The approaches outlined in this article merely scratch the surface because the list of possible deficits is inexhaustible. The behavioral and cognitive capacity during the various phases of recovery dictate the intervention method that will be appropriate and successful, with concepts and tasks progressing from the simple to the more complex. When confusion, agitation, and inappropriate behavior are evident, safety is a prime concern. Some individuals do not progress beyond this stage. Placement and appropriate future planning are major issues in this situation. When behavior becomes more appropriate, inpatient rehabilitation efforts will be most beneficial and successful, with the focus on helping the individual regain functional skills. Improvement may be rather dramatic during this time, especially when compared with previous stages. Recovery beyond this point, with intact memory, goal-directed behavior, adequate socialization skills, and vocational rehabilitation, occurs over an extended period of time, perhaps years. With discharge, new concerns for the individual and family emerge as the reality of the situation becomes clearer. Health care providers in the community setting must recognize the effects of injury on the individual and the resulting psychosocial stresses and strains on the individual and family. Adequate neuromedical and neuropsychological follow-up are essential during the outpatient recovery phase to monitor progress and provide input for future plans.

Adult↗
PubMed1982

Response of rhesus monkey lymphocytes to short-term administration of THC.

Four Rhesus monkeys were subjected to daily administration of 2.5 mg of tetrahydrocannabinol (THC)/kg body wt, after establishing the norms for complete blood count, T- and B-cell concentrations, and the dose response of thymidine incorporation after PHA stimulation. THC was administered daily for 3 weeks, the treatment was stopped, and then the animals were allowed to recover for 4 weeks. Cellular responses, incorporation studies and fibrinogen levels were determined during the treatment and recovery phases. Compared to 4 vehicle-treated animals, the THC-treated animals experienced significant augmentation of both their total white cell and their neutrophil counts during the recovery phase which returned to normal levels during the recovery phase. There was no alteration in total lymphocyte count or T- or B-cell concentrations. Fibrinogen levels of the THC-treated animals during the treatment phase were also elevated compared to controls, and the levels diminished to the same values as the vehicle-treated animals during recovery phase. Possible mechanisms for the response of Rhesus monkeys to short-term administration of THC are discussed.

Animals↗
PubMed1995

Using home health agencies to meet patient needs in phase III recovery.

Today third-party payers determine the types of surgical procedures that must be done on an ambulatory basis. After such surgical procedures, most patients are able to be discharged home for phase III recovery (the postdischarge period of recuperation), where they usually have adequate support systems. For a variety of reasons many patients need professional, assisted care in phase III recovery. Such care often is provided by home health agency personnel. Nurses in ambulatory surgery units need to recognize which patients need assisted care, understand how patients qualify for care, know what types of services are available and who provides the care, understand how the expenses are covered, and know how to access the system. By identifying and helping meet patients' and families' needs, nurses facilitate recovery, help alleviate anxiety, and work to reduce health care costs.

Ambulatory Surgical Procedures↗
PubMed2005

Squamous cell carcinoma-related antigen in children with acute asthma.

BACKGROUND: Increased serum levels of squamous cell carcinoma-related antigen (SCCA) have been observed in patients with allergic disorders, such as atopic dermatitis and bronchial asthma. T(H)2 cytokines, which are known to be involved in the pathogenesis of allergic disorders, stimulate new synthesis of SCCA in cultured human airway epithelial cells. OBJECTIVE: To investigate whether SCCA levels increase during acute exacerbations of asthma in children and whether the T(H)2 cytokines, interleukin 4 (IL-4) and IL-13, are associated with SCCA levels. METHODS: Serum levels of SCCA, IL-4, and IL-13 were measured by enzyme immunoassay during the acute phase of an asthma exacerbation (on hospital admission) and in the recovery phase (after symptoms had subsided). RESULTS: In the 35 children who participated in this study, serum levels of SCCA were significantly elevated in the acute phase (mean +/- SD, 3.09 +/- 2.03 ng/mL) compared with the recovery phase (mean +/- SD, 1.47 +/- 0.64 ng/mL) of an asthma exacerbation (P < .001). In 12 children, the IL-13 levels were observed to correlate with SCCA levels during the recovery phase (r = 0.68, P = .02) but not during the acute phase of an asthma exacerbation. CONCLUSIONS: Serum SCCA levels increase during the acute phase of an asthma exacerbation. During this phase, the increased synthesis of SCCA is not associated with IL-13 but rather mediated by other undefined stimuli. IL-13 may contribute to the basal production of SCCA in asthmatic children.

Acute Disease↗
PubMed1996

Anesthetic and postanesthetic management of sea turtles.

OBJECTIVE: To examine the physiologic effects of inhalation anesthesia in aquatic turtles to improve anesthetic techniques and postanesthetic monitoring. DESIGN: Retrospective case series. ANIMALS: 9 Kemp's ridley sea turtles. PROCEDURE: Isoflurane was used as the general anesthetic during 14 minor surgical procedures. Turtles were orotracheally intubated, and a surgical plane of anesthesia was maintained with 2.7 +/- 0.4% (mean +/- SE) isoflurane. The duration of anesthesia was 131 +/- 12 minutes. Pulse rate, blood pressure, blood gases (PaO2 and PaCO2) and pH, blood lactic acid concentration, and capnography were used to evaluate the physiologic responses of sea turtles to isoflurane. RESULTS: An isoflurane concentration of 3.4 +/- 0.3% provided anesthetic induction in 7 +/- 1 minutes. The mean duration of the recovery phase was 241 +/- 31 minutes. The duration of the recovery phase was not affected by the duration of anesthesia, type of carrier gas, method of ventilatory weaning, or use of selected pharmacologic agents. The recovery phase was characterized by hypoxemia, progressive acidemia, hypercapnia, and lactic acidosis. Awakening in the turtles was preceded by a characteristic tachycardia and tachypnea. All sea turtles recovered from isoflurane anesthesia without apparent adverse effects within 24 hours. CLINICAL IMPLICATIONS: Isoflurane appears to be safe and effective in providing surgical anesthesia in turtles that require a timely return to an aquatic environment. This study should assist veterinarians in predicting the physiologic responses of aquatic turtles to inhalation agents.

Anesthesia, Inhalation↗
PubMed1996

cDNA cloning of rat pS2 peptide and expression of trefoil peptides in acetic acid-induced colitis.

By using a combination of the methods of reverse transcription-PCR and rapid amplification of cDNA ends, a cDNA for rat pS2 peptide (rpS2) was successfully cloned and sequenced from rat stomach. By RNA blot analysis, the gene was shown to be expressed abundantly in the stomach and only faintly in the duodenum, but not in other tissues including the distal small and large intestines. rpS2 expression was also examined in the rectum during the course of acetic acid-induced colitis; rpS2 mRNA was detected during the acute phase of colitis but not in normal controls or during the recovery phase. On the other hand, expression of rat intestinal trefoil factor (rITF) was down-regulated during the acute phase of colitis and then up-regulated during the recovery phase, whereas rat spasmolytic peptide was not detectable throughout the course of the induced colitis. These results indicate that the patterns and timing of the expression of these trefoil peptides are different from each other. rpS2 may play an important role in the proliferation of intestinal epithelial cells during the acute phase of mucosal ulceration, whereas rITF may be involved in differentiation of the cells, particularly to form goblet cells, during the recovery phase.

Acetic Acid↗
PubMed1995

Faster force transient kinetics at submaximal Ca2+ activation of skinned psoas fibers from rabbit.

The early, rapid phase of tension recovery (phase 2) after a step change in sarcomere length is thought to reflect the force-generating transition of myosin bound to actin. We have measured the relation between the rate of tension redevelopment during phase 2 (r), estimated from the half-time of tension recovery during phase 2 (r = t0.5(-1)), and steady-state force at varying [Ca2+] in single fibers from rabbit psoas. Sarcomere length was monitored continuously by laser diffraction of fiber segments (length approximately 1.6 mm), and sarcomere homogeneity was maintained using periodic length release/restretch cycles at 13-15 degrees C. At lower [Ca2+] and forces, r was elevated relative to that at pCa 4.0 for both releases and stretches (between +/- 8 nm). For releases of -3.4 +/- 0.7 nm.hs-1 at pCa 6.6 (where force was 10-20% of maximum force at pCa 4.0), r was 3.3 +/- 1.0 ms-1 (mean +/- SD; N = 5), whereas the corresponding value of r at pCa 4.0 was 1.0 +/- 0.2 ms-1 for releases of -3.5 +/- 0.5 nm.hs-1 (mean +/- SD; N = 5). For stretches of 1.9 +/- 0.7 nm.hs-1, r was 1.0 +/- 0.3 ms-1 (mean +/- SD; N = 9) at pCa 6.6, whereas r was 0.4 +/- 0.1 ms-1 at pCa 4.0 for stretches of 1.9 +/- 0.5 (mean +/- SD; N = 14). Faster phase 2 transients at submaximal Ca(2+)-activation were not caused by changes in myofilament lattice spacing because 4% Dextran T-500, which minimizes lattice spacing changes, was present in all solutions. The inverse relationship between phase 2 kinetics and force obtained during steady-state activation of skinned fibers appears to be qualitatively similar to observations on intact frog skeletal fibers during the development of tetanic force. The data are consistent with models that incorporate a direct effect of [Ca2+] on phase 2 kinetics of individual cross-bridges or, alternatively, in which phase 2 kinetics depend on cooperative interactions between cross-bridges.

Animals↗
PubMed2005

Sydenham's chorea: positron emission tomographic (PET) scan studies.

Two patients with Sydenham's chorea were evaluated with positron emission tomographic (PET) scans in the active phase of the disease. One patient had repeat scanning in the recovery phase. PET scans showed hypermetabolic changes of the caudate nuclei and putamen in the active phase of Sydenham's chorea. The scan reverted to normal in the recovery phase. These changes can afford a basis for comparing concurrent serum antibody studies in the acute and recovery phases of Sydenham's chorea.

Caudate Nucleus↗
PubMed1992

Induction of azoospermia in normal men with combined Nal-Glu gonadotropin-releasing hormone antagonist and testosterone enanthate.

The effects of a combined GnRH antagonist and testosterone (T) replacement regimen on gonadotropins and spermatogenesis were examined to assess its potential as a male contraceptive regimen. The potent Nal-Glu GnRH antagonist ([Ac-D2-Nal1,D4-Cl-Phe2,D3-Pal3,Arg5, D4-p-methoxybenzoyl-2-amino butyric acid6,D-Ala10]GnRH) was administered daily (7.5 mg, sc) to eight normal men for 16 weeks. T enanthate was given im starting at week 2 and every 2 weeks thereafter through week 14 of the treatment phase. Serum LH, FSH, T, and estradiol concentrations were measured frequently during the 5-week control period, the 16-week treatment phase, and the 14-week recovery phase. Semen analyses were performed every week during the control phase and every 2 weeks during the treatment and recovery phases. Seven of eight subjects became azoospermic by 6-10 weeks of treatment; the eighth subject, who failed to achieve azoospermia, suppressed his sperm count to 7 million/mL by week 14 (from a mean baseline of 42 million/mL) before treatment was prematurely terminated because of localized swelling at each of his injection sites. Sperm counts returned to baseline 10-14 weeks after the end of Nal-Glu administration. Seven of the eight subjects showed suppression of LH to the limit of assay detection (less than 0.2 U/L), whereas the eighth subject showed incomplete suppression. Serum bioactive and immunoreactive LH concentrations showed concordant responses. Mean serum FSH concentrations were also markedly suppressed. Serum T and estradiol concentrations declined dramatically during the first 2 weeks of Nal-Glu GnRH treatment, but returned to the normal physiological range after T enanthate replacement was initiated. Libido and sexual potency were maintained. No systemic side-effects, other than erythema and induration at injection sites, were observed. These data demonstrate that combined GnRH antagonist plus T treatment can predictably and reversibly induce azoospermia in most men and has potential as a male contraceptive regimen.

Adult↗
PubMed2000

Plasma endotoxin and serum cytokine levels in patients with alcoholic hepatitis: relation to severity of liver disturbance.

BACKGROUND: Endotoxin plays an important role in the initiation and aggravation of alcoholic liver disease. In this study, we evaluated plasma endotoxin levels and serum concentrations of cytokines and lipopolysaccharide binding protein (LBP) during the acute and recovery phase of patients with alcoholic hepatitis; we also explored the prognostic factors associated with a fatal outcome. METHODS: Fourteen patients, consisting of eight patients with alcoholic hepatitis (AH), five cirrhotics with superimposed AH (LC+AH), and one patient with severe alcoholic hepatitis (SAH), were studied. Among these, two with LC+AH died of hepatic failure. RESULTS: Plasma endotoxin levels in the acute phase were higher in patients with AH (184.4 +/- 159.4 pg/ml) and LC+AH (206.9 +/- 174.9 pg/ml) than in healthy subjects (10.4 +/- 5.5 pg/ml, p < 0.001). In particular, in one patient with SAH and one of two nonsurvivors, plasma endotoxin levels were markedly high relative to the other cases. In most survivors, plasma endotoxin levels decreased in the recovery phase, whereas they further increased at the terminal stage in one of two nonsurvivors. Serum interleukin (IL)-6 and IL-8 levels in the acute phase were significantly higher in patients with AH and LC+AH as compared with healthy subjects. These levels were especially high in nonsurvivors and in one patient with SAH. IL-10 increased in two nonsurvivors, one patient with SAH, and one with LC+AH. In the recovery phase, these cytokine levels in survivors tended to decrease, but in nonsurvivors, IL-6 remained high, and IL-8 and IL-10 further increased. Tumor necrosis factor-alpha levels were below the detection limit throughout the course in all patients. Serum lipopolysaccharide binding protein (LBP) generally was elevated in the acute phase and decreased in the recovery phase in all survivors, but in one of the nonsurvivors, LBP was elevated markedly at the terminal stage. In the acute phase, plasma endotoxin levels were correlated positively with white blood cell counts, neutrophil counts, and serum IL-8. IL-8 was correlated positively with neutrophil counts and negatively with serum cholinesterase, hepaplastin test, and serum albumin levels. IL-6 was correlated positively with white blood cell and neutrophil counts, C-reactive protein, and serum total bilirubin and negatively with hepaplastin test and serum total protein levels. Serum LBP was correlated positively with white blood cell and neutrophil counts. CONCLUSIONS: Endotoxemia and related elevation of IL-8 may play an important role in the activation and migration of neutrophils in patients with alcoholic hepatitis. Marked elevation of inflammatory cytokines, IL-6 and IL-8, are related to severity and poor prognosis of alcoholic hepatitis. Serum LBP may serve as an index of inflammatory reaction in alcoholics.

Acute-Phase Proteins↗
PubMed2000

Patients' perception of sound levels in the surgical suite.

STUDY OBJECTIVES: To measure sound levels that our patients are exposed to in the surgical suite and their perception of these sound levels. DESIGN: Sound levels experienced by 100 patients undergoing general anesthesia for elective surgery during three phases: induction and maintenance of anesthesia in the operating room (OR), and recovery from anesthesia in the recovery room, were measured using a Type 4436 Noise Dose Meter. The equivalent continuous sound levels (Leq), maximum sound levels (Lmax), and the sources of sounds were noted. Patients were interviewed 24 hours after anesthesia about their perception of the sound levels they had experienced in the OR and recovery rooms. MEASUREMENTS AND MAIN RESULTS: The Leq during the induction, maintenance, and recovery phases were 70.3 +/- 16.8 dB(A), 66.2 +/- 4.1 dB(A) and 71.8 +/- 6.1 dB(A), respectively. These sound levels are much higher than international recommendations for hospital acute care areas and exceed the thresholds to produce noise-induced cardiovascular and endocrine effects. Sound levels were significantly higher during the induction and recovery phases compared to the maintenance phase. Thirty-two patients found the induction phase noisy and 33 patients found the recovery phase noisy. The sound levels distressed 16 patients and 52 patients would have preferred a quieter environment. There was no difference in the sound levels experienced by those who expressed dissatisfaction with the sound levels and those who did not. Much of the noise, particularly staff conversations, unnecessary alarms, and preparation of equipment, could have been prevented by simple measures. CONCLUSION: Noise prevention in the OR and recovery room needs more attention and should be a routine part of patient care.

Anesthesia↗
PubMedDate not supplied

Origin of electroretinogram amplitude growth during light adaptation in pigmented rats.

We assessed the growth of the rat photopic electroretinogram (ERG) during light adaptation and the mechanisms underlying this process. Full field ERG responses were recorded from anesthetized adult Brown-Norway rats at each minute for 20 min of light adaptation (backgrounds: 1.8, 2.1, 2.4 log scotopic cd m(-2)). The rat photopic b-wave amplitude increased with duration of light adaptation and its width at 33% maximal amplitude narrowed (by approximately 40 ms). These effects peaked 12-15 min after background onset. The narrowing of the b-wave reflected steepening of the b-wave recovery phase, with little change in the rising phase. OP amplitudes grew in proportion to the b-wave. Inhibition of inner retinal responses using TTX resulted in a greater relative growth of b-wave and OP amplitude compared with fellow control eyes, and delayed the change in recovery phase by approximately 5 min. Inhibition of all ionotropic glutamate receptors with CNQX/D-AP7 delayed both rising and recovery phases equally (approximately 12 ms) without altering b-wave width or the time course of adaptation changes. These outcomes suggest that inner retinal light responses are not directly responsible for b-wave amplitude growth, but may contribute to the change in its recovery phase during adaptation. A TTX-sensitive mechanism may help to hasten this process. The cone a-wave was isolated using PDA/L-AP4 or CNQX/L-AP4. A-wave amplitude (35 ms after stimulus onset) also increased with time during light adaptation and reached a maximum (130 +/- 29% above baseline) 12-15 min after background onset. B-wave amplitude growth in fellow control eyes closely followed the course and relative magnitude of cone a-wave amplitude growth. Hence, the increase of the cone response during light adaptation is sufficient to explain b-wave amplitude growth.

2-Amino-5-phosphonovalerate↗
PubMed1998

Influence of light physical activity on cardiac responses during recovery from exercise in humans.

To examine the influence of light exercise on cardiac responses during recovery from exercise, we measured heart rate (HR), stroke volume (SV), and cardiac output (Qc) in five healthy untrained male subjects in an upright position before, during, and after 10-min steady-state cycle exercise at an exercise intensity of 170 W, corresponding to a mean of 68 (SD 4)% of maximal oxygen uptake. The recovery phase was evaluated separately for three different conditions: 10 min of complete rest (passive recovery), 7 min of pedalling at 20-W exercise intensity followed by 3 min of rest (partially active recovery), and 7 min of pedalling at 40-W exercise intensity followed by 3 min of rest (partially active recovery), on an upright cycle ergometer. The time courses of decreases in HR in the two active recovery phases at different exercise intensities were almost identical to those in the passive recovery phase. However, the subsequent HR reductions during the rest after active recovery at 20 W and at 40 W were mean 7.5 (SD 4.4) and mean 10.0 (SD 3.1) beats x min(-1), respectively, both of which were significantly larger (P < 0.05 and P< 0.005) than the corresponding reduction [1.4 (SD 2.5) beats min(-1)] for passive recovery. The SV values at the two exercise intensities during the active recovery periods were maintained at levels similar to that during 170-W steady-state exercise. In contrast, the SV during passive recovery decreased gradually to a level significantly below the initial baseline level at rest before exercise (P < 0.05). The resultant time courses of CO values during active recovery were significantly higher (each P < 0.05) than that during passive recovery. It was concluded from these findings that light post-exercise physical activity plays an important role in facilitating the venous return from the muscles and in restoring the elevated HR to the pre-exercise resting level.

Adult↗
PubMed2002

Mechanism and treatment principle for cerebral vessel spasm caused by concussion.

OBJECTIVE: To discuss the mechanism of cerebral vessel spasm caused by concussion and the effect of Nimodipine on concussion. METHODS: A total of 224 patients who were treated from March 1995 to October 1999 were divided into two groups randomly, ie, Nimodipine group (113 cases) and control group (111 cases). Middle cerebral artery (MCA), basilar artery (BA) and the average peak forward velocity of cerebral blood flow were observed by color three-dimensional transcranial Doppler (3D-TCD) within 24 hours after admission and at the end of 3-6 days of treatment. Cerebral blood flow changes, characteristics and treatment effect were analyzed and determined by clinical main symptom disappearance rate. RESULTS: In concussion, cerebral blood flow was divided into 3 phases: cerebral blood flow low infusion dilation phase, cerebral blood vessel spasm phase and cerebral blood flow recovery phase. In the Nimodipine group, clinical main symptom disappearance rate was higher than that in the control group in the cerebral spasm and recovery phases with a significant difference (P < 0.01). CONCLUSIONS: Cerebral vessel spasm, hypoxia and ischemia lesion are the main pathological changes. Whether cerebral dysfunction is reversible or not is mainly determined by spasm time of cerebral blood vessel. Nimodipine has a good effect on releasing spasm and diminishing the cerebral blood flow velocity. It not only improves curative effect on concussion, but also reduces and prevents concussion sequelae. Hence, concussion patients who have cerebral spasm confirmed by 3D-TCD should be given Nimodipine routinely and early.

Adolescent↗
PubMed2003

Decision making in Greek and English registered nurses in coronary care units.

Clinical decision-making is an integral component of the role of the professional nurse. The aim of the study was to identify the quality of decision making of Greek and English coronary care nurses during the acute and recovery phases post-myocardial infarction (MI), and determine factors that best predict clinical decision-making in these two discrete groups of nurses. By identifying best practice from standard textbooks and expert practitioners, Clinical Decision-Making cards were developed and employed to explore nurse decision-making. A questionnaire (influencing factor questionnaire-IFQ) was also administered to determine which factors predicted quality nurse decision-making in the acute and recovery phase of post-MI patient care. The results showed that nurses in England made better quality clinical decisions in the recovery phase of MI than the Greek counterparts (p<0.001). Variables were identified which best-predicted decision-making. Interestingly, the main finding of this study was that English nurses had greater autonomy in the recovery phase and therefore made more clinical decisions concerning the patient psychosocial recovery than Greek nurses. Nurses perceived clinical experience as the strongest factor influencing decision-making.

Adult↗