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PubMed2006

Decreased activity of brush border membrane-bound digestive enzymes in small intestines from pigs experimentally infected with porcine epidemic diarrhea virus.

Brush border membrane-bound digestive enzymes such as disaccharidases (lactase, sucrase, and maltase), leucine aminopeptidase N, and alkaline phosphatase were measured in jejunum from pigs experimentally infected with porcine epidemic diarrhea virus (PEDV). Three piglets from the infected and control groups were euthanized by electrocution and subjected to necropsy at 24, 36, 48, 60, and 72 hours post-inoculation (hpi). The infection of PEDV to jejunum resulted in significant decreases in brush border membrane-bound digestive enzymes such as disaccharidases (lactase, sucrase, and maltase), leucine aminopeptidase N, and alkaline phosphatase. PEDV replication results in massive destruction of villous enterocytes leading to a marked reduction of intestinal epithelial surface and brush border membrane-bound digestive enzyme activity. Reduced enzymatic activity and villous atrophy in the small intestine is thought to result in a maldigestive and malabsorptive diarrhea.

Alkaline Phosphatase↗

PubMed2005

Unusual cases of human myiasis due to Old World screwworm fly acquired indoors in Hong Kong.

Myiasis is the infestation of tissue by the larvae of flies. We report eight cases of human myiasis in Hong Kong. All patients were nursing home residents with an average age of 81.8 years. Seven patients were bedridden with advanced dementia. Four patients had pre-existing wounds. Five had poor oral hygiene and four of those were on tube feeding. All of the five patients with poor oral hygiene suffered from oral myiasis. Two patients had vaginal infestations and one had wound myiasis in his diabetic foot ulcer. Seven cases were infested by Chrysomya bezziana, an obligatory parasite that requires living mammalian tissue for its larval development. Larvae of the Calliphoridae family were responsible for the remaining case. Patients were managed with manual removal of larvae and irrigation of the site of infestation with saline. All infestations were nosocomial, being acquired in nursing homes. Carers of the old and debilitated should be made aware of the need for better oral care, especially for those on tube feeding. The use of window screens in nursing homes should be encouraged to reduce the chance of flies entering the vicinity of these patients. Electrocuters could also be mounted indoors to kill flies that do enter.

Aged↗

PubMed2006

Development of treated targets for controlling stable flies (Diptera: Muscidae).

Electrocution techniques were used to determine if treated targets similar to those used for tsetse control could be developed for stable fly control. In a series of two experiments, a half blue and half black (UK) 1 m2 target constructed of trigger cotton poplin was determined to be acceptable for development studies. In the first experiment, an average of 350 stable flies per hour (maximum 794 flies in 1 h) was collected using the UK target. A time-delayed circuit trial using untreated UK targets demonstrated that stable flies remained on or around the targets for at least 30 s. Two experiments were conducted with time-delayed circuits and UK targets treated with 0.1% lambda-cyhalothrin. In the first experiment, the number of flies collected using the 30 s on/off treated target treatment was not different from the number of flies collected using the other treatments. In the second experiment, the number of flies collected using the 30 s on/off treated target treatment was not different than the untreated target continuous or 30 s on/off treatments, but was significantly lower than the treated target continuous treatment. The number of flies collected with UK trigger targets was significantly higher than that for alsynite cylinder traps in two experiments. The mean number of flies collected during 22 1h assays using targets was 6.1-fold higher than that for alsynite traps, and the mean number of flies collected during 40 3 h using the targets also was 6.1-fold higher than that for alsynite traps. The results of this study indicate that treated cloth targets may be a viable addition for stable fly control programs.

Animals↗

PubMed1997

Farm-related injury mortality in New Mexico, 1980-91.

To compare the epidemiology of farm with non-farm occupational injury deaths, we reviewed state medical examiner data for all occupational injury deaths in New Mexico from 1980 to 1991. We identified 53 farm-related injury deaths for a rate of 21.3 per 100,000 worker-years. Farm workers were four times more likely than non-farm workers to die from occupational injury. American Indians had the highest farm injury death rate. Farm decedents were older than non-farm decedents (t498 = 6.29, p < 0.0001). Half of the farm decedents were 50 years of age or older; one-third were 60 years of age or older. Crush injuries accounted for half of all farm injury deaths including 18 of 23 motor vehicle deaths, half of these involving a tractor rollover. One in six farm injury deaths were from electrocution: one in five involved alcohol. Our study indicates that New Mexico has high farm-related injury mortality related to tractor use, alcohol intoxication, farm animals, and exposure to electricity. American Indians and older males are especially susceptible to these factors.

Accidents, Occupational↗

PubMed1997

Motor vehicle fatalities in the United States construction industry.

A death certificate-based surveillance system was used to identify 2144 work-related motor vehicle fatalities among civilian workers in the United States construction industry over the years 1980-92. Construction workers were twice as likely to be killed by a motor vehicle as the average worker, with an annual crude mortality rate of 2.3/100,000 workers. Injury prevention efforts in construction have had limited effect on motor vehicle-related deaths, with death rates falling by only 11% during the 13-year period, compared with 43% for falls, 54% for electrocutions and 48% for machinery. In all industries combined, motor vehicle fatality rates dropped by 47%. The largest proportion of motor vehicle deaths (40%) occurred among pedestrians, with construction accounting for more than one-fourth of all pedestrian deaths. A minimum of 54 (6%) of these pedestrian fatalities were flaggers or surveyors. Flaggers accounted for half the 34 pedestrian fatalities among women, compared with only 3% among men. Along with previous studies and recent trends in the amount and type of road construction, these results underscore the need for better traffic control management in construction work areas to reduce pedestrian fatalities. As the second leading cause of traumatic death in construction, with an annual average share of 15% of the total deaths, exceeded only by falls, prevention of work-related motor vehicle research should become a greater priority in the construction industry.

Accidents, Occupational↗

PubMed1999

Occupational injuries in Shunde City--a county undergoing rapid economic change in southern China.

A survey was carried out in Shunde City of Southern China to look into the occurrence of occupational injuries in the 'township industries' during the years 1989-1993. A total of 981 major injuries and 159 fatal injuries were recorded for 602,533 person years over the 5 years, giving a major injury rate of 1.63/1000 per year and a fatal injury rate of 0.26/1000 per year. Both the major injury rate and the fatal injury rate increased from 1989 to 1993. Males had a higher fatal injury rate while females had a higher major injury rate. The majority of the injuries occurred in the younger age group with the 20-29 age group taking up more than half of the total casualties. Industries having high injury rates included building and construction, furniture, paper mill and printing. Electrical appliances manufacturing, sewing and shoe making were the industries having low injury rates. Enterprises with foreign capitals and those managed by individuals also had lower injury rates. Machinery injuries were the most common type of major injuries while electrocution, being hit by heavy objects and falling from height accounted for over 60% of fatal injuries. The implications of the differential distributions of the occurrence of the injures were discussed.

Accidents, Occupational↗

PubMed1991

Electroporation of cell membranes.

Electric pulses of intensity in kilovolts per centimeter and of duration in microseconds to milliseconds cause a temporary loss of the semipermeability of cell membranes, thus leading to ion leakage, escape of metabolites, and increased uptake by cells of drugs, molecular probes, and DNA. A generally accepted term describing this phenomenon is "electroporation." Other effects of a high-intensity electric field on cell membranes include membrane fusions, bleb formation, cell lysis... etc. Electroporation and its related phenomena reflect the basic bioelectrochemistry of cell membranes and are thus important for the study of membrane structure and function. These phenomena also occur in such events as electric injury, electrocution, and cardiac procedures involving electric shocks. Electroporation has found applications in: (a) introduction of plasmids or foreign DNA into living cells for gene transfections, (b) fusion of cells to prepare heterokaryons, hybridoma, hybrid embryos... etc., (c) insertion of proteins into cell membranes, (d) improving drug delivery and hence effectiveness in chemotherapy of cancerous cells, (e) constructing animal model by fusing human cells with animal tissues, (f) activation of membrane transporters and enzymes, and (g) alteration of genetic expression in living cells. A brief review of mechanistic studies of electroporation is given.

Animals↗

PubMed1991

Cell-attached patch clamp study of the electropermeabilization of amphibian cardiac cells.

Potential gradients imposed across cell or lipid membranes break down the insulating properties of these barriers if an intensity and time-dependent threshold is exceeded. Potential gradients of this magnitude may occur throughout the body, and in particular in cardiac tissue, during clinical defibrillation, ablation, and electrocution trauma. To study the dynamics of membrane electropermeabilization a cell-attached patch clamp technique was used to directly control the potential across membrane patches of single ventricular cells enzymatically isolated from frog (Rana pipiens) hearts. Ramp waveshapes were used to reveal rapid membrane conductance changes that may have otherwise been obscured using rectangular waveshapes. We observed a step increase (delta t less than 30 microseconds) or breakdown in membrane conductance at transmembrane potential thresholds of 0.6-1.1 V in response to 0.1-1.0 kV/s voltage ramps. Conductance kinetics on a sub-millisecond time scale indicate that breakdown is preceded by a period of instability during which the noise and amplitude of the membrane conductance begin to increase. In some cells membrane breakdown was observed to be fully reversible when using an intershock interval of 1 min (20-23 degrees C). These findings support energetic models of membrane electropermeabilization which describe the formation of membrane pores (or growth of existing pores) to a conducting state (instability), followed by a rapid expansion of these pores when the energy barrier for the formation of hydrophilic pores is overcome (breakdown).

Animals↗

PubMed2000

Prospective randomized study of transurethral vaporization resection of the prostate using the thick loop and standard transurethral prostatectomy.

OBJECTIVES: Transurethral vaporization resection of the prostate (TUVRP) is a recent modification of the standard transurethral prostatectomy (TURP). The procedure uses one of the novel, thick resection loops coupled to augmented electrocutting energy. We evaluated the safety and efficacy of TUVRP in comparison with TURP. METHODS: Sixty-eight patients with prostatic outflow obstruction were prospectively randomized between equal TUVRP and TURP treatment groups. Safety parameters evaluated included changes in serum hemoglobin, hematocrit, and sodium 1 and 24 hours after resection. Operative time, catheterization time, and incidence of complications were noted. Efficacy parameters included evaluation by the International Prostate Symptom Score and maximum flow rate. RESULTS: Patients of both groups were balanced for the different baseline variables. One hour after TURP, patients had significantly lower levels of hemoglobin, hematocrit, and sodium (P = 0.03, 0.03, and 0. 01, respectively). The prostate resection weight was similar in both groups; however, the difference in the mean operative time was significant (TUVRP group 42.4 minutes and TURP group 35.9 minutes, P = 0.02). The postoperative catheterization time was significantly shorter for the TUVRP group (23.1 +/- 10.3 versus 36 +/- 17.3 hours, P <0.0001). All patients were followed up for an average of 9 months. The International Prostate Symptom Score was 4 +/- 3.4 and 5.6 +/- 3.1 and the maximum flow rate was 19 +/- 6.5 and 15.2 +/- 10 mL/s for the TUVRP and TURP groups, respectively; these differences were statistically significant (P = 0.03 and 0.01, respectively). Complications included urethral strictures (6 patients) and delayed hemorrhage with clot retention (2 patients); no differences in the incidence of complications were noted between the two groups. CONCLUSIONS: The results of the present study have demonstrated that TUVRP is as safe and efficacious as TURP in the treatment of men with prostatic outflow obstruction. The shorter catheterization time observed after TUVRP may be clinically significant, considering the demand for lower morbidity profiles by patients. The longer operative time in TUVRP was related to the slower motion of the Wing electrode needed to add the advantages of electrovaporization.

Aged↗

PubMed1995

Effect of irrigating fluids and prostate tissue extracts on isolated cardiomyocytes.

OBJECTIVES: A higher mortality probably due to myocardial infarction has been demonstrated after transurethral resection of the prostate (TURP) compared with open prostatectomy. We used an experimental model system to study the possibility that this difference might be due to cardiotoxic effects of two events that frequently occur during TURP, namely, dissemination of electrolyte-free irrigating fluid and release of prostate tissue substances by electrocutting. METHODS: Cardiomyocytes were isolated from male Sprague-Dawley rats. Cell morphology and viability were examined repeatedly during 3 hours of incubation. Control experiments were compared with 34 preparations mixed with one of five different irrigating fluids and with 28 preparations mixed with a prostate extract, either from the same rat or from patients undergoing TURP. RESULTS: Most irrigating fluids reduced the viability of the myocytes. The fraction of viable cells in the incubation mixture averaged 83% (glycine 1.5%), 88% (glycine 1.5% plus ethanol 1%), 92% (glycine 2.2%), 92% (mannitol 3% plus ethanol 1%), and 99% (sorbitol 2% plus mannitol 1%) of that found in the respective control incubations. In contrast, the prostate extracts did not decrease the viability of the cardiomyocytes. Extract from the rats even seemed to have a trophic effect. CONCLUSIONS: Our results show that electrolyte-free irrigating fluids but not prostate extracts have mild cardiotoxic properties. This opens up the possibility that fluid absorption during TURP has a devitalizing effect on the heart.

Animals↗

PubMed1988

Comparison of CO2 laser and electrosurgery in the treatment of rhinophyma.

A number of surgical modalities, including the CO2 laser, have been advocated for the treatment of rhinophyma. The CO2 laser has been extensively promoted for the management of many skin lesions, including warts, keloids, and various nail problems. In many instances it has been suggested that the CO2 laser holds a distinct advantage over other surgical modalities. Three patients with rhinophyma are presented. Results are compared after treating one half of the nose with biterminal electrocutting current and the other half with the beam of the CO2 laser.

Electrosurgery↗

PubMed1998

Treatment of out-of-hospital cardiac arrest in Ljubljana: outcome report according to the 'Utstein' style.

We investigated survival of patients with out-of-hospital cardiac arrest in Ljubljana according to the 'Utstein' style. Ljubljana consists of urban, suburban and semi-rural communities which encompass an area of 1615 km2 with 397306 residents. The area is served by a single response emergency medical system and local family practitioners. Between January 1, 1995 and December 31, 1997 cardiac arrest was confirmed in 966 patients. Cardiopulmonary resuscitation was attempted in 454 patients (47%). Collapse of presumed cardiac etiology (337 patients) was either bystander-witnessed (89%), un-witnessed (9%) or EMS personnel-witnessed (2%). Asystole was documented in 55%, ventricular fibrillation or tachycardia in 36% and other non-perfusing rhythms in 9% of these patients. Lay-bystander basic life support was performed in 19%. Nineteen patients (5.6%) survived to hospital discharge and 12 of them were independent in daily life. The survival of subgroups with bystanders-witnessed collapse and bystanders-witnessed ventricular fibrillation was 6.4 and 13%, respectively. Collapse of non-cardiac etiology (117 patients) was preceded by either respiratory failure (41), politrauma (22), circulatory shock (19), cerebrovascular incident (ten), intoxication (nine), strangulation (seven), electrocution (five) or drowning (four patients). Only five patients (4.2%) survived to hospital discharge. Hospital treatment of patients after successful initial cardiopulmonary resuscitation was associated with high mortality and required considerable resources.

Activities of Daily Living↗

PubMed2002

Management of the burned trauma patient: balancing conflicting priorities.

PURPOSE: Approximately 5% of multiple trauma patients sustain concomitant burns. Complicated management issues arise in these patients as burn and trauma care often conflict. This study reviews 53 consecutive burned multiple trauma patients in order to examine common management conflicts and recommend appropriate compromises in caring for these difficult patients. PROCEDURE: A retrospective review of 53 consecutive burn patients with coincident trauma admitted to The Massachusetts General Hospital (MGH) from 1993-2001 was performed. FINDINGS: In the study period, 53 patients were admitted to the Massachusetts General Hospital with concomitant burns and trauma. Of this group, 42 (79%) were male. Average age was 31.5 +/- 15.0. Mechanisms included 11 motor vehicle collisions (MVC), 10 explosions, 10 electrocutions with subsequent falls, nine house fires, four motorcycle collisions (MCC), three pedestrian versus car accidents, two falls into fires, two plane crashes, and one each of a lawnmower accident and a patient drawn into a machine. Average burn size was 25.4% +/- 22.4. The most common traumatic injury was fracture (52). Management of fractures in burn patients and resuscitation in head injured burn patient represented the most common conflicts in patient care. There were five deaths (9.4%) in this series. CONCLUSIONS: Burns are a rare but significant complication in the trauma patient. Outcomes are dependent on rapid trauma evaluation as well as effective resuscitation and wound management. Given the complexities of their problems, these patients necessitate a balanced multidisciplinary approach to maximize their potential for full recovery. Thoughtful compromise between trauma and burn priorities is frequently necessary.

Adolescent↗

PubMed2000

A sandwich enzyme immunoassay for pulmonary surfactant protein D and measurement of its blood levels in drowning victims.

A sensitive sandwich enzyme immunoassay for human pulmonary surfactant protein D (SP-D) was developed and used to examine the blood SP-D levels of drowning victims. Human SP-D was purified from amniotic fluid by chromatographic methods, and an antibody against human SP-D was prepared. A polystyrene ball coated with anti-SP-D IgG was incubated with purified human SP-D, and then with anti-SP-D Fab'-peroxidase conjugate. Peroxidase activity bound to the polystyrene ball was assayed by fluorometry using 3-(4-hydroxyphenyl)propionic acid as the hydrogen donor. The detection limit of human SP-D was 5.2 pg per assay tube. Examination of cross-reactions of this sandwich enzyme immunoassay with proteins from other human organs showed it to be highly specific for lung, and Northern blot analysis detected specific SP-D mRNA expression only in lung. The SP-D concentration of normal human serum was 6.4+/-2.7 (mean+/-S.D.) ng ml(-1) (n=20). The recovery rates of 0.52 ng and 5.2 ng SP-D added to 5 microl normal human serum were 93.6+/-2.7% and 93.6+/-6.1%, respectively. Blood SP-D levels of victims from the saltwater drowning group (n=14) revealed higher concentrations (105.8+/-53.7 ng ml(-1)), while freshwater drowning victims (n=12) were estimated to be 74.1+/-43.9 ng ml(-1). The SP-D levels of 15 subjects who died of hemorrhage (n=5), heart failure (n=8), traumatic shock (n=1), and electrocution (n=1) were lower (22.0+/-8.5 ng ml(-1)), and those of asphyxia victims (n=10) were slightly higher (36.2+/-17.1 ng ml(-1)) than those of other causes of death, except for drowning. These results suggest that in drowning victims, SP-D flowed into the systemic circulation by physiological and physical mechanisms, and the differences of blood SP-D levels between saltwater drowning and freshwater drowning victims are presumed to be influenced by the type of agony and/or the length of survival time in water.

Adolescent↗

PubMed1985

Ventricular fibrillation.

Ventricular fibrillation is the most common mechanism of sudden unexpected cardiac death in persons with asymptomatic or symptomatic coronary artery disease. The electrophysiologic mechanisms reviewed in this article include: automaticity of pacemaker fibers, transformation of nonpacemaker into pacemaker fibers, "injury" currents and reentry. Some of the conditions facilitating ventricular fibrillation include bradycardia, long QT syndrome, electrocution, electrolyte imbalance, drugs, sympathetic stimulation and myocardial ischemia. Electrophysiologic studies during acute myocardial ischemia suggest that the earliest activity at the onset of arrhythmia may originate at the sites of the surviving Purkinje fibers or at the epicardial rim. Reentrant arrhythmias arising in ischemic myocardium are attributed to nonhomogeneous distribution of local hyperkalemia and acidosis.

Anti-Arrhythmia Agents↗

PubMed1996

Upper dorsal thoracoscopic sympathectomy for palmar hyperhidrosis: improved intermediate-term results.

PURPOSE: The purpose of this study was to examine the immediate and mid-term results of thoracoscopic upper dorsal (T2-T3) sympathectomy for primary palmar hyperhidrosis. METHODS: From June 1993 to October 1994 we performed 106 sympathectomies on 53 patients with palmar hyperhidrosis. Thirty-four female patients and 19 male patients ranging in age from 15 to 44 years, (mean 23.1 years) were studied. Both sides were operated during the same surgical procedure. The T2-T3 ganglia were resected by electrocuting with a hook and were removed for histologic examination. Follow-up for a mean of 19.25 months was obtained on 52 patients (104 operated limbs). RESULTS: All limbs were completely dry at the end of the procedure, and hyperhidrosis did not recur during the whole follow-up period. Short-term postoperative complications (mainly atelectasis, pneumonia, pneumothorax, and hemothorax) occurred in six (11.3%) patients. Long-term sequelae were observed in 43 (81.1%) patients and included Horner's syndrome (9 patients, 17.3%, one side only in each patient), neuralgia (7 patients, 13.5%), and compensatory hyperhidrosis (35 patients, 67.3%). These sequelae were not permanent in all cases, and the degree of severity was variable. Six (11.5%) patients, three of whom regretted being operated, were dissatisfied with their results: one because of Horner's syndrome, one because of persisting neuralgia, and four because of compensatory sweating. CONCLUSIONS: Despite the large number of postoperative long-term sequelae, 88.5% of patients expressed subjective satisfaction from the procedure. Obtaining 100% of dry hands on mid-term follow-up makes this approach rewarding.

Adolescent↗

PubMed2003

Spectrum of left ventricular dysfunction in potential pediatric heart transplant donors.

BACKGROUND: Although myocardial dysfunction severe enough to preclude harvest for transplantation has been reported in approximately 20% of potential adult organ donors, the incidence of myocardial dysfunction in the pediatric population has not been studied systematically. Therefore, the purpose of this study was to determine the spectrum of myocardial dysfunction in potential pediatric heart transplant donors. METHODS: We reviewed the pediatric cardiology database at Primary Children's Medical Center to identify all children who had screening echocardiograms for potential organ donation. We reviewed charts for patient age and size, cause of brain death, and type of pharmacologic support. Echocardiograms were reviewed retrospectively for left ventricular systolic function (shortening or ejection fraction), wall motion abnormalities, diastolic function (mitral E/A ratio), Tei index, and mitral regurgitation. RESULTS: We identified 23 potential donors (age, 6.7 +/- 4.4 years; range, 5 days to 15 years). All patients were receiving pharmacologic support. We found systolic left ventricular dysfunction, defined as an ejection fraction <50% or a shortening fraction <28%, in 57% (13/23) of the patients. We found mitral regurgitation in 85% (11/13) of the patients with systolic dysfunction and in zero of 10 with normal ejection phase indices. Diastolic dysfunction (mitral E/A reversal) was found in 45% (6/13) of those with systolic dysfunction and in 60% (6/10) of patients with normal systolic ejection phase indices. The Tei index was abnormal in 8 of 13 patients with left ventricular systolic dysfunction (range, 0.5-1.4), and was normal in the 6 patients with isolated diastolic dysfunction. One patient, who was electrocuted, had regional wall motion abnormalities. Of the 23 potential donors, 19 (87%) had evidence of systolic or diastolic dysfunction. A total of 13 hearts (3 with normal systolic function, 4 with systolic dysfunction, and 6 with isolated diastolic dysfunction) were harvested for transplantation. CONCLUSIONS: Left ventricular systolic and diastolic dysfunctions are common findings in potential pediatric organ donors. Despite this, previous studies have shown that some of these hearts can be transplanted successfully. We speculate that some of the abnormalities occur as a physiologic consequence of brain death and, thus, may be reversible after transplantation. To avoid wasting a valuable, limited resource, further study is needed to identify the donors suitable for pediatric heart transplantation.

Adolescent↗

PubMed2000

Changes of serum prostate-specific antigen following high energy thick loop prostatectomy.

We evaluated the effect of the high electrocuting energy used with the thick loop, in transurethral vaporization resection of the prostate (TUVRP), on serum prostate-specific antigen (PSA). Forty-eight patients with benign protatic hyperplasia (BPH) were included in this prospective single arm sequential study. All patients had TUVRP using the 'Wing' thick resection electrode (Richard Wolf, Germany). Serum PSA was measured before, 1 day and 6 weeks in the morning post TUVRP. PSA values were correlated to preoperative prostate size and to prostatic resection weight. Serum PSA values (mean +/- SD) were 6.29+/-4.4 ng/ml, 14.9+/-11.1 and 2.3+/-1.9 before, 1 day and 6 weeks post TUVRP respectively. The mean increase in the PSA at 1 day over baseline value was 2.72, this was statistically significant (p < or = 0.0001). The PSA level returned to less than pre TUVRP value in all but 3 patients by 6 weeks. The PSA value 1 day post TUVRP correlated well with the pre PSA level, prostate size and prostatic resection weight (r = 0.58, r = 0.38 and r = 0.44 respectively) however, the PSA level at 6 weeks correlated only to pre TUVRP values (r = 0.53). We conclude that that serum PSA is not reliable within 6 weeks of TUVRP. The reversible increase in serum PSA value is similar to other forms of prostatectomy which, suggests that the increased level of electrosurgical energy that is used in TUVRP does not have an added adverse effect on the PSA levels.

Aged↗