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PubMed1989

Specialized metaplastic columnar epithelium in Barrett's esophagus. A comparative transmission electron microscopic study.

Barrett's esophagus develops as a complication of regurgitant esophagitis and predisposes patients to the development of dysplasia and esophageal adenocarcinoma. Prior ultrastructural studies have suggested that Barrett's epithelium is a mucous secretory epithelium that shares some morphologic features with the intestine. The origin and development of Barrett's epithelium and the cellular abnormalities accompanying its neoplastic progression are poorly understood. In an attempt to better understand the histogenesis of the mucus-producing cells that predominate in Barrett's epithelium, these cells were studied by transmission electron microscopy and compared with other upper gastrointestinal epithelia: esophageal glands, normal gastric surface, pit, and cardiac gland regions, gastric intestinal metaplasia, and normal jejunal villous tip and crypt regions. A total of 134 mucosal biopsies from the stomach and esophagus of 28 patients with Barrett's esophagus and 37 biopsies from 14 other control patients were studied. Barrett's specialized metaplastic surface cells display a spectrum of ultrastructural features among three main surface columnar epithelial cell types: mucous cells resembling those seen in the normal gastric surface epithelium or resembling mucous neck cells normally seen in the gastric pits; goblet cells similar to those seen in the jejunum; and "pseudoabsorptive" cells with features of both gastric mucous secretory cells and jejunal absorptive cells. Cytoplasmic organelles of Barrett's specialized metaplastic, normal gastric mucous neck, and normal gastric surface mucous epithelial cells, including rough endoplasmic reticulum, glycogen aggregates, Golgi apparatus, and mucous secretory granules, have common ultrastructural features associated with mucus synthesis. The morphologic heterogeneity of Barrett's specialized metaplastic cells and common ultrastructural features associated with normal mucus biosynthesis suggest that they develop from a gastrointestinal stem cell that retains the capacity for a wide range of normal and abnormal differentiation in the esophagus. The identity of this undifferentiated cell, which may reside in normal proximal gastric or esophageal mucosa, remains unknown. However, the gastric mucous neck cell has properties that suggest it could be the progenitor cell for Barrett's esophagus because it is a stem cell that has ultrastructural similarities to Barrett's specialized metaplastic epithelial cells and it is located in intact gastric mucosa adjacent to where Barrett's esophagus forms.

Adult↗
PubMed1988

Emotions and hemispheric specialization.

Studies of lateralization and specialization of brain function have increased our understanding of emotional processes in the brain. It has been said that the way in which we understand the emotional interrelatedness of brain layers and segments may have important effects on human society. Earlier studies of brain function, especially of limbic effects, suggested a dichotomous state of affairs between the phylogenetically older brain and the newer cortical areas--between affect and cognition. Such concepts are considered here in the light of specialization studies. From the beginning hemispheric laterality research has implicated emotionality and emotional pathology. It also appears that some limbic functions may be mediated in a lateralized fashion. Neuropsychologists have directed much work toward localization of function from its earliest stage; since the 1960s an emphasis has been on "mapping" of cortical functions in terms of psychopathologic disabilities. Various disability groups have been studied in this way, and it may be concluded that neuropsychologic measures are sensitive to changes in cerebral functioning and may have effective lateralizing and localizing ability under specified conditions. Studies of limbic effects in the brain emphasize their importance in emotional behavior but also their interrelatedness with other structures, for example, the frontal and temporal lobes, and particularly the right hemisphere. Studies of commissurotomy (split-brain) patients tend to bear out these relationships. In split-brain subjects the marked reduction in affective verbal and nonverbal behavior reflects the interruption of transcallosal impulses that normally permit emotional infusion of cortical structures to take place. These effects include verbal, visual, and auditory patterns that mediate the ability to decode complex nonverbal patterns and may result in a reduction of "inner speech," that is, symbollexia. They may further lead to a condition of "functional commissurotomy" in psychiatric patients with presumably intact brains. It would also appear that lateralization may be variable in terms of inhibitory and facilitative effects; emotional factors may play a part in this variability in some clinical cases in which functional or reactive features predominate, for example, in alexithymia. Ideas of hemispheric specialization have been extended to other areas of individual and social behavior. Creative ability has been understood by some authors to be a product of the relatively dynamic relationships existing between specialized areas of the brain.(ABSTRACT TRUNCATED AT 400 WORDS)

Affective Symptoms↗
PubMed1988

Survey of special practices associated with College of American Pathologists proficiency testing in the Commonwealth of Pennsylvania.

A questionnaire concerned with special practices associated with proficiency testing was sent to the Chemistry Supervisor, Hematology Supervisor, and Chief Pathologist of 190 Pennsylvania hospital laboratories. Responses were received from 156 hospitals (82.1%) and included responses from 131 chemistry supervisors, 108 hematology supervisors, and 92 chief pathologists. The vast majority of respondents (85% to 95%) indicated moderate to great pressure to score acceptably. The survey showed a high prevalence of special practices, including analysis of controls just prior to survey specimens (23% to 42%), analysis in duplicate on a single instrument (52% to 88%), analysis on more than one instrument (17% to 31%), analysis on two or more separate days (20% to 39%), and delay of testing until an instrument is "working better" (24% to 34%). Approximately 63% of chemistry results and 72% of hematology results are reported as averages or medians. Pathologists consistently reported a lower prevalence of special practices than did laboratory supervisors. These high prevalences of special practices associated with proficiency testing specimens have important implications for proficiency testing programs.

Academies and Institutes↗
PubMed1985

[Special artificial respiration procedures and intracranial pressure. Animal experiment studies, development and use of a new pressure measuring technic, clinical aspects].

We investigated the influence of Forced Diffusion Ventilation (FDV), a special form of High Frequency Ventilation (HFV), on elevated intracranial pressure (ICP) in 5 dogs. Elevation of ICP was standardized by inflation of an epidural balloon. A typical finding with FDV is a reduced intrapleural pressure and therefore one could expect a better cerebrovenous drainage influencing ICP. Nevertheless, we found no changes in mean ICP under conditions of FDV compared with IPPV. Respirator-synchronous fluctuations of ICP, cisternal cerebrospinal fluid pressure and intrapleural pressure were drastically reduced with FDV. This phenomenon has been already reported by other groups as a typical effect of HFV with rates of 100/min. One can speculate, that this immediate impact of HFV on ICP-curves might be of some advantage in patients with critically reduced intracranial compliance requiring long-term artificial ventilation, because peaks and amplitudes of ICP are reduced. Our clinical experience with High Frequency Pulsation (HFP) includes 11 patients with severe brain trauma. In clinical routine this method of HFV is more facile to applicate than FDV, because there is no need of a special endotracheal tube and sufficient CO2-elimination is not strongly dependent on precise position of the tube. But HFP, as FDV, includes all advantages of respiratory systems, that are open against atmosphere (coughing and simultaneous breathing, without drastically increasing airway pressure, suction during respiration, etc.). However, we could find no special advantages or disadvantages in ICP-course during long-term application of HFP (up to 10 days). Because application of HFV is dependent on special technical equipment, we investigated in 6 patients the influence of respiratory frequency, tidal volume and inspiratory flow on ICP-fluctuations using conventional ventilators. ICP was recorded by a new, self constructed pneumatic epidural pressure sensor. Ventilator-related ICP-fluctuations were found to be markedly reduced at frequencies of 20/min and usually eliminated at 30/min. We found an exponential correlation between ICP-fluctuations and respiratory frequency and there was no correlation between tidal volume and ICP. Central venous pressure amplitudes were found to be in linear correlation with respiratory frequency and tidal volumes as well. The amplitude of respiratory ICP-fluctuations seems to be more dependent on duration of expiratory time. As our findings demonstrate, artificial ventilation without entilator-related fluctuations in ICP ("brain-protective" ventilation) may be performed by conventional volume-constant, time-cycled ventilators.(ABSTRACT TRUNCATED AT 400 WORDS)

Adult↗
PubMed1986

A randomized trial of special packaging of antihypertensive medications.

This article reports a randomized controlled trial designed to test the effects of special packaging of antihypertensive medication on compliance and blood pressure control. One hundred eighty subjects who had exhibited elevated blood pressure greater than 90 mmHg in the two years prior to the study were recruited from patients receiving care at a community hospital-based family medicine practice. After completing preenrollment interviews and blood pressure measurements, subjects were randomly assigned to receive their antihypertensive medications either in the usual vials or in special unit dose-reminder packaging. Follow-up interviews, pill counts, and blood pressure measurements were performed at three-month intervals. There were no statistically significant differences between the control and experimental groups with regard to age, sex, race, employment, education, marital status, insurance coverage, or blood pressure regimens. Prior to the intervention, the experimental group had slightly lower diastolic blood pressure and reported better compliance than the control group. Analyses performed on 165 subjects completing the first follow-up visit revealed no significant improvements in blood pressure control or compliance for patients receiving special medication packaging. While some patients found it easy to remember to take pills packaged using this format, they also found the packages somewhat more difficult and inconvenient to use. In contrast to previously reported work, this study did not demonstrate any significant improvement in compliance with special packaging of antihypertensive medications.

Adult↗
PubMed1974

Educating Hungarian medical librarians in special literature.

In Hungary the completion of a thirty-month course is required of those who wish to qualify as medium-level librarians. Medical librarians are given a special course which differs from the general course in that it covers the subjects of medical terminology and information in special literature. The latter subject is accorded the highest number of teaching hours, since the subject matter is vast and since, in addition to theory, much time must be spent on exercises and the presentation of reference books. The students become familiar with the main Hungarian and foreign information systems in the medical and related fields and with special bibliographies, encyclopedias, handbooks, and dictionaries. We take special care to familiarize students with the abstracting journals and indices. For several semesters they have homework and lesson exercises in the use of the Hungarian Medical Bibliography and Index Medicus.

Education, Graduate↗
PubMed1970

A socio-epidemiological study of out-patients attending a city tuberculosis clinic in India to judge the place of specialized centres in a tuberculosis control programme.

In India, specialized tuberculosis clinics exist mostly in cities. These clinics treat mainly persons with an awareness of symptoms who present themselves of their own accord. The few persons without symptoms are those who have been advised to have an examination. The urge to attend a specialized centre, presumably motivated by suffering or discomfort from symptoms and by awareness that specialized services exist, does not appear to be strong enough to overcome all the "obstacles" that lie between the patient and the tuberculosis clinic. A distance of 4 miles (6.4 km) or more is a major obstacle, irrespective of where the town limits lie. The socio-economic value of the patient to his family also appears to influence attendance. There is evidence that most patients first approach treatment sources, without regard to the nature of the service, whether specialized or general. It has been observed that if the quality of service rendered by a centre is unsatisfactory, the patient may constantly search for "better" treatment. Social considerations, other than suffering, which influence attendance could be termed "social preference". The justification for strengthening general health institutions (with adequate means for the diagnosis and treatment of tuberculosis), without taking urban or rural factors into consideration, is discussed in the light of the findings of this study.

Adolescent↗
PubMed1980

[Reaction time experiment on absolute or relative functional specialization of the cerebral hemispheres in man].

Lateralized presentations of verbal stimuli yield faster reaction times in the right visual field-left hemisphere, whereas nonverbal stimuli yield faster reaction times in the left visual field-right hemisphere. However, the problem of how lateral asymmetries in response latency are determined is still unsolved. The hypothesis of an absolute functional specialization of the two hemispheres suggests that information presented in the visual field connected with the unspecialized hemisphere has to travel along a less direct pathway, implying a crossing through the forebrain commissures, to reach the processing center. The hypothesis of a relative functional specialization assumes that stimuli are processed by the hemisphere contralateral to the field of presentation but speed of processing varies as a function of hemispheric specialization. The present study tried to find empirical evidence in favor of one of the two hypotheses. Choice reaction times to lateralized verbal stimuli were studied in normal subjects. In half of the trials the subjects had to carry out a concomitant task known to interfere selectively with mechanisms responsible of the organization of the responses of the left hemisphere. Both with and without concomitant task reaction times were significantly faster in the right visual field-left hemisphere. While the concomitant task produced an overall lengthening of reaction time, it did not affect interhemispheric asymmetry. This finding was discussed as evidence in favor of the absolute specialization hypothesis.

Acoustic Stimulation↗
PubMed1995

[Special complications of cholecystectomy performed by micro- and modern mini-laparotomy].

There is no data on the special complications of micro (less than 4 cm incision) and modern mini laparotomy cholecystectomies (4.1-6 cm incision). Out of 710 non selected patients, 643 micro laparotomy cholecystectomies were performed and 61 modern mini laparotomies due to choledocholithiasis. On three occasions, conventional mini (6.1-10 cm) laparotomy was performed and in another three, conventional laparotomy (over 10 cm incision) was executed. Intraoperative bleeding was encountered in 15 cases (2.1%) while accidental hepatic duct clipping occurred in one case (0.1%). Damage to the bile duct did not occur in any case reported. Postoperative bleeding was reported in 8 cases (1.1%) and delayed bile leakage was reported in 10 cases (1.4%). Special complications reported as a result of pathological alteration in the bile tract as follows: Intraoperative bleeding encountered during simple cholecystectomy-1% but cholecystectomy due to obstructive cholecystitis 3.8%, also caused by intraoperative bleeding. Delayed bile leakage in simple cholecystectomy was not observed, but after cholecystectomy for obstructive cholecystitis it encountered in 3.4%. Special complications resulted in four early reoperations (0.5%). Two other patients were re-operated within three weeks, independent of special complications. The percentage of both intra and postoperative complication was significantly higher in obstructive cholecystitis with an operative delay of 11 or more days.

Adolescent↗
PubMed1995

Parent perspectives of peer relationships and friendships in integrated and specialized programs.

In-depth interviews of a large community-based sample of mothers of preschool-age children with established disabilities and those classified as at-risk were conducted focusing on issues of children's peer relations and friendships. Results revealed that mothers of children enrolled in both integrated and specialized programs perceived their respective settings as valuable for the development of their child's peer relations and friendships. Mothers of children in integrated settings reported that their child played better and was more social due to the participation of children without special needs. A similar pattern was obtained for mothers of children enrolled in specialized programs in response to a hypothetical situation. Nevertheless, both groups of mothers were clearly concerned about peer rejection and noted the importance of having other children with special needs in the program available as a means of promoting tolerance and acceptance.

Attitude↗
PubMed1995

The hospital information system as a source for the planning and feed-back of specialized health care.

1. INTRODUCTION. In university hospitals, choices are made to which extend specialized health care will be supported. It is characteristic, for this type of care, that it takes place in a process of the continual advance of medical technology and the growing awareness by consumers and payors. Specialized healthcare contributes to the hospital qualifiers having a political and strategic impact. The hospital board needs information for planning and budgeting these new tasks. Much of the information will be based on data stored in the Hospital Information System (HIS). Due to load limitations, instant retrieval is not preferred. A separate executive information system, uploaded with HIS data, features statistics, on a corporate level, with the power to drill-down to detailed levels. However, the ability to supply information on new types of healthcare is limited since most of these topics require a flexible system for new dedicated cross-sections, like medical treatment from several specialisms and functional levels. 2. DATA RETRIEVAL AND DISTRIBUTION. During the information analysis, details were gathered on the necessary working procedures and the administrative organization, including the data registration in the HIS. In the next phase, all relevant data was organized in a relational datamodel. For each topic of care, dedicated views were developed at both low and high aggregation levels. It revealed that a matching change of the administrative organization was required, with an emphasis on financial registration aspects. For the selection of relevant data, a bottom-up approach was applied, which was based on the registrations starting from the patient administrative subsystem, through several transactional systems, ending at the general ledger in the HIS. Data on all levels was gathered, resulting in medical details presented in quantities, up to financial figures expressed in amounts of money. This procedure distinguishes from the predefined top-down techniques generally used for management and executive information systems. Data was regularly collected from the HIS, then converted and reorganized into relational datasets using XBase protocols. After having performed central quality controls and privacy protection measures, the datasets were distributed electronically to local PCs. Standard low-cost software packages enable analyses by user-friendly selection and presentation facilities. 3. EVALUATION. The method developed for data retrieval is flexible and easy to implement. If all basic data is registered in the HIS, the procedure can be applied for all strategic hospital functions that require planning and controlling during a certain time. Critical success factors and pitfalls will be presented in the poster. Using one consistent dataset, the information required about production and budget is presented at several functional levels and is quantified in units familiar to that level. The motivation for fast and accurate registration in the HIS was improved from the moment the medical and administrative staff recognized their own data in the feed-back on specialized health care.

Decision Making, Organizational↗
PubMed1996

[Special treatment methods in general practice--legal medicine viewpoint].

There is only one common medical law which is valid for all physicians. No therapy method can claim a special status or special rights. However, due to the considerable differences in training and qualification, the jurisdiction grants special rights to a healer without medical exam (non-medical practitioner) in comparison to a physician. Additionally, a physician has to take into account the limitations by the social legislation when he uses "special treatment methods" to avoid claims for compensation.

Complementary Therapies↗
PubMedDate not supplied

[The lead concentration in the converted and special-formula milks used in infant feeding].

In the last years a strict correlation between chronic exposure to low lead doses and neuropsychological impairment in first childhood is often reported in literature. The authors have measured and than compared the lead content of milk-based formulas, of special-formulas (hypoallergenic-protein formulas, lactose-free formulas, proteic-hydrolysate formulas) and soya formulas. 20 samples of milk-based formula, have been measured along with, 22 samples of special formula and 14 samples of soya formula. Lead mean concentration in milk-based formula was 73 +/- 139.11 microgr./l, whereas 23.95 +/- 13.76 microgr./l and 22.57 +/- 13.42 were measured in special formula and soya formula respectively. These results were compared with Student t-test and no significative difference was found. Lead mean concentration of milk-based formula was higher than that of special formula or soya formula. The authors hope milk-formula industry to have a more specific control on lead milk content for children feeding. In order to avoid possible toxic injuries in little infants, industry should certainly pay more attention both in supplying and in technological management of milk.

Animals↗
PubMed1996

[Placebo-controlled double-blind study of the effectiveness of Ginkgo biloba special extract EGb 761 in trained patients with intermittent claudication].

This monocenter, randomized, placebo-controlled double-blind study with parallel-group comparison was carried out in order to demonstrate the efficacy of Ginkgo biloba special extract EGb 761 on objective and subjective parameters of the walking performance in trained patients suffering from peripheral arterial occlusive disease in Fontaine stage IIb. In total 60 patients were recruited (42 men; aged 47-82 years) with angiographically proven peripheral arterial occlusive disease of the lower extremities and an intermittent claudication existing for at least 6 months. No improvement had been shown despite consistent walking training and a maximum pain-free walking distance on the treadmill of less than 150 m was recorded at the beginning of the study. The therapeutic groups were treated with either Ginkgo biloba special extract EGb 761 at a dose of 3 times 1 film-coated tablet of 40 mg per day by oral route or placebo over a duration of 24 weeks following a two-week placebo run-in phase. The main outcome measure was the difference of the walking distance between the start of treatment and after 8, 16 and 24 weeks of treatment as measured on the treadmill (walking speed 3 km/h and slope of 12%). As secondary parameters the corresponding differences for the maximum walking distance, the relative increase of the pain-free walking distance, the Doppler index and the subjective evaluation of the patients were analyzed. The absolute changes in the pain-free walking distance in treatment weeks 8, 16 and 24 as against the treatment beginning (median values with 95% confidence interval) led to the following values for the patients treated with Ginkgo biloba special extract EGb 761:19 m (14, 33), 34 m (18, 50) and 41 m (26, 64). The corresponding values in the placebo group were as follows: 7 m (-4, 12), 12 m (5, 22) and 8 m (-1, 21). The advantage of the EGb 761-treated group as compared to the placebo group could be verified statistically at the 3 time points with p < 0.0001, p = 0.0003 and p < 0.0001. The test for the presence of a clinically relevant difference of 20% between EGb 761 and placebo also produced a statistically significant result (p = 0.008). The Doppler index remained unchanged in both therapeutic groups: A corresponding statistically significant advantage for the EGb 761 group was observed on a descriptive level for the other parameters tested. The tolerance of the treatment was very good. The results of this placebo-controlled study show that treatment with Ginkgo biloba special extract EGb 761 produces a statistically highly significant and clinically relevant improvement of the walking performance in trained patients suffering from intermittent claudication with very good tolerance of the study preparation.

Aged↗
PubMed1997

Referral to specialized geriatric services. Which elderly people living in the community are likely to benefit?

PROBLEM BEING ADDRESSED: As the Canadian population ages, family physicians encounter increasing numbers of elderly people with medical, functional, psychological, and social difficulties. In the past two decades, most regions of Canada have developed systems of specialized geriatric services, available on a consultative basis, to assist family physicians evaluating and managing elderly patients with these difficulties. For many family physicians, however, it is often unclear which of their elderly patients are likely to benefit from referral to these geriatric services. OBJECTIVE OF PROGRAM: Using an interdisciplinary approach, specialized geriatric services seek to optimize health, maximize function, promote independence, and prevent or delay institutionalization of elderly people. Yet not all elderly people benefit from referral to specialized geriatric services. This article offers a clear and clinically practical framework to help family physicians identify elderly patients in their practices who are likely to benefit from referral to specialized geriatric services. MAIN COMPONENTS OF PROGRAM: By synthesizing previous work on the concept of frail elderly persons into a 2 x 2 matrix, the level and intensity of geriatric intervention most appropriate for different segments of the elderly population is clarified. CONCLUSIONS: Using the simple approach described in this article, family physicians should be able to use available geriatric resources easily and efficiently to optimize the health and function of their elderly patients.

Activities of Daily Living↗
PubMed1997

Vision profile of the athletes of the 1995 Special Olympics World Summer Games.

BACKGROUND: Special Olympics were organized in 1968 by Eunice Shriver as a program of physical fitness for individuals with mental handicaps. Numerous epidemiologic studies report an increase in visual problems in this population. METHODS: A comprehensive vision screening was conducted at the 1995 Special Olympic World Summer Games to identify the prevalence of visual anomalies in this select group. Testing included visual acuity, refractive error, ocular motor skills, stereopsis, color vision, contrast sensitivity, eye-hand coordination, eye-foot coordination, and an ocular health evaluation. RESULTS: Nine hundred five special athletes, ranging in age from 8 to 58 years, participated in the screening. More than 65% of the participants had not received eye care for more than 3 years. The most commonly reported symptom was difficulty in seeing. Other ocular health problems included refractive errors, poor distance monocular acuity, and strabismus. CONCLUSION: The results of the study indicate that Special Olympians have a high prevalence of vision anomalies that may go undetected. This population demonstrates a high prevalence of refractive errors, decreased visual acuity, ocular health problems, and strabismus. In addition, based on the number of individuals who have not received eye care within the last year, there is a need to increase the availability of vision care to these and other people with mental retardation.

Adolescent↗
PubMed1976

Special-class EMR children mainstreamed: a study of an aptitude (learning potential) X treatment interaction.

Academic, personal, and social growth were compared for special-class EMR children who were assigned randomly to regular grades or retained in special classes at three time intervals: prior to the assignment, 2 month after assignment, and at the conclusion of the school year. There were no significant differences between the two groups prior to or 2 months after reintegration. After one school year, the reintegrated children were more internally controlled, had more positive attitudes toward school, and were more reflective in their behavior. The hypothesis that the more able students by the learning potential criterion would benefit more from regular than special-class placement was supported. These students expressed more positive feelings toward themselves as students, felt others perceived them as more competent, and behaved more reflectively when they were integrated than when assigned to special class. The high-able (learning potential) students performed more competently academically than the low-able (learning potential) students, regardless of placement.

Achievement↗
PubMed1998

Influence of special-effect contact lenses (Crazy Lenses) on visual function.

PURPOSE: Special-effect contact lenses (opaque, tinted soft contact lenses that incorporate decorative images such as "cateyes," stars, or hearts to alter eye color and structure) have become increasingly popular. The purpose of this study was to investigate whether such lenses impair visual function. METHODS: A clear soft contact lens and a special-effect soft contact lens (Crazy lens,) were fit in changing sequence in nine healthy subjects. The parameters studied included: visual acuity, contrast sensitivity (with and without glare), visual field, and mesopic vision (with and without glare). RESULTS: The following parameters displayed a statistically significant difference (P < 0.05). Visual acuity was decreased to 0.9 +/- 0.23 in the Crazy lens group as compared with 1.2 +/- 0.13 in the clear lens group. Goldmann visual field displayed a significant constriction of the isopters: III/4, I/4, and I/3. Mesopic vision without glare was reduced from 1:2.5 to 1:7.4. Contrast sensitivity was significantly reduced in a photopic condition with and without glare and in a scotopic condition without glare. Furthermore, the special-effect lenses were associated with a decrease in lens wearing comfort. CONCLUSIONS: Special-effect contact lenses were associated with a reduction of many visual functions, including visual acuity and contrast sensitivity. For some wearers this may interfere with activities where excellent vision is crucial, such as driving a car.

Adult↗