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PubMed1996

Hydroxyzine premedication--does it provide better anxiolysis than a placebo?

OBJECTIVES: To determine how effective hydroxyzine is compared with a placebo in providing pre-operative anxiolysis in our hospital population, and to assess the anxiolytic effect of our pre-operative visit. DESIGN: Double-blind, randomised, prospective, controlled trial. Anxiety levels assessed with visual analogue scales (VAS), by patient and investigator. Haemodynamic parameters measured: heart rate, blood pressure, respiratory rate. SETTING: Hillbrow Hospital, Johannesburg. PARTICIPANTS: Sixty female patients aged 20-60 years, American Society of Anesthesiologists status I-III, scheduled for elective gynaecological surgery under general anaesthesia. The overall participation rate was 100%. All cases were randomly selected. INTERVENTION: Hydroxyzine (Aterax) 1-2 mg/kg, or a placebo administered orally as anaesthetic premedication. OUTCOME MEASURES: Anxiolytic effect of agents and of pre-operative visit. Time interval between premedication and induction of anaesthesia. Blood pressure, heart rate, respiratory rate, other signs of autonomic hyperactivity (restlessness, tremors, sweating). RESULTS: A statistically significant reduction in anxiety followed the administration of hydroxyzine (P < 0.05) and the placebo (P < 0.03); however, no statistically or clinically significant difference could be demonstrated between the two agents. No significant anxiolysis occurred following the premedication visit. The average premedication-induction interval was 72 minutes. There were no significant differences in haemodynamic parameters between the two groups. CONCLUSIONS: Hydroxyzine, in the dose administered and after an appropriate premedication-induction interval, provided no better anxiolysis than a placebo in the pre-operative period. No significant anxiolytic effect was demonstrated by our routine premedication visit.

Administration, Oral↗
PubMed2000

Premedication for anxiety in adult day surgery.

BACKGROUND: Surgery is increasingly performed on a day-case basis. Many patients are anxious pre-operatively and might benefit from pharmacological anxiolysis. Drugs are sometimes not used, however, for fear of delaying discharge from hospital. OBJECTIVES: To asses the effect of anxiolytic premedication on time to discharge in adult patients undergoing day case surgery under general anaesthesia. SEARCH STRATEGY: Trials were identified by computerised searches of the Cochrane Controlled Trials Register, MEDLINE, EMBASE, by checking the reference lists of trials and review articles, by hand-searching three main anaesthesia journals and by contacting five researchers active in the field and the Product Information departments of the manufacturers of five commonly used premedicants. SELECTION CRITERIA: All randomised controlled trials comparing an anxiolytic drug(s) with placebo before general anaesthesia in adult day case surgical patients. DATA COLLECTION AND ANALYSIS: We collected data on anaesthetic drugs used, results of tests of psychomotor function where these were used to assess residual effect of premedication, and on times from end of anaesthesia to ability to walk unaided or readiness for discharge from hospital. Formal statistical synthesis of individual trials was not performed in view of the variety of drugs studied. MAIN RESULTS: Searching identified twenty-nine reports; fourteen studies, with data from a total of 1263 patients, were considered eligible for analysis. Only two studies specifically addressed the discharge question; both found no delay in premedicated patients. Three other studies used clinical criteria to assess fitness for discharge, though times were not given. Again, there was no difference from placebo. Four studies used both clinical measures and tests of psychomotor function as tests of recovery from anaesthesia. In none of these studies did the premedication appear to delay discharge, although performance on tests of psychomotor function was sometimes still impaired. Of the four studies which used tests of psychomotor function to assess recovery, three showed impaired recovery (after midazolam 7.5mg, midazolam 15mg or diazepam 15mg) which might possibly interfere with discharge from hospital. REVIEWER'S CONCLUSIONS: We have found no evidence of a difference in time to discharge from hospital in patients who received anxiolytic premedication. However, in view of the age and variety of anaesthetic techniques used, inferences for current day-case practice should be made with caution.

Adult↗
PubMed1975

Effect of premedication on stress and plasma cortisol in patients bronchoscoped under local anaesthesia.

Four groups of 8 patients undergoing bronchoscopy were premedicated with either pentobarbitone 1 mg/kg i.m. followed by i.v. saline, or diazepam 10 mg and saline i.v., or diazepam 10 mg i.m. followed by diazepam 20 mg i.v. and, diazepam 20 mg i.m. and then saline i.v. Both the patients and the bronchoscopist were asked to score the premedication as excellent, satisfactory, unsatisfactory or bad. Plasma cortisol was measured before premedication and before and after bronchoscopy. Preoperatively plasma cortisol increased in every group except that given diazepam 20 mg i.m., and during bronchoscopy it rose in all except the group who received 20 mg diazepam i.v. In patients who considered the premedication unsatisfactory, the rise in plasma cortisol from before premedication until after bronchoscopy was significantly higher than in satisfied subjects. It appears that in patients undergoing bronchoscopy higher doses of diazepam (20-30 mg) gave better suppression of stress than 10 mg diazepam, or 1 mg/kg pentobarbitone.

Adult↗
PubMed1997

Premedication with the opioid analgesic butorphanol raises the threshold for ischemic preconditioning in dogs.

Elucidation of the subcellular mechanism of myocardial ischemic preconditioning should be facilitated by precise knowledge of the biology of the cardioprotective response. Any proposed molecular mechanism for preconditioning must be initiated during the required ischemic stress period. The studies reported in this paper were undertaken to determine whether the infarct-limiting effect of four 5-min episodes of ischemia interspersed by reperfusion can be achieved by a single 5-min episode. Adult open-chest mongrel dogs, premedicated with the analgesic butorphanol, and anesthetized with sodium pentobarbital, underwent occlusion of the circumflex coronary artery for 60 min, followed by reperfusion of 3 h. Treated dogs were preconditioned with one, two or four cycles of 5-min occlusion followed by reperfusion. Additional dogs, not premedicated with butorphanol, were either untreated (not preconditioned) or preconditioned with one cycle of ischemia. Infarcts were identified using triphenyl-tetrazolium chloride (TTC) macrochemistry and infarct size (as % of area-at-risk, AAR) was measured and analyzed (using analysis of covariance [ANCOVA]) with respect to coronary collateral blood flow (measured using radioactive microspheres). Four 5-min cycles of preconditioning ischemia markedly limited infarct size. Two cycles were as effective as four. In contrast, infarct size was not different from control infarct size after a single episode of preconditioning ischemia. However, when pentobarbital anesthesia was used without premedication with butorphanol, a single 5-min ischemic stress did induce cardioprotection. Thus, the ischemic stress required for myocardial preconditioning in dogs is dependent on the anesthetic and premedication protocol employed. A single 5-min stimulus is effective in dogs anesthetized with pentobarbital. Premedication with the opioid analgesic, butorphanol, increases the threshold for induction of cardioprotection.

Analgesics, Opioid↗
PubMed2006

Are newborns receiving premedication before elective intubation?

AIMS: To determine the extent and type of premedication used for elective endotracheal intubation in neonatal intensive care units (NICUs). METHODS: A pretested questionnaire was distributed via e-mail to the program directors of the neonatology divisions with accredited fellowship programs in Neonatal-Perinatal Medicine in the United States. RESULTS: Of the 100 individuals contacted, 78 (78%) participated in the survey. Only 34 of the 78 respondents (43.6%) always use any premedication for elective intubation. Nineteen respondents (24.4%) reported to have a written policy regarding premedication. Morphine or fentanyl was used most commonly (57.1%), with a combination of opioids and midazolam or other benzodiazepines used less frequently. Fourteen respondents (25%) also use muscle relaxants with sedation for premedication, but only nine respondents combined paralysis with atropine and sedation. CONCLUSION: Most neonatology fellowship program directors do not report always using premedication for newborns before elective endotracheal intubation despite strong evidence of physiologic and practical benefits. Only a minority of the NICUs has written guidelines for sedation, which may preclude effective auditing of this practice. Educational interventions may be necessary to ensure changes in clinical practice.

Analgesics, Opioid↗
PubMed2000

Effect of clonidine premedication on haemodynamic responses to fibreoptic bronchoscopy.

The usual haemodynamic response to fibreoptic bronchoscopy is an increase in heart rate and blood pressure. We therefore compared, in a prospective, randomised, double-blind study, the effect of two doses of oral clonidine premedication (150 microg or 300 microg) with placebo (control group) on the haemodynamic alterations in 62 patients who underwent elective fibreoptic bronchoscopy. Significant increases in blood pressure and heart rate were observed during fibreoptic bronchoscopy only in the control group. Clonidine 150 microg blunted the haemodynamic response to fibreoptic bronchoscopy (p < 0.05). Significant decreases in systolic blood pressure (< 90 mmHg) were observed in all patients premedicated with 300 microg clonidine. Throughout the study nine patients (75%) in the 300 microg clonidine group were treated at least once for hypotension. Compared with the control group, time to awakening was significantly longer only in patients premedicated with 300 microg clonidine. In conclusion, premedication with 150 microg oral clonidine attenuates haemodynamic responses to fibreoptic bronchoscopy, without causing excessive haemodynamic depression and sedation. These data encourage the administration of clonidine as premedication in patients undergoing fibreoptic bronchoscopy, particularly in those with, or at risk for, coronary artery disease.

Adrenergic alpha-Agonists↗
PubMed2002

Facilitation of neonatal nasotracheal intubation with premedication: a randomized controlled trial.

OBJECTIVES: To determine if premedication reduces the time and number of attempts by junior medical staff to achieve nasotracheal intubation in neonates. The experimental design was a non-blinded randomized controlled pilot trial. The setting was a perinatal centre in a university teaching hospital. METHODS: Twenty infants (within the ranges of 25-40 weeks gestation, 650-3660 g and 1 h to 81 days of age) requiring semi-urgent intubation were randomized to either premedication with morphine, atropine and suxamethonium, or to awake intubation. RESULTS: There were no significant differences between the two groups in regard to prior intubation experience of the staff or infant weight or gestation. The intubation procedure, including intervening events, to completion was significantly faster in premedicated infants (median 60 s vs 595 s; P = 0.002) who were intubated at a younger postnatal age. It took twice as many attempts to intubate a conscious infant (median 2 vs 1; P = 0.010). There was a greater decrease in heart rate from the baseline in the unpremedicated group (mean 68 b.p.m. vs 29 b.p.m.; P = 0.017), but decreases in oxygen saturation were not different. Blood was observed in the oral and nasal passages after intubation in five of the awake infants and in one of the premedicated infants. CONCLUSIONS: The use of premedication reduces the total time and number of attempts taken to achieve successful nasotracheal intubation of neonates by junior medical staff under supervision.

Analgesics, Opioid↗
PubMed1995

Effect of colonoscopy premedication containing diazepam and pethidine on the release of mast cell mediators in gut mucosal samples.

BACKGROUND AND STUDY AIMS: To date there is no information available on whether drugs that are commonly used in premedication for colonoscopy procedures, such as diazepam and pethidine, may activate intestinal mast cells and thereby give rise to adverse effects. Since opioids such as pethidine are well-known for their ability to induce histamine release from several mast cell subtypes, the present study investigated the effect of diazepam and pethidine, intravenously administered as premedication for colonoscopy, on mast cell mediator secretion from colonic and rectal mucosa. PATIENTS AND METHODS: The secretion of the mast cell mediators histamine and tryptase was followed from biopsies of patients with and without premedication for 30 minutes in an air-bubbled incubation medium (mucosa oxygenation). The mediator release and tissue histamine content were studied prospectively in 17 control persons (histologically normal mucosa) as well as in 71 patients with inflammatory bowel disease (IBD) (histologically uninvolved and involved tissue). RESULTS: Although a significant accumulation of histamine was found in inflamed IBD-tissue, the results indicate, however, that this premedication does not enhance the release of histamine or tryptase from gut mucosal samples, neither in the histologically normal mucosa of control persons nor in tissue unaffected or affected by inflammatory bowel disease. CONCLUSION: This study demonstrates that colonoscopy premedication with diazepam and pethidine is safe in terms of gut mucosal mast cell activation.

Adult↗
PubMed2002

Anxiolytic premedication reduces preoperative anxiety and pain during oocyte retrieval. A randomized double-blinded placebo-controlled trial.

BACKGROUND: The role of anxiolytic premedication remains unclear and significant postoperative side-effects may result from routine use. METHODS: In this double-blinded study, 100 infertile patients were randomized on the day of ultrasound-guided oocyte retrieval (TUGOR) by a computer-generated randomization list in sealed envelopes to receive either (i) 50 mg pethidine and 25 mg promethazine (premedication group) or (ii) normal saline (placebo group) i.m. 30 min prior to TUGOR. Anxiety level, pain levels and severity of postoperative side-effects were recorded. RESULTS: No differences were seen in demographic data, TUGOR duration, number of follicles punctured and clinical outcome. Preoperative anxiety level was significantly higher than the basal anxiety level in the placebo group only. The vaginal and abdominal pain levels during TUGOR and 4 h after TUGOR were significantly higher in the placebo group than the premedication group. Significantly more patients complained of drowsiness after TUGOR in the premedication group than the placebo group and other side-effects were comparable in both groups. CONCLUSION: Routine use of anxiolytic premedication prevented an increase of preoperative anxiety level, reduced pain levels during oocyte retrieval but was associated with a higher percentage of moderate/severe drowsiness in the postoperative period.

Adult↗
PubMed1998

Premedication with oral dextromethorphan reduces postoperative pain after tonsillectomy.

UNLABELLED: The aim of the present study was to examine whether premedication with dextromethorphan, a clinically available N-methyl-D-aspartic acid (NMDA) receptor antagonist, could reduce postoperative pain after tonsillectomy. Thirty-six patients scheduled for elective bilateral tonsillectomy were investigated in a double-blinded, randomized study. The patients were randomly assigned to one of three groups: control, dextromethorphan 30 mg (Dex 30), and dextromethorphan 45 mg (Dex 45) groups. In the control group, premedication was with oral placebo and intramuscular (i.m.) midazolam and atropine. In the Dex 30 and Dex 45 groups, patients were premedicated with i.m. midazolam and atropine and oral dextromethorphan 30 mg and 45 mg, respectively. Pain was evaluated repeatedly throughout 7 postoperative days, at rest and on swallowing, using a self-rating visual analog scale (VAS). The total doses of analgesics administered postoperatively were also recorded. The Dex 45 group showed significantly lower VAS scores than the control group both at rest and on swallowing throughout the 7 days. The total doses of postoperative analgesics in the Dex 45 group were significantly less than those in the control group. The Dex 30 group showed significantly lower VAS scores than the control group at rest, but not on swallowing. These results indicate that premedication with Dex 45 reduces postoperative pain after tonsillectomy, not only at rest but on swallowing. IMPLICATIONS: Recently, it has been suggested that central sensitization caused by the activation of N-methyl-D-aspartic acid receptors may contribute to the postoperative pain. We found that premedication with 45 mg of dextromethorphan, a clinically available N-methyl-D-aspartic acid receptor antagonist, reduced postoperative pain after tonsillectomy.

Administration, Oral↗
PubMed2005

Premedication with acetaminophen or diphenhydramine for transfusion with leucoreduced blood products in children.

Febrile non-haemolytic or allergic reactions occur in 0.1-30% of transfusions; physicians often premedicate patients with acetaminophen or diphenhydramine to prevent these reactions. The effectiveness of this practice has not been demonstrated. In this retrospective review of all transfusions at our institution during 2002, 385 patients received 7900 evaluable leucoreduced, irradiated blood products (4280 single-donor apheresis platelets and 3620 packed red blood cells). Febrile reactions occurred in 0.95% of 4108 transfusions with, and 0.53% of 3792 transfusions without, acetaminophen premedication. Allergic reactions occurred in 0.90% of 4315 transfusions with, and 0.56% of 3585 transfusions without, diphenhydramine premedication. In a multivariate analysis that adjusted for age, patient category, transfusion location, product, transfusion history, and reaction history, premedication with acetaminophen was associated with a statistically non-significant increase in the odds of a febrile reaction (odds ratio 1.74; 95% confidence interval 0.71-4.23; P = 0.22), and diphenhydramine with a non-significant increase in allergic reactions (odds ratio 1.74; 95% confidence interval 0.99-3.06; P = 0.054). Reactions occurred in only 1.3% of the 518 transfusions to patients with a history of two or more prior reactions. Febrile and allergic transfusion reactions were rare in paediatric patients transfused with leucoreduced, irradiated blood products, whether premedication was used or not.

Acetaminophen↗
PubMed1992

Premedicating children for painful invasive procedures.

Children with cancer experience a great deal of anxiety concerning their treatment and invasive tests such as bone marrow aspirations (BMAs) and lumbar punctures (LPs). Responses of pain, fear, and anxiety are well documented and may cause regression, developmental delay, sleeping and eating problems, nausea and vomiting, nightmares, and depression. Diagnostic and treatment procedures need not cause such adverse effects if sufficient pharmacological sedation, analgesia, and anesthesia are used. However, studies show that inappropriate interventions such as underdosing and limited use of medications occur because of certain myths, beliefs, and lack of pharmacological knowledge on the part of health professionals. Studies that specifically address premedication for painful procedures in children with cancer have shown that only a small percentage of children receive premedications and that there is no clear consensus or standard for either drugs or dosages. The issue of premedicating children before procedures remains controversial and deserves further investigation. This study explored the attitudes and perceptions of oncology physicians and nurses concerning medicating children before procedures. Findings showed that most pediatric oncology specialists medicate their patients before invasive procedures and that the most common premedications used are Versed; Demerol, Phenergan, Thorazine; chloral hydrate; Ativan; fentanyl; Demerol; and Xylocaine. Most pediatric oncology specialists believe that premedication is necessary for children for BMAs and LPs.

Adolescent↗
PubMed1990

Fiberoptic bronchoscopy without premedication. A retrospective study.

The objective of this study was to determine if flexible FOB could be performed safely without premedication other than topical anesthesia. A total of 281 procedures performed during a 12-month period at a VA medical center were reviewed. Ninety-one procedures performed without premedication were compared with 190 procedures performed with premedication. Complications occurred in 5 percent of patients in each group. Statistical analysis revealed no significant differences in age, spirometry, P(A-a)O2 or SaO2 between both groups. Despite the proven safety of outpatient FOB without sedation, many bronchoscopists administer complicated premedication regimens and employ ambulatory surgery beds or recovery rooms to monitor patients before and after procedures. These results support a simplified approach to routine FOB which would include no premedications and greater use of outpatient facilities resulting in decreased expenditures without compromising patient care, safety or comfort.

Adult↗
PubMed2000

Effect of oral clonidine premedication on perioperative hemodynamic response and postoperative analgesic requirement for patients undergoing laparoscopic cholecystectomy.

BACKGROUND: To investigate the clinical efficacy of oral clonidine premedication in anesthesia and analgesia in patients undergoing laparoscopic cholecystectomy (LC). METHODS: One hundred and ten patients, scheduled for elective laparoscopic cholecystectomy, were recruited for the prospective, randomized, single-blind, comparative study. They were randomly allotted to either of the placebo or clonidine group. Patients of the placebo group (n = 65) were premedicated with oral antacid (alugel hydroxide 300 mg), while those in the clonidine group (n = 45) were premedicated with oral clonidine 150 micrograms prior to anesthesia. The premedication was given 60 to 90 min before the anticipated time of induction of anesthesia. Normocapnia was maintained throughout the perioperative period. Mass spectrometer was used to assess the inspired and expiratory concentrations of isoflurane, the anesthetic used for maintenance of anesthesia. Postoperative pain intensity, sedation scores, adverse events, time to the first dose of postoperative analgesic and cumulative analgesic requirement in 24 hours were recorded. Data were expressed as mean +/- SD. RESULTS: Patients in the clonidine group displayed greater hemodynamic stability perioperatively and the isoflurane requirement was also reduced (30% less). The postoperative analgesic requirement was less (1.5 +/- 1.3 vs. 2.2 +/- 1.3 dose, P < 0.05) and the time for the first dose of analgesic was prolonged (411 +/- 565 vs. 264 +/- 441 min) in comparison with the placebo group but no statistic difference was found. CONCLUSIONS: Oral clonidine premedication helped to provide perioperative hemodynamic stability, spared the use of isoflurane and reduced the requirement of postoperative analgesia so as to smoother the way to recovery in patients undergoing LC.

Administration, Oral↗
PubMed1979

Premedication for out-patient endoscopy of the upper gastro-intestinal tract.

Upper gastrointestinal endoscopy was performed on 342 out-patients. The patients were allocated to four groups according to premedication given. The premedication used was atropine 0.1 mg/10 kg (A), atropine 0.1 mg/10 kg and diazepam 5 mg (AD), atropine 0.1 mg/10 kg and fentanyl 0.2 mg (AF), atropine 0.1 mg/10 kg diazepam 5 mg and fentanyl 0.2 mg (ADF). Premedication was given about 30 minutes before the procedure intramuscularly; the mouth and pharynx were sprayed with 10% lidoc,ine. The patients as well as the endoscopist considered the premedication in groups A and AD to be satisfactory. From the patient's point of view there were hardly any differences between the var;ous groups, except in drowsiness, which occurred more often in groups where fentanyl had been used. From the endoscopist's point of view groups A and AD were preferred because they offered better working conditions for the procedure. The longest period of observation was required in group ADF. On the basis of these results premedication with only atropine or if desired a combination of atropine and diazepam in addition to local sprayed anaesthesia of the mouth and pharynx is sufficient, and is recommended for endoscopy of the upper gastrointestinal tract.

Aged↗
PubMed1982

Risks to children from computed tomographic scan premedication.

We observed serious adverse reactions after premedication for computed tomographic (CT) head scans and therefore determined rates and risk factors for such reactions among 106 hospitalized children monitored by an intensive drug surveillance program. Reactions occurred in 13 patients (13%), including four cases of life-threatening cardiorespiratory depression or arrest after narcotic premedication. Other reactions included CNS depression, behavior changes, voiding problems, and vomiting. The risk of reaction was elevated in subjects who received high doses of a premedication drug (relative risk, 5.2) and in those who received four or more premedication (relative risk, 3.7). All life-threatening reactions occurred among infants younger than 3 months, and two of these followed medication with only morphine sulfate, in the recommended dose. Risks of adverse reactions from premedication should be considered by physicians who order CT scans for hospitalized children.

Adolescent↗
PubMed1994

Midazolam and ketamine as premedication in colonoscopies: a pharmacodynamic study.

As colonoscopy is often painful, a premedication appears to be indispensable. Commonly, benzodiazepines, i.e. midazolam, alone or in combination with analgesic drugs are used. Besides all advantages, midazolam especially is known to have the risk of oversedation and respiratory depression. Therefore it should be used at minimal dose. In a double-blind, randomized study, three premedication-schedules of midazolam (mid) plus ketamine (ket) were compared in 33 patients, aged between 8 and 60 years, with regard to safety and acceptance by patients and endoscopist. I: ket 1 mg/kg+mid 0.1 mg/kg, max. 5 mg II: ket 1 mg/kg+mid 0.05 mg/kg, max. 2.5 mg III: ket 0.75 mg/kg+mid 0.1 mg/kg, max. 5 mg Oxygen-saturation, heart rate and blood pressure were recorded as well as the evaluations of sedation, cooperation and complaint of pain. To assess the recovery-time of the patients, the reaction time and the attention were evaluated by "Wiener's determination apparatus" and "test d2", respectively, before and at 1, 2, 3 and 4 hours after premedication. Medication I resulted in heavy sedation, good cooperation and amnesia but had the strongest tendency towards hypoxemia. Under schedule III, reduced cooperation and acceptance were seen due to a strong experience of pain. The best conditions during the examination with regard to cooperation, experience of pain and acceptance were found after premedication II without relevant depression of vital parameters. It can be concluded that midazolam can be used at minimal recommended doses as premedication for colonoscopy if combined with ketamine in a sufficient analgesic dosage.

Adolescent↗
PubMed1994

Changes in blood glucose induced by upper GI diagnostic endoscopy: the influence of various premedications.

In this study we measured the blood glucose before and after diagnostic upper GI endoscopy as an index of the stress induced by the procedure. The possible influence of various premedications in the blood glucose was also studied. One hundred and twenty consecutive non-diabetic patients of both sexes aged 20-75 years were randomly allocated into four groups (A,B,C,D) according to the premedication used. Sixty non-diabetic patients, who were not endoscoped, were allocated into three groups (C1, C2, C3) and served as controls. Blood glucose increased significantly in the patients but not in the controls. No correlation was found between the changes in the blood glucose and the time needed for the endoscopy. Changes in the blood glucose did not differ among the patients (F = 0.214; p = 0.886) irrespective of the premedication; however the increase was numerically less when 10% lidocaine spray was used as a premedication (Groups A and C). It is concluded that diagnostic upper GI endoscopy induced a significant increase in blood glucose, irrespective of the premedication. This increase seemed to be mainly the result of the stress induced by the irritation of the pharynx during the intubation.

Adult↗