Biomedical subjects

D Rodrigues

Publications and source records attributed to D Rodrigues.

At least 19 recordsLinked to original sources

PubMed2002

Geographical variation in larval host-plant use by Heliconius erato (Lepidoptera: Nymphalidae) and consequences for adult life history.

Adult body size, one of the most important life-history components, varies strongly within and between Heliconius erato phyllis (Lepidoptera: Nymphalidae) populations. This study determines if this variation is caused by geographical changes in host-plant used by the larval stage, whose reproductive parameters are influenced by female body size, with estimates of the corresponding heritability. The variation in adult body size was determined together with a survey of passion vine species (Passifloraceae) used by the larvae in seven localities in Rio Grande do Sul State: three located in the urban area of Porto Alegre and Triunfo Counties, two within Eucalyptus plantations (Barba Negra Forest, Barra do Ribeiro County, and Aguas Belas Experimental Station-Viamão County), one in a Myrtaceae Forest (Itapuã State Park-Itapuã County) and one in the Atlantic Rain Forest (Maquiné Experimental Station-Maquiné County). Effects of female body size on fecundity, egg size and egg viability were determined in an outdoor insectary. Size heritability was estimated by rearing in the laboratory offspring of individuals maintained in an insectary. The data showed that adults from populations where larvae feed only upon Passiflora suberosa are smaller than those that feed on Passiflora misera. The larvae prefer P. misera even when the dominant passion vine in a given place is P. suberosa. Fecundity increases linearly with the increase in size of females, but there is no size effect on egg size or viability. Size heritability is null for the adult size range occurring in the field. Thus, the geographical variation of H. erato phyllis adult size is primarily determined by the type, corresponding availability and quality of host-plants used by the larval stage. Within the natural size range of H. erato phyllis, the variation related to this character is not genetically based, thus being part of H. erato phyllis phenotypic plasticity.

Animals↗

PubMed2002

Plasma total and free fatty acids composition in human non-alcoholic steatohepatitis.

BACKGROUND AND AIM: Non-alcoholic steatohepatitis (NASH), the association of steatosis with an inflammatory response, is a novel liver disease of unknown pathogenesis and prognosis. Triacylglycerols and their precursors, the fatty acids, are the likely candidates to accumulate in the hepatocyte. Disturbed fatty acid metabolism can be involved in the pathogenesis of NASH but there is no information concerning its plasma fatty acid profile. The aim of this study was to evaluate plasma total (esterified plus free) and free fatty acids concentrations to assess the association of NASH with plasma fatty acid accumulation. MATERIALS AND METHODS: Overnight fasting blood samples from 22 biopsy-proven NASH patients and of 6 matched age healthy controls were studied. RESULTS: NASH patients had significantly higher concentration of total and free fatty acids than controls (P<0.05), higher total saturated and monounsaturated levels in both studied lipid fractions (P<0.05), mainly due to the increase of hexadecanoic, hexadecenoic and octadecenoic acids. Absolute polyunsaturated fatty acids (PUFA) concentrations were similar in both groups. The C20:4/C18:2 and the C18:1/C18:0 ratios as well as the peroxidability index were not significantly different. CONCLUSION: In overweight/obese patients NASH is associated with deranged fatty acid metabolism which may be involved in its pathogenesis and/or progression.

Adult↗

PubMed2002

Evaluation of two commercial methods for the detection of Listeria sp. and Listeria monocytogenes in a chicken nugget processing plant.

This study measures the detection performances of two rapid test systems (Listeria Rapid Test Clearview and Bax system) for the screening of Listeria sp. and Listeria monocytogenes, respectively. A total of 413 samples from different sources (product from (i) different stages of processing, (ii) different environments, and (iii) different food handlers), collected from a chicken nugget processing plant, were analysed by both rapid methods and a cultural method consisting of pre-enrichment, enrichment, and isolation onto selective agars (PALCAM, LPM, and HCLA). Overall, results showed an excellent correlation between data obtained using Clearview and the cultural method, with Clearview presenting an efficiency of 99%. Bax showed a lower correlation using the cultural method, with an efficiency of 71.1%. The type of sample did not affect the efficiency of Clearview, which varied from 98.1% for product samples to 100% for environmental and food handler samples, while for Bax it had a marked influence. Efficiency of Bax varied from as high as 100% for food handlers to 37.9% for product samples.

Animals↗

PubMed2000

[Cervical cancer screening among indigenous women in the Xingu Indian Reservation, central Brazil].

Although the literature presents worrisome data regarding the incidence of cervical cancer among indigenous populations, in Brazil there is very little information regarding the occurrence of this type of cancer among indigenous peoples. Therefore, the objective of the present descriptive study was to assess the prevalence of cervical cancer and of cervical and vaginal infections among 423 indigenous women living in the Xingu Indian Reservation, in the state of Mato Grosso, Brazil. These women were or had been sexually active. Data were collected between 1989 and 1996. Clinical and gynecological examinations were carried out prior to the collection of cervical specimens and to the performance of cytologic analyses. Upon detection of abnormalities, a colposcopy and a biopsy were also performed. Our results show that 1% of the women studied presented invasive carcinoma and that 3% presented premalignant lesions. In addition, 84% presented inflammatory atypia, resulting from sexually transmitted genital infections. The present findings are in accordance with the results of other international reports regarding the high prevalence of cervical conditions among indigenous populations, and they underscore the need to extend to the indigenous peoples of Brazil programs aiming at the control of sexually transmitted diseases and at the early detection and treatment of cervical cancer.

Adolescent↗

PubMed2000

[Rural nursing].

This paper describes the experience of a teacher and four students of the Federal University of Rio Grande do Sul within a sitting of members of a rural social movement that claims for land in Brazil. The work began with an activity of familiarization and ended up being an extension project. The aim of this project was the development of a Nursing assistencial model for the population of the rural area, considering the specificities of this movement, wishing to adapt Nursing teaching to this reality. The author sought for theoretical references in Breilh (1999) and Freire (1981). The activities were developed in 1996 and consisted of home care and group education.

Brazil↗

PubMed1998

Adherence patterns and adherence-related DNA sequences in Escherichia coli isolates from children with and without diarrhea in São Paulo city, Brazil.

The correlation between various adherence patterns and adherence-related DNA sequences in Escherichia coli isolates from 1- to 4-year-old children with and without diarrhea in São Paulo, Brazil, was evaluated. A total of 1,801 isolates obtained from 200 patients and 200 age-matched controls were studied. The adherence patterns found were classified as diffuse, aggregative, aggregative in a 6-h assay, aggregative predominantly in coverslips, localized, localized-like, and noncharacteristic. In general, the DNA sequences used as probes showed excellent specificities (>93%), but their sensitivities varied. Thus, the results of bioassays and assays with DNA probes normally used to search for adherent E. coli did not correlate well, and the best method for the identification of these organisms in the clinical research setting remains controversial. Isolates presenting diffuse adherence or hybridizing with the related daaC probe, or both, were by far the most frequent in patients (31.5, 26.0, and 23.0%, respectively), followed by isolates presenting aggregative adherence or hybridizing with the related EAEC probe, or both (21.5, 13.0, and 10.5%, respectively). None of the different combinations of adherence patterns and adherence-related DNA sequences found were associated with acute diarrhea.

Bacterial Adhesion↗

PubMed1998

[Visual and volumetric analysis with magnetic resonance of hippocampus formations in a group of patients with clinical diagnosis of temporal lobe epilepsy].

The purpose of this study is to test the sensitivity of the volumetric analysis compared to the visual analysis of the hippocampal formations of a group of 153 patients with clinical diagnosis of temporal lobe epilepsy and candidates to temporal lobectomy, evaluated by magnetic resonance (MR), using a 0.5 Tesla machine and inversion-recovery T1-weighted images and 5 mm coronal slices. There was agreement between the prospective visual analysis and another retrospective visual analysis carried out by two independent observers (C = 0.748 and C = 0.720). There was also agreement between the retrospective analysis of the two investigators (C = 0.733). There was genuine agreement (C = 0.788) between the results of the qualitative and quantitative analyses carried out prospectively. Volume measurements showed a nonsignificant tendency to lateralize more cases of clinically presumed hippocampal atrophy. Our results confirm the reliability of a qualitative visual analysis and indicate the utility of hippocampal volumetry as a supplementary, objective and quantitative measure of hippocampal sclerosis.

Adult↗

PubMed1998

In vitro evaluation of dissolution properties and degradation products of omeprazole in enteric-coated pellets.

This report describes results of an in vitro study in which capsules containing omeprazole in enteric-coated pellets from different Brazilian manufacturers were evaluated. The original product was the reference in comparison to three similar products (A, B, and C). Samples were submitted to severe conditions (40 degrees C and 75% relative humidity during 120 days), and the tests performed were the omeprazole content, the percentage of omeprazole dissolved from the pellets, and the amount of H 238/85, its main degradation product. The data obtained suggest that these products could not be considered interchangeable. Differences in physical and physicochemical properties of products A, B, and C indicated that they did not maintain the required stability and that bioavailability might be affected by the poor dissolution of omeprazole from the pellets.

Biological Availability↗

PubMed1998

[Kidney transplantation in patients with type I and type II diabetes mellitus].

A total of 618 patients with end-stage renal disease received kidney transplants between 1980 and September 1996. Twenty eight of them were diabetics. Better results were achieved for type 1 diabetic patients than for type 2 (mortality: 5.9% vs 27.3%; functioning graft: 88.2% vs 72.7%). The morbility was also higher in those patients (infections: 81.8% vs 29.4%; vascular complications: 45.5% vs 17.6%). Actuarial patient and graft survival were lower for type 2 than for non diabetic patients. For type 1 diabetics the results are similar to those for non diabetics. Better results can probably be achieved by restricting the selection criteria. The decision to transplant or maintain on dialysis should be made on a case by case basis.

Adult↗

PubMed1997

Absence of block to polyspermy at the human oolemma.

OBJECTIVE: To study the fusiogenic ability of human spermatozoa and oocytes. DESIGN: Retrospective study of 3,027 oocytes included in a program of subzonal insemination (SUZI). SETTING: Assisted fertilization program in an academic research environment. PATIENT(S): Couples with characterized male factor infertility or previous unexplained IVF failures. INTERVENTION(S): Subzonal insemination (SUZI) was performed after study of the sperm pathology. The number of microinjected spermatozoa was controlled. MAIN OUTCOME MEASURE(S): Fertilization and polyspermia rates were analyzed according to the number of microinjected spermatozoa and to the indication of SUZI. RESULT(S): The fertilization rate increased linearly between one and three microinjected spermatozoa. Above this number, the rate plateaued around 25%. Polyspermia was correlated with the number of microinjected spermatozoa (r = 0.97). The fusiogenic ability of motile sperm cells was dependent on the semen characteristics and the sperm pathology. Observed diploid and polyspermia rates did not differ from the calculated probability of microinjecting only one or at least one fertilizing spermatozoon into the perivitelline space, respectively. CONCLUSION(S): Data support the hypothesis that a physiologic block at the human oolemma is absent. The post-SUZI fertilization rate also can be explained by the probability of finding one fertilizing spermatozoon among those that were microinjected and by the limited number of sperm heads allowed to decondense in the ooplasm.

Female↗

PubMed1997

[Physiology of human gamete interaction].

Subzonal insemination was the first micromanipulation technique used in the treatment of male factor sterility. Analysis of the sperm pathology prior to patient inclusion in the program allowed us to study gamete interaction in the human and the early embryogenesis. A series of 523 cycles and 3,027 micro-injected oocytes is reported.

Animals↗

PubMed1997

[The prevalence of hypertension in acromegaly].

AIM: To estimate the prevalence of hypertension (HT) in a group of patients with acromegaly at the moment of diagnosis and after treatment. PATIENTS AND METHODS: Fifty-seven patients, 43 females and 14 males with a mean age of 45.19 +/- 11.9 years were studied retrospectively. In the last visit 9 patients (15.7%) were in remission and 47 (84.2%) had active acromegaly. We considered hypertensive the patients with systolic BP > or = 140 and/or diastolic BP > or = 90 mmHg. Hypertension was classified in four stages:- mild, moderate, severe and very severe. RESULTS: The prevalence of hypertension at the moment of diagnosis was 35%. The hypertensive patients had a mean age of 51.75 +/- 9.3 years and normotensive patients 41.65 +/- 11.6 years (p < 0.001). In females the prevalence of HT was 27.9% and in males it was 57% (p = NS). In hypertensive patients (n = 20), the mean BP was 159 +/- 15 (syst.)/97.2 +/- 9.8 (diast.), 16 patients (80%) had mild to moderate HT and the remainder had severe (n = 2) and very severe (n=1) HT. In the last visit, 22.2% of patients were cured and 46.8% of those with active acromegaly were hypertensive. None of the patients cured and initially normotensive developed HT; among those that were hypertensive (n = 3), 2 remained hypertensive and 1 became normotensive. Among patients with active acromegaly and initially normotensive, 7 developed HT 4.85 +/- 2.03 years later; of those hypertensive at diagnosis (n = 16), only one became normotensive. The last case was 27 years old. The patients that remained hypertensive had a mean age of 53.8 +/- 6.85 years (41-62 years). CONCLUSIONS: The prevalence of hypertension at the moment of diagnosis was 35%, similar to the majority of studies published and higher than the general population. The hypertensive patients were significantly older the normotensive patients and most of them had mild to moderate HT. We observed an increase in the prevalence of HT over the years in the cases that maintained active acromegaly. In our series only one of the three patients cured became normotensive, therefore, we concluded that HT in acromegaly is frequently irreversible. The chances of normalization seems higher in younger patients and probably with a shorter duration of acromegaly.

Acromegaly↗

PubMed1997

[24-hour arterial pressure study and diabetic neuropathy and angiopathy of the lower limbs].

AIMS: To study the circadian variation of BP in diabetics with chronic late complications (autonomic neuropathy, peripheral neuropathy and macroangiopathy of the lower limbs). PATIENTS AND METHODS: We studied 35 NIDDM patients, 22 male and 13 female, with a mean age of 62.17 +/- 8.66 years, all with hypertension (HBP) or with BP levels close to normal, many of them under anti-hypertensive therapy (mean BP in clinical measurements: 164 +/- 23.16 mmHg systolic and 92.14 +/- 11.06 mmHg diastolic). Twenty-four suffer from autonomic neuropathy, 23 from peripheral neuropathy and 11 from macroangiopathy of the lower limbs. The control group is composed of 10 patients with essential HBP without other observable pathology, with a mean age of 68.5 +/- 3.63 years and BP in clinical measurements: systolic 192 +/- 15.49 mmHg and diastolic 88 +/- 4.21 mmHg (without any previous therapy). The record of the BP circadian profile was made, with the use of a Spacelab monitor, model 90207, 5 days after anti-hypertensive therapy was suspended. RESULTS: The mean BPs in 24 hours were: control group-systolic BP 152.6 +/- 13 mmHg and diastolic 79.8 +/- 13 mmHg; diabetics-systolic BP 136.82 +/- 15 mmHg and diastolic 77.4 +/- 8 mmHg. The daily and nocturnal mean BPs were 158.5 +/- 8.5 and 146 +/- 8.4 mmHg (systolic) and 82.8 +/- 5.7 and 70.9 +/- 5.1 mmHg (diastolic) in the control group, while they were, in diabetics, 141.3 +/- 15.7 and 135.6 +/- 16.6 mmHg (systolic) and 79.6 +/- 7.1 and 72 +/- 8.2 mmHg (diastolic). In diabetic patients, considering the groups with and without autonomic neuropathy, the difference between daily and nocturnal mean BP was 1.6 vs 9.4 mmHg systolic and 4.9 vs 9.4 mmHg, diastolic. CONCLUSIONS: In both groups, the mean BP levels in 24 hours were notoriously lower than those obtained from the clinical measurements: the differences were 40 mmHg (control group) and 27.2 mmHg (diabetics) for systolic BP and 8.2 mmHg (control group) and 14.7 mmHg (diabetics) for diastolic. The BP circadian profiles show a lower variability, with absence of the nocturnal reduction, specially evident in diabetic patients with autonomic neuropathy versus other groups.

Aged↗

PubMed1997

[Craniocerebral imaging in children with short stature].

OBJECTIVE: To analyse the type and frequency of cranial CT and NMR imaging anomalies in children of short stature. PATIENTS AND INTERVENTIONS: We studied 57 children of short stature with a mean age (+/-SD) of 10.1 +/- 3.8 years, 34 boys and 23 girls, all of them with auxometric criteria of GH deficiency. After studying the pituitary function and determination of karyotype in the girls, the children were classified in to five groups:-Isolated GHD (IGHD) (n = 32), multiple pituitary hormone deficiency (MPHD) (n = 6), neurosecretory dysfunction (NSD) (n = 8), Turner syndrome (n = 7) and idiopathic short stature (ISS) (n = 4). The imaging methods used were cranial CT or NMR. RESULTS: Of the 57 children studied the CT/NMR was abnormal in 37(64.9%) children. We found anomalies in 65.6% of IGHD patients, 62.5% of NSD patients, 100% of MPHD patients and 57.1% and 25% in the Turner s. patients and ISS patients respectively. The most frequent anomaly was hypoplastic pituitary found in 50% of IGHD patients, 37.5% of NSD patients and 33.3% of MPHD patients. None of the cases of Turner s. or ISS had hypoplastic pituitary. An empty sella was the second most frequent anomaly found in 7 patients (IGHD-3, MPHD-3, DNS-1). Of the 25 children in which NMR was performed, 8 had hypoplastic pituitary and stalk and 2 had interruption of the pituitary stalk and ectopic neurohypophysis. CONCLUSION: These results strengthen the necessity for CT/NMR imaging in children of short stature which, besides allowing identification of tumors, also permits the diagnosis of idiopathic GHD because of its frequent association with cranial imaging anomalies, mainly hypoplastic pituitary.

Body Height↗

PubMed1997

[Prevalence of arterial hypertension in Cushing's syndrome].

OBJECTIVE: To determine the prevalence of hypertension (HT) in patients with Cushing's syndrome. PATIENTS AND METHODS: We studied 23 patients with Cushing's syndrome, 17 women (mean +/- SD age = 42.8 +/- 15.6 years) and 6 men (mean +/- SD age = 34.8 +/- 10.2 years). The etiologies were: 16-Cushing's disease, 3-suprarenal adenoma, 2-suprarenal carcinoma and 2-iatrogenic. Blood pressure (BP) was measured at least three times and we consider hypertension when systolic BP > or = 140 mmHg and/or diastolic BP > or = 90 mmHg. RESULTS: The prevalence of HT, at diagnosis, was 73.9% (64.7% in women and 100% in men) and the mean BP was 163 +/- 25/100 +/- 16 mmHg (158 +/- 26/97 +/- 15 mmHg in women and 182 +/- 5/114 +/- 10 mmHg in men). From the 16 patients with Cushing's disease, 13 (81%) had HT; all the patients (n = 3) with suprarenal adenoma had HT; none with suprarenal carcinoma (n = 2) had HT and only 1 of the 2 patients with iatrogenic Cushing's syndrome had HT. After treatment, 14 patients entered remission, 6 persisted with active disease and 1 was missed during the follow-up. In the group of patients that entered remission, the prevalence of HT at diagnosis was 78.5% (n = 11), 57.1% (n = 8) being after treatment. CONCLUSIONS: In this study, we found a high prevalence of HT at diagnosis (73.9%). After treatment and in the patients that entered remission, the prevalence of HT remained high (78.5% vs 57.1%). The high prevalence of HT in Cushing's syndrome, suggests its importance as a morbidity factor and also as an important diagnostic indicator, when present.

Adult↗

PubMed1996

Estimation of regional end-systolic wall stress during exercise in coronary artery disease.

Estimating left ventricular wall stress has recognized applications, but formulae for global stress cannot be applied to ischemic ventricles. A mathematic method for estimating regional stress in infarcted ventricles has been described. The hypothesis tested was that exercise-induced ischemia increases end-systolic wall stress. Subcostal four-chamber echocardiograms were recorded at rest and during peak symptom-limited exercise in 19 controls and 41 patients with chest pain undergoing coronary arteriography. Centerline regional wall motion and regional end-systolic wall stress were measured at rest and at peak exercise. The normal controls had increased wall motion with exercise, but wall stress remained low. All 32 of the patients with coronary artery disease (> or = 50% diameter narrowing) had wall motion abnormalities with exercise, but the sensitivity of identifying right coronary artery obstructions was poor. Patients with coronary disease had higher regional stress at peak exercise than did the controls. The sensitivity of identifying lesions in all three coronary arteries (0.95 to 1.0) was better than that for wall motion (p < 0.04). The specificity of wall stress needs to be tested in a larger population. Exercise-induced ischemia causes increased regional end-systolic wall stress that reflects its distribution in patients with coronary artery disease. These changes can be measured non-invasively during exercise echocardiography.

Case-Control Studies↗

PubMed1996

Fertilizing ability of sperm with unexplained in vitro fertilization failures, as assessed by the zona-free hamster egg penetration assay: its prognostic value for sperm-oolemma interaction.

OBJECTIVE: To investigate the fertilizing ability of sperm with previous unexplained IVF failure using the zona-free hamster egg penetration assay. DESIGN: Three hundred ninety-six tests were performed after multiple IVF failures. In a subsequent prospective study, 38 IVF attempts using the microdrop insemination technique and 81 subzonal inseminations (SUZI) were performed. One hundred thirty-two tests with donor sperm were carried out as controls. PATIENTS: Three hundred fifty-two patients who had a minimum of two unexplained IVF failures including at least 10 metaphase II oocytes were included in the study. RESULTS: The ability of the patient sperm to bind to hamster oocytes was lower than that of controls. The largest differences were the percentage of oocytes with swollen sperm heads and the mean number of decondensed sperm heads per penetrated oocyte: both were much lower for patients than controls. Patients with a test result nil did not fertilize any oocytes during the SUZI cycles (n = 7; 50 oocytes), and the post-SUZI fertilization rate for patients with a test value < 10% was significantly lower than that of others (5.4 +/- 10.3 versus 23.8 +/- 8.4, respectively). CONCLUSIONS: The defect of sperm involved in IVF failures is mainly a reduction of their fusiogenic ability and not their ability to recognize and bind to the oolemma. Patients with a test result < 10% had a significantly reduced post-SUZI fertilization rate. A test score of zero indicates a major and permanent impairment of the sperm fusiogenic ability.

Animals↗

PubMed1995

An objective definition of shoulder dystocia: prolonged head-to-body delivery intervals and/or the use of ancillary obstetric maneuvers.

OBJECTIVE: To generate an objective definition of shoulder dystocia by timing the events of the second and third stages of labor, and to define the true incidence of shoulder dystocia. METHODS: In 34 arbitrarily selected 24-hour time periods, a nonparticipating observer prospectively timed intervals of the second stage of labor in all vaginal deliveries and recorded the use of obstetric maneuvers (McRoberts, episiotomy after delivery of the fetal head, intentional extension of initial episiotomy after delivery of the fetal head, suprapubic pressure, posterior arm rotation to an oblique angle, rotation of the infant by 180 degrees, delivery of the posterior arm, and general anesthesia) and whether the obstetric attendant identified a delivery with shoulder dystocia. All data are reported as mean +/- standard error of the mean. RESULTS: Two hundred fifty deliveries were timed and recorded prospectively. Mean intervals (in seconds) in nonmaneuver patients were as follows: head to anterior shoulder 14.8 +/- 1.0, anterior to posterior shoulder 3.9 +/- 0.6, posterior shoulder to body 5.4 +/- 0.8, and total head-to-body time 24.2 +/- 1.3. Three groups of patients were defined after delivery. The maneuver group consisted of 27 patients requiring any of the aforementioned obstetric maneuvers, although the obstetric attendant identified only 16 of these as shoulder dystocia. The prolonged delivery group included 29 patients with the head-to-body delivery interval exceeding the mean plus two standard deviations (60 seconds) of nonmaneuver patients. Sixteen of the 27 maneuver patients were identified as prolonged. The 210 not identified as maneuver or prolonged were considered to be normal. Normal patients had a significantly lower newborn birth weight (3269 +/- 38 g), and a lower proportion of 1-minute Apgar scores of 7 or less (11%) than did the maneuver (4247 +/- 86 g, 41%) and prolonged groups (3952 +/- 118 g, 34%). Defining shoulder dystocia as a prolonged head-to-body delivery time and/or the use of obstetric maneuvers identified 40 patients who had birth weights and 1-minute Apgar scores significantly different from the normal patients. CONCLUSION: The incidence of shoulder dystocia, as defined by the use of ancillary obstetric maneuvers, is higher than that reported previously, and the reporting of shoulder dystocia appears to be unreliable. The interval from head-to-body delivery is delayed significantly in patients with shoulder dystocia, despite the lack of recognition of shoulder dystocia. We propose defining shoulder dystocia as a prolonged head-to-body delivery time (eg, more than 60 seconds) or the need for ancillary obstetric maneuvers.

Adult↗