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Biomedical subjects

J A Levine

Publications and source records attributed to J A Levine.

At least 19 recordsLinked to original sources

Orexin A mediation of time spent moving in rats: neural mechanisms.

The brain regulates energy balance and spontaneous physical activity, including both small- and large-motor activities. Neural mediators of spontaneous physical activity are currently undefined, although the amount of time spent in sedentary positions versus standing and ambulating may be important in the energetics of human obesity. Orexin A, a neuropeptide produced in caudal hypothalamic areas and projecting throughout the neuraxis, enhances arousal and spontaneous physical activity. To test the hypothesis that orexin A affects the amount of time spent moving, we injected orexin A (0-1000 pmol) into three orexin projection sites in male Sprague-Dawley rats: hypothalamic paraventricular nucleus, rostral lateral hypothalamic area and substantia nigra pars compacta, and measured spontaneous physical activity. Orexin A affects local GABA release and we co-injected orexin A with a GABA agonist, muscimol, in each brain site. Dopamine signaling is important to substantia nigra function and so we also co-injected a dopamine 1 receptor antagonist (SCH 23390) in the substantia nigra pars compacta. In all brain sites orexin A significantly increased time spent vertical and ambulating. Muscimol significantly and dose-dependently inhibited orexin A effects on time spent moving only when administered to the rostral lateral hypothalamic area. In the substantia nigra pars compacta, SCH 23390 completely blocked orexin A-induced ambulation. These data indicate that orexin A influences time spent moving, in three brain sites utilizing separate signaling mechanisms. That orexin A modulation of spontaneous physical activity occurs in brain areas with multiple roles indicates generalization across brain site, and may reflect a fundamental mechanism for enhancing activity levels. This potential for conferring physical activity stimulation may be useful for inducing shifts in time spent moving, which has important implications for obesity.

Analysis of Variance↗

Elevated hypothalamic orexin signaling, sensitivity to orexin A, and spontaneous physical activity in obesity-resistant rats.

Selectively-bred obesity-resistant [diet resistant (DR)] rats weigh less than obesity-prone [diet-induced obese (DIO)] rats, despite comparable daily caloric intake, suggesting phenotypic energy expenditure differences. Human data suggest that obesity is maintained by reduced ambulatory or spontaneous physical activity (SPA). The neuropeptide orexin A robustly stimulates SPA. We hypothesized that DR rats have greater: 1) basal SPA, 2) orexin A-induced SPA, and 3) preproorexin, orexin 1 and 2 receptor (OX1R and OX2R) mRNA, compared with DIO rats. A group of age-matched out-bred Sprague-Dawley rats were used as additional controls for the behavioral studies. DIO, DR, and Sprague-Dawley rats with dorsal-rostral lateral hypothalamic (rLHa) cannulas were injected with orexin A (0, 31.25, 62.5, 125, 250, and 500 pmol/0.5 microl). SPA and food intake were measured for 2 h after injection. Preproorexin, OX1R and OX2R mRNA in the rLHa, and whole hypothalamus were measured by real-time RT-PCR. Orexin A significantly stimulated feeding in all rats. Orexin A-induced SPA was significantly greater in DR and Sprague-Dawley rats than in DIO rats. Two-mo-old DR rats had significantly greater rLHa OX1R and OX2R mRNA than DIO rats but comparable preproorexin levels. Eight-mo-old DR rats had elevated OX1R and OX2R mRNA compared with DIO rats, although this increase was significant for OX2R only at this age. Thus DR rats show elevated basal and orexin A-induced SPA associated with increased OX1R and OX2R gene expression, suggesting that differences in orexin A signaling through OX1R and OX2R may mediate DIO and DR phenotypes.

Age Factors↗

Neuromedin U in the paraventricular and arcuate hypothalamic nuclei increases non-exercise activity thermogenesis.

Brain neuromedin U (NMU) has been associated with the regulation of both energy intake and expenditure. We hypothesized that NMU induces changes in spontaneous physical activity and nonexercise activity thermogenesis (NEAT) through its actions on hypothalamic nuclei. We applied increasing doses of NMU directly to the paraventricular (PVN) and arcuate hypothalamic nuclei using chronic unilateral guide cannulae. In both nuclei, NMU significantly and dose-dependently increased physical activity and NEAT. Moreover, NMU increased physical activity and NEAT during the first hour of the dark phase, indicating that the reduction of sleep is unlikely to account for the increased physical activity seen with NMU treatment. As a positive control, we demonstrated that paraventricular NMU also significantly decreased food intake, as well as body weight. These data demonstrate that NMU is positively associated with NEAT through its actions in the PVN and arcuate nucleus. In co-ordination with its suppressive effects on feeding, the NEAT-activating effects of NMU make it a potential candidate in the combat of obesity.

Animals↗

International survey of seat belt use exemptions.

BACKGROUND: Substantial evidence of seatbelt efficacy has been shown by several studies, and it is widely recommended that motor vehicle occupants use properly fitted seat belts. However, some (but a heretofore unknown number of) countries with national seat belt laws permit various exemptions which may lower use rates. The aim of this study was to survey the variety of exemptions to national seat belt laws. METHODS: This investigation relied on identifying respondents from national traffic safety agencies, other governmental and non-governmental organizations, Internet searches, personal contacts, and other sources. Questionnaires were deployed through a web based survey supplemented by email and postal versions. RESULTS: Responses were received from 30 countries of which 28 (93.7%) had a national seat belt law. About two thirds (63.7%) of the 28 national laws applied to both front and back seat passengers. The leading exemption types included vehicles made before a certain year (n = 13), antique vehicles (n = 12), military vehicles (n = 11), buses (n = 9), and emergency vehicles (n = 8). Most responding countries reported one or more specific categories of individuals as exempt including those with medical exemptions (n = 20), taxi drivers (n = 11), police (n = 9), emergency medical personnel (n = 8), physically disabled people (n = 6), and pregnant women (n = 6). Out of 26 responses to the question regarding current level of enforcement, 42.3% felt enforcement was "very good or good" and 57.7% characterized it as "fair or poor". CONCLUSIONS: This study represents one of the largest international traffic law surveys reported. Most national seatbelt laws offer perilous exemptions to a broad array of vehicle types and road user groups. These findings, coupled with concern over the level of enforcement in the majority of countries surveyed, suggest that international road safety efforts have a long way to go to improve coverage and enforcement of national seat belt laws.

Accidents, Traffic↗

NEAT--non-exercise activity thermogenesis--egocentric & geocentric environmental factors vs. biological regulation.

Non-exercise activity thermogenesis (NEAT) is the energy expenditure of all physical activities other than volitional sporting-like exercise. NEAT includes all those activities that render us vibrant, unique and independent beings such as going to work, playing guitar, toe-tapping and dancing. The factors that account for the 2000 kcal day(-1) variability of NEAT can be categorized as environmental or biological. The environmental determinants of NEAT can be view using one of two models. In the egocentric model we consider a single person as the focus, e.g. 'my job'. In the geocentric model we consider the 'environment' as the focus, e.g. well-lit and safe walk ways. These models provide us with a theoretical framework to understand NEAT and how best to intervene to promote NEAT. As well as environmental effectors of NEAT, there are also biological regulatory mechanisms that enable us to account for three-quarters of the biological variance in susceptibility and resistance to fat gain with human over-feeding. NEAT is likely to be regulated through a central mechanism that integrates NEAT with energy intake and energy stores so that NEAT is activated with over-feeding and suppressed with under-feeding. In conclusion, NEAT is likely to serve as a crucial thermoregulatory switch between energy storage and dissipation that is biologically regulated and influenced, and perhaps over-ridden, by environment. Deciphering the role of NEAT may lead to a better understanding of the pathogenesis, prevention and treatment of obesity.

Eating↗

Differential effects of adrenocorticotropic hormone on human and mouse adipose tissue.

Adrenocorticotropic hormone (ACTH) induces lipolysis in a dose-dependent fashion in rodent adipose tissue and adipocytes in vitro. The role of ACTH on lipolysis in human adipose tissue is less clear, however. In this study, we address the hypothesis that ACTH induces lipolysis in human adipose tissue. We used ex vivo organ culture to examine lipolysis in human and mouse adipose tissue. Adipose tissue fragments suspended in culture medium and human ACTH, isoproterenol (positive control), or insulin (negative control) was added in varying concentrations. Lipolysis was measured using glycerol appearance. ACTH receptor mRNA expression was assessed using reverse-transcription polymerase chain reaction (RT-PCR). In mouse adipose tissue, ACTH induced lipolysis in dose-dependent manner; 100 pmol/l ACTH induced 67+/-19% of isoproterenol-stimulated lipolysis and 500 pmol/l ACTH: 86+/-13%. In contrast, human adipose tissue shared no significant response to 100 pmol/l ACTH; ACTH was associated with 9+/-6% and 500 pmol/l of ACTH, 8+/-6% of isoproterenol-stimulated lipolysis. ACTH receptor mRNA was present in mouse adipose tissue, but undetectable in human adipose tissue. These results suggest lipolysis regulation differs between human and mouse adipose tissue in response to ACTH.

Adipose Tissue↗

Is there a role for gastric accommodation and satiety in asymptomatic obese people?

OBJECTIVE: The relationships of gastric accommodation and satiety in moderately obese individuals are unclear. We hypothesized that obese people had increased gastric accommodation and reduced postprandial satiety. The objective of this study was to compare gastric accommodation and satiety between obese and non-obese asymptomatic subjects. RESEARCH METHODS AND PROCEDURES: In 13 obese (body mass index [BMI] > or = 30 kg/m(2); mean BMI, 37.0 +/- 4.9 kg/m(2)) and 19 non-obese control subjects (BMI < 30 kg/m(2); mean BMI, 26.2 +/- 2.9 kg/m(2)), we used single photon emission computed tomography to measure fasting and postprandial gastric volumes and expressed the accommodation response as the ratio of postprandial/fasting volumes. The satiety test measured maximum tolerable volume of ingestion of liquid nutrient meal (Ensure) and symptoms 30 minutes after cessation of ingestion. RESULTS: Total fasting and postprandial gastric volumes and the ratio of postprandial/fasting gastric volume were not different between asymptomatic obese and control subjects. However, the fasting volume of the distal stomach was greater in obese than in control subjects. Maximum tolerable volume of ingested Ensure and aggregate symptom score 30 minutes later were also not different between obese and control subjects. DISCUSSION: Asymptomatic obese individuals (within the BMI range of 32.6 to 48 kg/m(2)) did not show either increased postprandial gastric accommodation or reduced satiety. These data suggest that gastric accommodation is unlikely to provide an important contribution to development of moderate obesity.

Adult↗

Validation of the Tracmor triaxial accelerometer system for walking.

PURPOSE: Walking is likely to contribute substantially to nonexercise activity thermogenesis. The Tracmor triaxial accelerometer system (Maastricht, The Netherlands) is the most widely validated system for detecting body movement in free-living subjects. The aim of this study was to validate the Tracmor triaxial accelerometer system for estimating the energy expenditure of walking. METHODS: Experiments were conducted in healthy subjects. First, baseline variability for Tracmor output was determined for subjects standing still. Second, Tracmor output was compared for walking on a treadmill and on level ground. Third, both Tracmor output and energy expenditure were compared for walking on a treadmill and walking on level ground. Finally, the effect of gradient on Tracmor output and energy expenditure was compared for subjects walking on a treadmill. RESULTS: The data demonstrated excellent reproducibility for comparing Tracmor output for standing (CV < 2%). There were excellent log-linear relationships between velocity and Tracmor output walking on a treadmill (r = 0.998) and on level ground (r = 0.999). Tracmor output and the energy expenditure of walking were inseparable for the two modalities of walking. However, the variance in response was such that to reliably derive the relationship between Tracmor output and energy expenditure, separate regression equations are needed for each subject. Finally, the Tracmor accelerometer did not detect the increased energy expenditure of walking that occurs as gradient increases. CONCLUSION: The Tracmor triaxial accelerometer provides reproducible and reliable data on the body motion associated with walking regardless of whether a subject walks on a treadmill or level ground. Tracmor units can be used to predict the energetic cost of walking provided that separate regression equations are derived for each subject to convert Tracmor output to energy expenditure.

Adult↗

Relationship between duration of pain and secondary signs of obstruction of the urinary tract on unenhanced helical CT.

OBJECTIVE: The objective of this study was to investigate the relationship between duration of flank pain and the frequency of secondary signs of ureteral obstruction on unenhanced helical CT. SUBJECTS AND METHODS: The duration of flank pain was prospectively determined in 227 consecutive patients diagnosed with acute ureterolithiasis on unenhanced helical CT. These CT studies were evaluated for the presence or absence of perinephric stranding, ureteral dilatation, perinephric fluid, collecting system dilatation, periureteral stranding, and nephromegaly. The frequency of each sign was determined as a function of the duration of pain. RESULTS: The frequency of moderate or severe perinephric stranding increased from 5% at 1--2 hr to 51% at 7--8 hr (p < 0.001); ureteral dilatation increased from 84% at 1--2 hr to 97% at more than 8 hr (p < 0.03); moderate or severe perinephric fluid increased from 0% at 1--2 hr to 22% at 3--4 hr (p < 0.03); collecting system dilatation increased from 68% at 1--2 hr to 89% at 7-8 hr (p < 0.03); periureteral stranding increased from 35% at 1--2 hr to 76% at 7--8 hr (p < 0.004); and nephromegaly increased from 40% at 1--2 hr to 54% at 7--8 hr (p < 0.36). CONCLUSION: All CT secondary signs of ureteral obstruction except nephromegaly showed a significant increase in frequency as duration of flank pain increased. This observation may explain why the CT studies of some patients with acute ureterolithiasis show negative findings for some or all CT secondary signs of obstruction. Therefore, knowledge of the duration of pain is important when interpreting unenhanced CT studies in patients with acute ureterolithiasis.

Adult↗

Body composition and resting energy expenditure in humans: role of fat, fat-free mass and extracellular fluid.

OBJECTIVE: The objective of this study was to determine whether there are independent effects of extracellular fluid volume (ECF) and fat mass (FM) on resting energy expenditure (REE) relative to fat-free mass (FFM) in adult men and women. METHODS: Multiple linear regression analysis was used to relate REE, as determined by indirect calorimetry, to FFM and FM (measured using dual energy X-ray absorptiometry) and ECF (measured using bromide space and/or the radiosulfate washout space) in 153 women and 100 men with varying amounts of body fat. RESULTS: REE correlated significantly with FFM and FM in women (r=0.65 and r=0.63, both P<0.001) and men (r=0.62 and r=0.48, both P<0.001, FFM and FM, respectively). In a multiple linear regression analysis FFM, FM and age significantly contributed to the ability to predict REE in both genders. The models that were derived were not significantly different between women and men. In women the contribution to REE from FM was easier to detect when FM was greater. Adjustment of FFM for ECF did not improve the relationship between FFM and REE. CONCLUSIONS: FFM, FM and age are significant, independent predictors of REE in both men and women. Adjustment of FFM for ECF does not improve the ability of FFM to predict REE, which suggests that ECF is a highly integrated component of FFM in healthy adults. Expressing REE relative to FFM alone will introduce errors when lean and obese populations are compared.

Absorptiometry, Photon↗

Energy expenditure in chronic alcohol abuse.

BACKGROUND: In healthy subjects, alcohol decreases lipid oxidation favouring fat deposition. However, individuals who chronically abuse alcohol are not obese. To investigate this paradox, we measured energy expenditure (EE) and fuel utilization in chronic alcohol abusers in relation to their drinking behaviour. METHODS: Resting and postprandial EE and nonprotein respiratory quotient (NPRQ) were measured using indirect calorimetry, in 36 alcohol abusers [mean (+/- SE) age 42 +/- 2 years; weight 67 +/- 2 kg; 21 with steatosis, eight with hepatitis; seven with cirrhosis] and in 36 gender-, age- and weight-matched healthy controls. Alcoholic patients were re-evaluated either after 14 days (n = 14) or on days 2, 4, 6, 8, 14 and 42 (n = 6) after abstinence. RESULTS: When alcoholics were compared to healthy controls, mean energy intake was greater, 15 +/- 1 MJ day-1 (38 +/- 2% from alcohol) cf. 9 +/- 1 MJ day-1 (P < 0.001), resting EE increased, 82 +/- 2 cf. 65 +/- 2 W (P < 0.001) and NPRQ decreased, 0.75 +/- 0.02 cf. 0.82 +/- 0.01 (P < 0.001). The postprandial increases in EE and NPRQ were of similar magnitude in both groups. Abstinence from alcohol for 14 days was accompanied by reduced energy intake, 16 +/- 1 cf. 11 +/- 1 MJ day-1 (P < 0.005) and decreased resting EE, 84 +/- 5 cf. 73 +/- 4 W (P < 0.05). The decrease in resting EE consistently occurred 4 days after abstinence from alcohol. CONCLUSIONS: Chronic alcohol abuse is associated with energy wasting and inhibition of adipose tissue accumulation. This may explain why alcoholics are not obese despite high total energy intakes.

Adipose Tissue↗

Energy expenditure of nonexercise activity.

BACKGROUND: We found recently that changes in nonexercise activity thermogenesis (NEAT) mediate resistance to weight gain with overfeeding in sedentary adults. A potentially important, yet seldom investigated, component of NEAT is the energy expenditure of fidgeting-like activities. OBJECTIVE: Our goal was to measure changes in energy expenditure with fidgeting-like activities. DESIGN: Energy expenditure was measured in 24 subjects (17 women and 7 men x+/- SD body weight: 76 +/- 21 kg) while recumbent at rest, sitting motionless, standing motionless, partaking of self-selected fidgeting-like movements while seated and while standing, and walking on a treadmill at 1.6, 3.2, and 4.8 km/h (1, 2, and 3 mph). Measurements were performed by using a high-precision, indirect calorimeter connected to the subject via a transparent, lightweight facemask that enabled almost unrestricted movement. RESULTS: Compared with metabolic rate in the supine position (5.4 +/- 1.5 kJ/min), energy expenditure increased while sitting motionless by 4 +/- 6%, while fidgeting while seated by 54 +/- 29% (P: < 0.0001), while standing motionless by 13 +/- 8% (P: < 0.0001), while fidgeting while standing by 94 +/- 38% (P: < 0.0001), while walking at 1.6 km/h by 154 +/- 38% (P: < 0.0001), while walking at 3.2 km/h by 202 +/- 45% (P: < 0.0001), and while walking at 4.8 km/h by 292 +/- 81% (P: < 0.0001). There was a significant, positive correlation between changes in energy expenditure and body weight for fidgeting-like activities while standing (r = 0.43, P: = 0.02) but not while seated. CONCLUSIONS: There is marked variance between subjects in the energy expenditure associated with self-selected fidgeting-like activities. The thermogenic potential of fidgeting-like and low-grade activities is sufficiently great to substantively contribute to energy balance.

Adult↗

Measuring leg muscle and fat mass in humans: comparison of CT and dual-energy X-ray absorptiometry.

Dual-energy X-ray absorptiometry (DEXA) is reported to be inferior to computed tomography (CT) to measure changes in appendicular soft tissue composition. We compared CT- and DEXA-measured thigh muscle and fat mass to evaluate the random and systematic discrepancies between these two methods. Thigh skeletal muscle area (single-slice CT) was suboptimally (r(2) = 0.74, P < 0.0001) related to DEXA-measured thigh fat-free mass (FFM). In contrast, thigh muscle and adipose tissue volumes (multislice CT) were highly related to DEXA-measured thigh FFM and fat (both r(2) = 0.96, P < 0.0001). DEXA-measured leg fat was significantly less than multislice-CT-measured leg adipose tissue volume, whereas multislice-CT-measured leg muscle mass was less (P < 0.0001) than DEXA-measured leg FFM. The systematic discrepancies between the two approaches were consistent with the 10-15% nonfat components of adipose tissue. In conclusion, CT and DEXA measures of appendicular soft tissue are highly related. Systematic differences between DEXA and CT likely relate to the underlying principles of the techniques.

Absorptiometry, Photon↗

Preventing stroke in patients with atrial fibrillation.

CONTEXT: Atrial fibrillation, a common disorder that affects nearly one sixth of the population aged 75 years and older, is a major risk factor for stroke. OBJECTIVES: To review and evaluate the evidence supporting the use of warfarin and/or aspirin for stroke prevention in patients with atrial fibrillation. DATA SOURCES: Prospective, randomized trials of patients with atrial fibrillation evaluating either warfarin or aspirin or both, from MEDLINE from January 1, 1966, to February 23, 1999. STUDY SELECTION: Five primary prevention placebo-controlled studies, which had been formally pooled, 1 study evaluating secondary prevention of stroke, 1 study comparing warfarin with aspirin, and 3 studies of warfarin in combination with aspirin were identified. DATA SYNTHESIS: The risk of developing stroke is heterogeneous and increases with each decade above 65 years; history of high blood pressure, diabetes mellitus, previous transient ischemic attack, or stroke; poor ventricular function; and in women older than 75 years. For patients younger than 65 years, without risk factors, and not receiving antithrombotic therapy, the risk of stroke is 1%/y; those without risk factors between the ages of 65 and 75 years have a risk of 1.1%/y if taking warfarin and 1.4%/y if taking aspirin. For all other patients, stroke risk is reduced from an untreated rate of between 4.3%/y and more than 12%/y to a rate of 1.2%/y to 4%/y with warfarin use. CONCLUSION: The protection afforded by warfarin is most pronounced in patients at the highest risk for stroke, while aspirin treatment seems adequate in low-risk populations.

Adult↗

Role of nonexercise activity thermogenesis in resistance to fat gain in humans.

Humans show considerable interindividual variation in susceptibility to weight gain in response to overeating. The physiological basis of this variation was investigated by measuring changes in energy storage and expenditure in 16 nonobese volunteers who were fed 1000 kilocalories per day in excess of weight-maintenance requirements for 8 weeks. Two-thirds of the increases in total daily energy expenditure was due to increased nonexercise activity thermogenesis (NEAT), which is associated with fidgeting, maintenance of posture, and other physical activities of daily life. Changes in NEAT accounted for the 10-fold differences in fat storage that occurred and directly predicted resistance to fat gain with overfeeding (correlation coefficient = 0.77, probability < 0.001). These results suggest that as humans overeat, activation of NEAT dissipates excess energy to preserve leanness and that failure to activate NEAT may result in ready fat gain.

Activities of Daily Living↗

Leptin responses to overfeeding: relationship with body fat and nonexercise activity thermogenesis.

Administration of leptin to rodents results in weight loss through decreased food intake and increased energy expenditure that occurs in part through increased spontaneous activity. In humans, low levels of spontaneous physical activity and below normal plasma leptin concentrations predict subsequent excess weight gain. We recently found that failure to increase nonexercise activity thermogenesis (NEAT) with overfeeding results in greater fat gain in humans, and subsequently evaluated whether changes in leptin are related to NEAT activation. We measured plasma leptin concentrations and adipose tissue leptin messenger ribonucleic acid together with the components of energy expenditure in 16 nonobese humans before and after overfeeding to assess the relationship between leptin responses to overfeeding and the changes in NEAT. Adipocyte leptin expression was up-regulated with overfeeding, and leptin concentrations increased. Leptin concentrations correlated with body fat before and after overfeeding. Changes in leptin with overfeeding were strongly related to changes in body fat, but not to changes in NEAT. Changes in NEAT correlated inversely with fat gain. It is, therefore, unlikely that leptin mediates activation of NEAT with overfeeding in nonobese humans; rather, leptin directly reflects body fat mass and fat mass gain.

Adipose Tissue↗

Clinical usefulness of MR imaging of the breast in the evaluation of the problematic mammogram.

OBJECTIVE: This study was undertaken to determine the usefulness of MR imaging of the breast as an adjunct to mammography in problematic cases in which the significance, presence, or location of an abnormality could not be determined. MATERIALS AND METHODS: From January 1993 through February 1998, 86 lesions for which histologic or mammographic follow-up was available were evaluated by breast MR imaging because of equivocal findings on mammography. MR studies were performed with a dedicated breast multicoil on a 1.5-T scanner. Early studies were done using a T1-weighted two-dimensional spin-echo sequence before and after the administration of contrast material. Later studies were performed using a three-dimensional fast spoiled gradient sequence with fat suppression. Studies were considered to be positive for an abnormality if a focal area of enhancement was seen after contrast administration. RESULTS: MR imaging had positive findings in 38 sites. Twenty-six of these sites corresponded in location to the mammographic abnormality that had prompted the recommendation for MR imaging. The remaining 12 sites occurred in areas not suspected mammographically. At biopsy, 10 (26%) of the 38 positive sites were malignant. MR imaging had negative findings at 60 other sites that had been suspected mammographically. Of these 60 sites, six were treated with excision, all with benign results; the remaining 54 sites showed mammographic stability on follow-up that ranged from 5 to 66 months (mean, 19 months). CONCLUSION: MR imaging of the breast can be a valuable adjunct to mammography for selected problematic cases.

Adult↗