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J Senges

Publications and source records attributed to J Senges.

At least 19 recordsLinked to original sources
PubMed2006

[Predictive value of an ischemia test in men and women with stable angina pectoris in clinical practice. Results of the heart catheter registry of the Working Society of Senior Hospital Cardiologists].

BACKGROUND AND OBJECTIVE: Symptoms of coronary artery disease (CAD) and the accuracy of non-invasive tests differ between men and women. This study sought to evaluate the difference between the predictive value of a stress test in clinical practice for the diagnosis of significant coronary heart disease (CHD: stenosis > 50%) between women and men with stable angina. PATIENTS AND METHODS: 143,848 consecutive patients undergoing diagnostic coronary angiography at 99 hospitals during 2002 were included in the prospective cardiac catheter registry of the Working Party of Senior Hospital Cardiologists (Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte [ALKK]). All patients with stress test and stable angina CCS class I-III (n=27387; 20.4%) were included, 10,911 (39.8%) of them female. 70.6% of women and 73.2% of men had a positive stress test. RESULTS: In 46.1% of women and 71.5% of men with positive test and stable angina had relevant CHD (p<0,001). Diabetes increased the prevalence of CHD in patients with a positive test both in women (65.5%) and men (80.5%), with CCS class III angina to 63.3% and 85.8%, respectively. CONCLUSIONS: In clinical practice a positive stress test in women with stable angina is associated significantly less often with clinically relevant CHD than in men. The low positive predictive value of 46.1% underlines the need for additional clinical features like diabetes or cardiac symptoms (CCS class) before invasive diagnosis is performed.

Adult↗
PubMed2006

Beneficial effects of abciximab in patients with primary percutaneous intervention for acute ST segment elevation myocardial infarction in clinical practice.

OBJECTIVES: To assess the safety and effectiveness of abciximab in patients with ST elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI) in clinical practice. METHODS: Data were analysed of 2184 consecutive patients treated with primary PCI for acute STEMI and either concomitant abciximab or no glycoprotein IIb/IIIa inhibitor (control group), who were prospectively enrolled in the Acute Coronary Syndromes (ACOS) registry between July 2000 and November 2002. RESULTS: Patients who were treated with abciximab were younger than the control group, and fewer of them had a history of stroke/transient ischaemic attack and systemic hypertension, but more of them had three-vessel coronary artery disease and cardiogenic shock. Cumulated mid-term survival for patients treated with abciximab was significantly higher than in the control group (91% v 79%, log rank p < 0.05, median observational time 375 days, range 12-34 months). The Cox proportional hazards model of mid-term mortality after admission with adjustment for baseline characteristics showed that mortality was significantly lower in the abciximab group than in the control group (hazard ratio 0.68, 95% confidence interval 0.49 to 0.95). Whereas overall there was no difference in bleeding complications, patients older than 75 years had more major bleeding events with abciximab (12.5% v 3.4%, p = 0.03). CONCLUSION: In clinical practice adjunctive treatment with abciximab in patients with primary PCI for acute STEMI was associated with a reduction in mid-term mortality. The subgroup of patients older than 75 years who were treated with abciximab had more major bleeding complications.

Abciximab↗
PubMed2005

[Mortality of patients who are older than 75 years after ST elevation myocardial infarction in clinical practice].

BACKGROUND: Patients who are older than 75 years are often excluded in clinical trials evaluating therapies for ST elevation myocardial infarction. Therefore there is a lack of prospective data for this steadily increasing number of elderly patients. PATIENTS AND METHODS: Between 07/2000 and 11/2002 a total of 16 823 patients with acute coronary syndromes in 154 hospitals were enrolled in the ACOS registry, with 8309 having a STEMI. Baseline characteristics, therapies during the hospital course and at discharge, hospital-mortality and 1-year mortality were prospectively collected. In this study we analysed the outcome of patients older than 75 years with STEMI of less than 24 duration. RESULTS: A total of 2045 patients > 75 years (median age 80.1 years, 53.9 % women) were included. Of the latter 51 % were treated conservatively, 19 % with fibrinolysis and 30 % with primary PCI. In-hospital mortality in the three groups was 23.4 %, 25.4 % und 10.2 %, while total mortality after one year was 52.4 %, 41.3 % und 19.3 %, respectively. In the multivariate analysis both primary PCI (odds ratio 0.36, 95 % CI 0.25 - 0.52) and fibrinolysis (odds ratio 0.65, 95 % CI 0.44 - 0.97) where associated with a lower mortality after discharge. CONCLUSION: Hospital- as well as 1-year mortality in patients with STEMI who are older than 75 years are high. Primary PCI is associated with a decrease of in-hospital and 1-year mortality, while fibrinolysis improves mortality after discharge. Therefore early reperfusion therapy, preferably with primary PCI should be considered in elderly patients, after taking in count biological age and major comorbidities.

Acute Disease↗
PubMed2005

Carotid artery stenting in clinical practice results from the Carotid Artery Stenting (CAS)-registry of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausarzte (ALKK).

BACKGROUND: Carotid artery stenting (CAS) for symptomatic and asymptomatic carotid stenosis seems to be on the doorstep of more widespread use. However, its feasibility and safety in clinical practice at a broad spectrum of hospitals needs to be determined. METHODS: We analyzed data of the prospective multi-centre Carotid Artery Stenting (CAS) Registry of the German Arbeitsgemeinschaft Leitende Kardiologische Krankenhausarzte (ALKK). RESULTS: From 7/1996 to 5/2004 1888 patients from 28 hospitals were included in the CAS Registry. The median hospital stay from CAS until hospital discharge was 3 days (quartiles: 2-6 days). Median patients age was 70 years (quartiles: 64-76 years) with 72.1% males. CAS for symptomatic stenosis was performed in 55% of cases. Patients treated with CAS suffered from coronary artery disease in 66.5%, had arterial hypertension in 91.7%, hyperlipidemia in 86.3% and 34.2% were diabetics. The intended CAS procedure was completed in 98.1% of cases. A stent was implanted in 97.3% of completed cases. The median intervention time was 43 min (quartiles: 30-60 min). During the hospital stay death rate was 0.3% (5/1888) and the rate of ipsilateral stroke 3.2% (58/1840). A contralateral ischemic event occurred in 1.4% (26/ 1840) of patients. The combined rate of all death or strokes was 3.8% (70/1841). Between 1996 and 2004 there was a steady increase in the use of protection devices during CAS (0% in 1996 and 97.9% in 2004; p for trend <0.0001). There was also an increase in the proportion of patients treated for asymptomatic stenoses (p for trend <0.0001). We observed a decrease of the combined endpoint of death or stroke from 6.3% in 1996 to 1.9% in 2004 (p for trend=0.021). CONCLUSION: The multi-centre ALKK CAS Registry data confirm the feasibility and shot-term safety of CAS even in daily clinical practice. There was a rapid penetration of the use of embolic protection devices, an increase in treatment of asymptomatic carotid stenoses and a decrease in acute complication rates from 1996 to 2004.

Aged↗
PubMed2005

Sirolimus-eluting stent treatment for isolated proximal left anterior descending artery stenoses. Results from the prospective multi-center German Cypher Registry.

BACKGROUND: Stenting of isolated proximal LAD stenoses is still a controversial issue since it is associated with higher target vessel revascularization (TVR) rate than both bypass surgery using the internal mammary artery, and stenting of other coronary artery territories. The sirolimus- eluting stent (SES) has been reported to significantly reduce restenosis rates in de novo coronary lesions. Therefore, we compared patients from the German Cypher Registry treated with SES for isolated proximal LAD lesions with those stented for isolated lesions in the proximal LCX or RCA. METHODS: A total of 349 patients treated with SES were analyzed. 249 patients were treated for proximal LAD stenosis, and 100 for proximal LCX/RCA stenoses. The combined clinical endpoint was MACCE (death of any cause, non-fatal MI and non-fatal stroke) and TVR at 6 months. RESULTS: In-hospital events (death, MI and TVR) did not differ significantly between both groups (3.2% for the LAD group vs 2.0% for the LCX/RCA-group, p=0.73). The combined end point of death of any cause, non-fatal MI and non-fatal stroke at six months was 2.6% in the LAD group, and 2.2% in the LCX/RCA group (p=1.0). TVR occurred in 4.8% of the LAD group and in 6.5% of the LCX/RCA group at six months (p=0.58). The percentage of patients free from angina at daily activities was 80.6% in the LAD group, and 77.4% in the LCX/ RCA group (p=0.52). CONCLUSION: SES once implanted into isolated proximal LAD stenoses appears as effective as reported in other vessel territories. Accordingly, stenting of the proximal LAD using SES might prove a suitable alternative to surgery.

Activities of Daily Living↗
PubMed2005

Incications and complications of invasive diagnostic procedures and percutaneous coronary interventions in the year 2003. Results of the quality control registry of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausarzte (ALKK).

BACKGROUND: The ALKK registry contains about 20% of the invasive and interventional cardiological procedures performed in Germany. METHODS: In 2003 a total of 82,282 consecutive diagnostic invasive and 30,689 interventional procedures from 75 hospitals were centrally collected and analyzed. RESULTS: The main indication for an invasive diagnostic procedure was coronary artery disease in 92.5% of cases, myocardial disease in 1.6%, impaired left ventricular function in 4.0%, valve disease in 4% and other indications in 1.9%. An acute coronary syndrome was present in 25% of the patients. The rate of severe complications in patients with a lone diagnostic invasive procedure was low (<0.5%). The indication for percutaneous coronary intervention (n=30,689) was stable angina in 44.1%, ST elevation myocardial infarction in 22.3%, non ST elevation myocardial infarction in 14.8%, unstable angina in 10.0%, silent ischemia in 2.2%, prognostic in 5.2% of patients. The majority of interventions were performed directly after the diagnostic procedure (n=23,887=78.6%). The intervention was successful in 94.6% of cases. Stent implantation was performed in 77.2%, with 1 stent in 88.4%, two stents in 7.6% and 3 or more stents in 3.3%. A drug-eluting stent was implanted in 3.6% of the cases. The complication rate after PCI was influenced by the indication for the intervention. The in-hospital mortality in patients with cardiogenic shock was 33%, while in patients with stable angina, silent ischemia and prognostic indication only 0.2% died. CONCLUSION: There is an increase of invasive diagnostic and interventional procedures in patients with acute coronary syndromes, with 47% of PCIs performed in these patient. PCIs were performed in 75% of the cases directly after the diagnostic procedure. The rate of stent implantation seems to have reached a plateau at around 80%, while drug-eluting stents were implanted only in a minority of cases. The complication rate is mainly dependent on the clinical presentation of the patients and the indication for PCI.

Aged↗
PubMed2005

Stent-supported angioplasty versus endarterectomy for carotid artery stenosis: evidence from current randomized trials.

BACKGROUND: Carotid artery stenting (CAS) for carotid artery stenoses is evolving as an alternative to carotid endarterectomy (CEA). However, the value of CAS is still a matter of debate. Therefore, we performed a metaanalysis of the randomized controlled clinical trials (RCT) on this issue. METHODS: RCTs were identified through searching MEDLINE, textbooks and by personal communication. RESULTS: Six finished RCTs on this issue could be identified, including 1263 patients, 628 randomized to CAS and 635 to CEA. The 30-day death or stroke rate was 8.0% (50/628) in patients treated with CAS compared to 6.1% (39/635) in CEA patients (OR=1.36, 95% CI: 0.88-2.11; p=0.17; p for heterogeneity=0.009). The rate of cranial nerve palsy was 7.1% in the CEA compared to 0% in the CAS group (p<0.0001). The rate of myocardial infarctions was reduced from 3.1 to 1% (OR=0.32, 95% CI: 0.12- 0.81; p=0.02; p for heterogeneity=0.49). The death or stroke rate during follow-up was 12.1% in patients treated with CAS compared to 12.2% in CEA patients (OR=0.99, 95% CI: 0.70-1.42; p=0.98; p for heterogeneity=0.02). CONCLUSION: The available RCT data on CAS vs. CEA suggest that both methods seem to be equally effective concerning short- and medium-term results, while CAS is associated with lower minor complications than CEA. However, because of the significant heterogeneity between the study outcomes, the results of the large RCTs underway should be awaited before it can be advised to use CAS in a broader perspective.

Angioplasty, Balloon↗
PubMed2005

In-hospital time to treatment of patients with acute ST elevation myocardial infarction treated with primary angioplasty: determinants and outcome. Results from the registry of percutaneous coronary interventions in acute myocardial infarction of the Arbeitsgemeinschaft Leitender Kardiologischer Krankenhausarzte.

OBJECTIVE: To determine the predictors of time between presentation and primary angioplasty and the influence of this delay time on in-hospital mortality in clinical practice. DESIGN: Analysis of data from the registry of percutaneous coronary interventions in acute myocardial infarction of the Arbeitsgemeinschaft Leitender Kardiologischer Krankenhausärzte (ALKK). PATIENTS: Data of 4815 patients registered at 80 hospitals between 1994 and 2000 were analysed. RESULTS: Mean age of the patients was 61.4 (12.5) years. Cardiogenic shock was present in 14.1%. Mean time from admission to primary angioplasty ("door to angiography" time) was 83 (122) minutes. Logistic regression analysis showed the presence of a bundle branch block (odds ratio (OR) 1.95, 95% confidence interval (CI) 1.15 to 3.29), prior coronary artery bypass grafting (OR 1.67, 95% CI 1.08 to 2.59), pre-hospital delay > 3 hours (OR 1.61, 95% CI 1.37 to 1.89), and female sex (OR 1.21, 95% CI 1.01 to 1.45) to be independently associated with longer door to angiography times, whereas a higher hospital volume of performing primary angioplasty (OR 0.53, 95% CI 0.46 to 0.62) and the year of the investigation (OR 0.96, 95% CI 0.92 to 1.00) were independently associated with shorter door to angiography times. Independent predictors of in-hospital mortality were cardiogenic shock (41.6% v 4.0% without cardiogenic shock, p < 0.0001), technical success (29.2% with TIMI (thrombolysis in myocardial infarction) flow < 3 v 6.5% with TIMI flow 3, p < 0.0001), age (16.5% > or = 70 years v 6.6% < 70, p < 0.0001), three vessel disease (16.5% v 6.8% with < 3 vessel disease, p < 0.0001), anterior location of infarction (12% v 7.4% without anterior infarction, p < 0.0001), year of inclusion (adjusted OR 0.92 per year, p = 0.011), and volume of primary angioplasty at the hospital (11% for < 20 angioplasty procedures/year v 8.3% for > or = 20/year, p = 0.027) but not the door to angiography time (adjusted OR 1.14 per tertile, p = 0.397). CONCLUSIONS: In current clinical practice in Germany median door to angiography time is quite short (83 (122) minutes). Some patients and hospital factors are independently associated with a longer door to angiography time. Within the observed short in-hospital delays door to angiography time did not influence in-hospital mortality. However, efforts to keep them as short as possible should be continued.

Angioplasty, Balloon, Coronary↗
PubMed2004

[Quality registries in cardiology].

Prospective registries performed in consecutive patients with frequent cardiac diseases and procedures are able to provide important information about therapies, complications, clinical outcome, and temporal trends in cardiology. Since 1992 all consecutive percutaneous coronary interventions (PCI) performed in over 80 hospitals of the ALKK (Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte) have been centrally collected in a registry. This registry contains over 20% of all PCI procedures performed in Germany during the last 10 years. By restricting the documentation to a limited number of items, it was possible to establish this registry with a high degree of completeness of the data. A similar concept formed the basis for five consecutive registries in patients admitted with acute myocardial infarction. In these registries the participating investigators were asked to provide reasons for their treatment decisions, e. g., withholding guideline- adherent therapies. With this feature an increase in the use of guideline-adherent therapies could be observed, which was associated with an improvement in clinical outcome.

Angioplasty, Balloon, Coronary↗
PubMed2004

"Real life" use of sirolimus-eluting coronary stents in Germany. Results from the prospective multi-centre German Cypher Registry.

BACKGROUND: Drugeluting stents (DES) are currently judged to be a "break-through" technology for the prevention of restenosis after percutaneous coronary interventions (PCI). However, experience is limited to randomised controlled clinical trials (RCT) in selected lesions and the currently available DES are more expensive compared to conventional "bare" stents. Therefore, actual clinical practice may be very different to RCT. METHODS: We analysed the data of the German Cypher trade mark Registry, a nationwide registry which was initiated in parallel to the launch of the first DES, the Cypher trade mark sirolimus-eluting coronary stent, in April 2002. RESULTS: From April 2002 until March 2003, 1638 procedures at 88 hospitals were included in the German Cypher trade mark Registry. The mean inclusion rate per centre and month remained low (<3 procedures/month and participating hospital) during the whole inclusion period. Most patients presented with stable angina pectoris (45.8%); however, 6.4% of patients were treated for a non-ST elevation myocardial infarction, 10.3% of patients for ST elevation myocardial infarction and 1.7% in cardiogenic shock. In patients without ST elevation myocardial infarction, a de novo stenosis was treated in 68.4% of cases, a restenosis in 4.1%, and an in-stent restenosis in 25.5% of cases. Chronic total occlusions were treated in 6.1% of patients. Predilatation was performed in 68.3% of patients and 1.05 +/- 0.35 Cypher trade mark stents were implanted per patient with a median (quartiles) stent length of 18 (13-21) mm. PCI-related death occurred in 0.1% of patients and a Q-wave myocardial infarction in 1.1%. Urgent re-PCI before hospital discharge was performed in 1.3% and urgent bypass surgery in 0.1% of cases. CONCLUSIONS: The use of the sirolimus-eluting coronary stents in this "real life" registry was found to be safe concerning acute complications. In about one half of the registry patients, the DES was implanted in lesions that were excluded from RCTs.

Blood Vessel Prosthesis↗
PubMed2004

Antibody levels against Chlamydia pneumoniae and outcome of roxithromycin therapy in patients with acute myocardial infarction. Results from a sub-study of the randomised Antibiotic Therapy in Acute Myocardial Infarction (ANTIBIO) trial.

BACKGROUND: Results of studies concerning prevention of cardiovascular disease by treatment with macrolide antibiotics targeting C. pneumoniae infection are still controversial. This study describes the results of different tests for infection with C. pneumoniae as well as the effect of treatment with roxithromycin in patients with acute myocardial infarction (AMI) in relation to their serostatus against C. pneumoniae. METHODS: We analysed blood of 160 patients who came from the ANTIBIOtic therapy after an AMI ( ANTIBIO-) study, a prospective, randomised, placebo-controlled, double-blind study to investigate the effect of roxithromycin 300 mg/OD for 6 weeks in patients with an AMI. Anti- Chlamydia IgG-, IgA-, and IgM-antibodies of these patients were analysed by means of different test systems. RESULTS: There was a good correlation between the two IgG and IgA methods (r = 0.900, p < 0.001 and r = 0.878, p < 0.001, respectively), but marked differences in the prevalence of positive tests. This resulted in only moderate concordance values, as expressed by the Kappa coefficients, for IgG kappa = 0.611 (95% CI = 0.498-0.724, p < 0.001) and for IgA kappa = 0.431 (95% CI: 0.322-0.540, p < 0.001). No significant association between positive C. pneumonia titers and the combined clinical endpoint during the 12 month follow-up could be found. In all test systems used, patients with positive anti- C. pneumoniae titers did not benefit from roxithromycin therapy (p = ns). CONCLUSION: Depending on the test system used, there are large differences in the prevalence of anti- C. pneumoniae seropositive patients. Clinical events during the 12 month follow-up after AMI did not depend on serostatus against C. pneumoniae and treatment with roxithromycin did not influence these events, independently of the serostatus against C. pneumoniae. However, the power of this subgroup analysis was low to detect small but significant differences.

Anti-Bacterial Agents↗
PubMed2004

[Prehospital delay-not just a question of patient knowledge].

Patients with acute myocardial infarction reaching the hospital within the first hour after symptom onset preserve their chances for an optimal treatment. But only about one fifth of them actually reach the hospital within this "golden hour". Information of the public to reduce time from symptom onset to medical service call have shown success only during the time the continuous publicity was maintained. Soon after the end of such activities the prehospital delay again reached the initial duration. Because of restricted resources, prehospital thrombolysis as another means of reducing time to treatment is as yet only used for a very small proportion of patients. Reduction of door-to-balloon and -treatment time seems to have reached its limit in recent years. In patients with delayed hospital admission, the use of PTCA interventions seems to result in better outcome data compared to thrombolysis.

Angioplasty, Balloon, Coronary↗
PubMed2003

[Too many heart catheter procedures in Germany ?].

BACKGROUND AND OBJECTIVE: Absolute numbers of cardiovascular procedures are higher in Germany as compared to other European countries. This fact is used as an argument for overuse. Therefore other indicators of an inappropriate use of these resources should be of interest. PATIENTS AND METHODS: The relationship between diagnostic cardiac catheterisations and consequent revascularisation procedures were compared in 8 European countries. In addition the indication criteria for cardiac catheterisations were reviewed in a German registry of 205.581 consecutive inpatients. RESULTS: Revascularisation procedures after diagnostic catheterisations in 8 countries range from 39,1 % to 57,9 %. Germany reaches 43,2 %. A relation between absolute numbers of diagnostic and percent subsequent revascularisation procedures does not exist. In a German registry the following indications for cardiac catheterisation could be identified: Acute Coronary Syndrome 22,9 %. Angina pectoris according to the Canadian Cardiac Society classification was present: CCS II/III in 80,3 %, CCS IV in 17,2 %. An exercise test was performed in 43 %. Final diagnoses were: significant coronary disease 69,5 %, exclusion of disease 9,4 %, lesions < 50 % 9 %, other cardiac disease 12,1 %. CONCLUSION: Absolute numbers cannot be used as an indicator of overuse of cardiovascular procedures. Instead standards for data acquisition should be established on European, national and regional levels. In addition a validation procedure for criteria has to be developed in order to judge the appropriateness of indications for invasive cardiac procedures in different health care systems.

Angiocardiography↗
PubMed2003

Prognostic value of non-sustained ventricular tachycardias after acute myocardial infarction in the thrombolytic era: importance of combination with frequent ventricular premature beats.

PURPOSE: of this study was to re-evaluate the association between ventricular arrhythmias and long-term mortality after acute myocardial infarction (AMI) in the thrombolytic era. METHODS: MITRA (maximal individual therapy in patients with AMI) is a multicenter registry of 54 hospitals in Germany investigating patients with AMI. RESULTS: 2420 patients received Holter ECG. Positive Holter ECG was defined: > or =10 ventricular premature beats (VPB)/h, or > or =4 couplets/d, or > or =1 non-sustained ventricular tachycardia (nsusVT)/d, or their combination. Mortality rates (median 17 months) were 6.5% without ventricular arrhythmias, with > or =10 VPB/h 15.2% and with the combination of > or =10 VPB/h plus either > or =4 couplets/d or > or =1 nsusVT/d 23.4%. In multivariate analysis, none of the ventricular arrhythmias alone correlated with mortality. There was a significant association between mortality and the combination of > or =10 VPB/h plus > or =4 couplets/d (OR 2.3) or > or =10 VPB/h plus > or =1 nsusVT/d (OR 2.8). CONCLUSION: Non-sustained VTs are only associated with poor prognosis if combined with frequent VPBs.

Adrenergic beta-Antagonists↗
PubMed2003

Usefulness of a non-invasive scoring system in predicting the outcome of electrophysiologic studies in non-invasively unexplained syncope.

BACKGROUND: An electrophysiologic study is a useful method to clarify the cause of non-invasively unexplained syncope in 18-60% of patients. However, it is invasive with possible procedure-related complications. Therefore, it would be helpful to identify patients in whom an electrophysiologic study is useful for diagnosis of syncope. METHODS: Patients with unexplained syncope were prospectively enrolled in a registry, if an electrophysiologic study was performed. The study group comprised of 643 consecutive patients. RESULTS: The electrophysiologic study revealed conduction abnormalities and tachyarrhythmias accounting for syncope in 35% of patients. Using a logistic regression model, history of injury during syncope (p<0.001), ejection fraction < or =40% (p=0.03), and PR interval >0.2 s (p=0.001) were independent predictors of an abnormal electrophysiologic study. These three clinical and easily measurable variables were entered into a scoring system. The maximal score consisted of 3 points. A score of >1 predicts a positive electrophysiologic study result in more than 70% of patients with non-invasively unexplained syncope. CONCLUSION: Electrophysiologic abnormalities were detected in 35% of patients with unexplained syncope. A history of injury, ejection fraction < or =40% and a PR interval >200 ms were independent predictors for a positive electrophysiologic study.

Adult↗