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Biomedical subjects

K Wegscheider

Publications and source records attributed to K Wegscheider.

At least 19 recordsLinked to original sources
PubMed1999

Risk stratification following myocardial infarction in the thrombolytic era: a two-step strategy using noninvasive and invasive methods.

OBJECTIVES: We prospectively performed a two-step risk assessment in patients in the early phase after acute myocardial infarction (MI). BACKGROUND: Noninvasive methods like Holter electrocardiographic monitoring (HM) and determination of the left ventricular ejection fraction (EF) as well as the invasive technique of programmed ventricular stimulation (PVS) have been used to identify patients in the late phase after MI as candidates for prophylactic implantation of a cardioverter/defibrillator. However, it is unclear whether these results can be transferred to patients following acute MI. METHODS: A series of 657 patients with acute MI (< or = 75 years) underwent HM and EF. If one of the two methods yielded abnormal findings (HM > or = 20 ventricular ectopic beats/h/> or =10 ventricular pairs/day/ventricular tachycardia; EF < or = 40%), PVS was done (abnormal PVS: induction of monomorphic ventricular tachycardia, duration >10 s, cycle length > or = 230 ms). RESULTS: Of 657 patients, 304 (46%) had either an abnormal HM or EF. The PVS performed in 146 of 304 patients was abnormal in 22. During a mean follow-up of 37 months, there were 106 (16%) deaths, being sudden in 24 (3.6%), nonsudden cardiac in 45 (6.8%). The incidence of arrhythmic events (sudden cardiac death, symptomatic ventricular tachycardia, cardiac arrest) was 18% (4/22) with an abnormal PVS and only 4% (5/124) with a normal PVS (odds ratio 4.0, p=0.032). CONCLUSIONS: The rate of arrhythmic events is low in post-MI patients in the 1990s. Nevertheless, a two-step risk stratification is helpful in selecting candidates for a defibrillator trial aiming at primary prevention of sudden cardiac death after MI.

Combined Modality Therapy↗
PubMed1998

Effects of thrombolytic therapy in acute inferior myocardial infarction with or without right ventricular involvement. HIT-4 Trial Group. Hirudin for Improvement of Thrombolysis.

OBJECTIVES: This study assessed the prognostic impact of right ventricular involvement (RVI) in streptokinase-treated patients with inferior acute myocardial infarction (AMI) stratified for small or large AMI. BACKGROUND: Only scant data exist from small studies about the impact of reperfusion therapy on survival in patients with RVI during inferior AMI. METHODS: Right ventricular involvement was assessed by ST-segment elevation > or =0.1 mV in lead V4R and infarct size by the extent of ST-segment deviation on the baseline electrocardiogram: small AMI=sum ST-segment elevation < or =0.8 mV and no precordial ST-segment depression (small ST); large AMI=presence of precordial ST-segment depression or sum ST-segment elevation >0.8 mV (large ST) in 522 inferior AMI patients of the Hirudin for Improvement of Thrombolysis (HIT-4) Trial. In 187 patients, 90-min coronary angiography was performed. RESULTS: Right ventricular involvement was present in 169 patients (32%). Higher 30-day cardiac mortality rates with RVI (5.9% vs. 2.5%) were related to larger infarct size rather than to RVI. For large ST, a proximal right coronary artery lesion was observed in 52% with and in 23% without RVI. Patency rates at 90 min were similar (54% vs. 52%). In the 28% of patients who had small ST, cardiac mortality was less than 1% irrespective of the presence of RVI. Coronary artery lesions were mostly located distally. Patency rates were 27% with and 80% without RVI. CONCLUSIONS: ST-segment elevation of > or =0.1 mV in V4R in inferior AMI patients is associated with larger infarct size and higher 30-day mortality rates. Right ventricular involvement is not an independent predictor of survival. In patients with small ST, cardiac mortality is low, even if ST V4R is > or =0.1 mV.

Coronary Angiography↗
PubMed1997

Significance of initial ST segment changes for thrombolytic treatment in first inferior myocardial infarction.

OBJECTIVE: To evaluate the benefit to risk ratio of thrombolytic treatment in patients with small inferior acute myocardial infarction (AMI). Controlled studies relating the benefit from thrombolysis with initial electrocardiographic features are scarce and of limited sample size. DESIGN: Retrospective study of 728 patients with a first inferior AMI of six hours' duration from the Intravenous Streptokinase in Acute Myocardial Infarction (ISAM) study comparing streptokinase with placebo stratified by the initial sum ST segment elevation (sigma ST) of 0.8 mV or less and greater than 0.8 mV, and 636 patients from the International Joint Efficacy Comparison of Thrombolytics (INJECT) trial comparing double blind streptokinase with reteplase stratified by either sigma ST or the presence of precordial ST segment depression. RESULTS: ISAM study patients with an sigma ST of greater than 0.8 mV had a significant mortality benefit from streptokinase throughout six years, while those with an sigma ST of 0.8 mV or less showed a trend to higher mortality at six months (6.3% streptokinase v 5.1% placebo). Despite significantly smaller infarcts and fewer clinical complications in patients with an sigma ST of 0.8 mV or less (ISAM and INJECT) or the absence of precordial ST segment depression (INJECT) thrombolytic treatment was associated with higher early mortality than in those with initially larger ST segment deviations. CONCLUSION: Thrombolytic treatment in patients with inferior AMI presenting with larger ST segment deviations is associated with improved survival throughout six years. The risk to benefit ratio, however, in terms of early mortality in patients who have an sigma ST of 0.8 mV or less and no precordial ST segment depression may be unfavourable.

Electrocardiography↗
PubMed1996

Circadian, day-of-week, and seasonal variability in myocardial infarction: comparison between working and retired patients.

The circadian, day-of-week, and seasonal distributions of acute myocardial infarction and its association with the patients' working status were analyzed in a regionally defined population (n = 103, 322) monitored from 1980 to 1988. Included were 2906 consecutive patients (1746 [60.1%] men and 1160 [39.9%] women; mean age 67.8 years) with confirmed diagnosis (by standardized diagnostic criteria in hospitalized patients and autopsy results in out-of-hospital deaths). The time of myocardial infarction on the basis of onset of symptoms was known in 1901 cases. Myocardial infarction occurred more frequently (p < 0.05) during the morning from 7:00 to 10:00 AM, on Mondays, and during the winter from January to March compared with other times of day, days of the week, and seasons. Compared with retired patients, working patients (32%) had a second circadian peak, in the afternoon at 4:00 PM (p < 0.05), and a trend toward an additional seasonal peak in September (p value not significant), whereas the day-of-week pattern was similar in the two subgroups. The occurrence of myocardial infarction demonstrates marked circadian, day-of-week, and seasonal variations, with some differences between working and retired patients. Further investigation of possible triggering events may aid in identifying underlaying mechanisms and perhaps in improving prevention of the disease.

Aged↗
PubMed1996

Cancer incidence on a small island--research opportunities in general practice.

OBJECTIVE: To test the impression of an increased cancer incidence on the island of Pellworm (in the far North of Germany) and to illustrate the feasibility of a general practice-based approach in epidemiological research. DESIGN: Cancer incidence on Pellworm was prospectively registered in the only general practice on the island from 1986 to 1992. Age-standardized rates and expected rates were calculated on the basis of the Saarland cancer registry, the only registry in Germany. Standardized incidence ratios and 95% confidence intervals (CI) for Poisson-distributed events were also calculated. The cancer data were summed up over a seven-year period. SETTING: The only general practice on the island of Pellworm, a North Frisian marshland-island. SUBJECTS: The total practice population between 1986 and 1992 (N = 1172) RESULTS: The crude annual cancer incidence rate for Pellworm was, according to the impression, unexpectedly high: 634/100 000 for men and 502/100 000 for women. After age standardization, however, this increased rate of cancer incidence was even lower than in the Saarland (ratios: 0.86 for men and 0.95 for women). Only the incidence of neoplasms of the lymphatic and haematopoietic tissue in men exceeded the limits of statistical likelihood (ratio: 3.21; 95% CI: 1.17-7.10). CONCLUSION: The impression of an increased rate of cancer on Pellworm could not be validated. The overall incidence rate was even lower than expected. Only the rate of leukaemia/lymphoma (men) was significantly higher. Reasons for this result could not be detected by a descriptive approach. General practice is a suitable place for studies in cancer epidemiology, especially in such ideal circumstances as a clearly limited area and complete and reliable documentation.

Adolescent↗
PubMed1996

[Potential embolism sources in transesophageal echocardiography--prognostic value in patients with cerebral ischemia].

To determine whether potential sources of embolism such as atrial septal aneurysm (ASA), patent foramen ovale (PFO), mitral valve prolapse and atherosclerotic aortic debris can influence the outcome of patients after first cerebral ischemic event (CIE), 214 patients (124 stroke, 21 RIND, 69 TIA) were examined by transesophageal echocardiography (TEE) up to 3 weeks after CIE and followed up for 12 months. For risk estimation, the patients were subdivided into group I = without and group II = with potential sources of embolism. We additionally took into account cardiovascular diseases and atherosclerotic risk factors (group la + IIa without, Ib + IIb with). Recurrence occurred in 14 out of 214 patients (6.5%). Univariate analysis demonstrated that the presence of ASA, PFO and aortic debris as well as cardiovascular diseases and atherosclerotic risk factors was associated with a twofold to threefold higher incidence of recurrent events. While potential sources of embolism alone had no influence on the recurrence rate (group I:8/111 = 7.2% versus group II: 6/103 = 5.8%, n.s.), this was significantly different in relation to cardiovascular diseases and atherosclerotic risk factors (groups Ia + IIa: 0/66 = 0%, groups Ib + IIb: 14/148 = 9.8%, p < 0.01). Our results show that potential sources of embolism do not appear to influence the recurrence rate in cardiac healthy subjects. In patients with cardiovascular diseases, however, potential sources of embolism are associated with a higher risk of recurrence, and should therefore be imaged by TEE.

Adult↗
PubMed1996

Uric acid lowering effect of oxipurinol sodium in hyperuricemic patients - therapeutic equivalence to allopurinol.

OBJECTIVE: Oxipurinol has been shown to be sufficiently absorbed after oral administration as a rapid release preparation of oxipurinol sodium. We compared the uric acid lowering affect of allopurinol and oxipurinol. METHODS: In a multicenter, randomized, double blind crossover trial in 99 hyperuricemic patients with normal renal function we investigated the uric acid lowering effect of oxipurinol sodium (O) in daily amounts equimolar to 300 mg allopurinol (A). Mean pretreatment plasma uric acid concentrations in groups A/O and O/A were 8.3 +/- 1.4 and 8.7 + /- 1.4 mg/dl, respectively. RESULTS: In group A/O the mean plasma uric acid decreased to 5.4 +/- 1.2 mg/dl with allopurinol treatment, and increased slightly to 5.7 + /- 1.3 mg/dl during the consecutive oxipurinol period. In group O/A plasma uric acid declined to 6.0 +/- 1.4 mg/dl with oxipurinol and was 5.6 + /- 1.3 mg/dl at the end of the allopurinol period. The overall average reduction compared to baseline was 3.0 mg/dl with allopurinol and 2.6 mg/dl with oxipurinol. The difference between the 2 treatments was small but significant (multiple p=0.027,2 tailed). The corresponding mean plasma oxipurinol concentrations were 9.24 mu g/dl at the end of the allopurinol period and 9.9 mu g/dl after treatment with oxipurinol (NS). CONCLUSION: Oxipurinol is well absorbed and sufficiently effective in hyperuricemic patients when administered as a rapid release preparation of oxipurinol sodium. Oxipurinol sodium could be a substitute for allopurinol in hyperuricemic patients and possibly also with new uses for allopurinol.

Adult↗
PubMed1995

Extent of early ST segment elevation resolution: a strong predictor of outcome in patients with acute myocardial infarction and a sensitive measure to compare thrombolytic regimens. A substudy of the International Joint Efficacy Comparison of Thrombolytics (INJECT) trial.

OBJECTIVES: This study was undertaken to assess prospectively the prognostic power of early ST segment elevation resolution in a large cohort of patients with myocardial infarction and to test the value of differences in ST segment resolution as a surrogate end point. BACKGROUND: Previous studies revealed that the use of two cutoff points for three groups of ST segment resolution within 3 h after the start of thrombolysis is most effective in predicting outcome. METHODS: The International Joint Efficacy Comparison of Thrombolytics (INJECT) trial compared mortality in 6,010 patients randomized to receive either reteplase or streptokinase. The 1,909 German patients form the basis of this substudy. The three groups of ST segment resolution were defined as complete (> or = 70%), partial (70% to 30%) and no resolution (< 30% to > or = 0%). RESULTS: In 1,398 patients presenting < or = 6 h from onset of acute myocardial infarction, the 35-day mortality rate for complete, partial and no ST segment resolution was 2.5%, 4.3% and 17.5%, respectively (p < 0.0001). Peak creatine kinase levels (fraction of normal) were 9.8, 13.4 and 14.0, respectively (p < 0.0001). When baseline characteristics were included, ST segment resolution was the most powerful independent predictor of 35-day mortality. The proportion of patients with complete ST segment resolution was larger, and that with no ST segment resolution smaller, with reteplase than with streptokinase (p = 0.006). CONCLUSIONS: No ST segment resolution, indicating failed thrombolysis, predicts very high early mortality, whereas complete resolution is associated with a small infarct area and low mortality. Partial ST segment resolution also predicts larger infarct areas, but early mortality is relatively low. Different extents of ST segment resolution may serve as a sensitive surrogate end point in clinical trials.

Aged↗
PubMed1994

Extent of early ST segment elevation resolution: a simple but strong predictor of outcome in patients with acute myocardial infarction.

OBJECTIVES: This study proposed to verify the prognostic power of early ST segment elevation resolution in patients with acute myocardial infarction from the Intravenous Streptokinase in Acute Myocardial Infarction study data base. BACKGROUND: Data from a small prospective study suggested that use of two cutoff points for three different levels of ST segment resolution 3 h after the start of thrombolysis may be an efficient way to predict outcome in an individual patient. METHODS: The three groups of ST segment resolution were defined as 1) complete resolution (> or = 70% [552 patients]) or only slight ST segment elevation (127 patients); 2) partial resolution (< 70% to 30% [475 patients]); 3) no resolution (< 30% to > 0% [362 patients]). Infarct size was measured from creatine kinase isoenzyme, MB fraction, release and from the number of Q waves. Left ventricular function was assessed in 818 patients 1 month after infarction. RESULTS: For complete, partial and no ST segment resolution 3 h after the start of streptokinase or placebo infusion, enzyme release was 1.2, 1.8 and 2.1 IU/ml x h; number of Q waves 1.7, 2.5 and 3.0; and ejection fraction 60%, 53% and 49%, respectively (all adjusted p = 0.0000). Mortality rate at 21 days was 2.2%, 3.4% and 8.6%, respectively. No ST segment resolution was the most powerful independent predictor of early mortality (p = 0.0001). Survival rate curves at 6-year follow-up showed significant mortality differences with increasing divergence (p = 0.0003 anterior infarction; p = 0.005 inferior infarction). In subgroups with an overall higher risk of dying, mortality was strongly determined by the extent of early ST segment resolution. CONCLUSIONS: The extent of ST segment elevation resolution conveys useful early information about outcome in an individual patient after acute myocardial infarction.

Aged↗
PubMed1991

Outcome prediction of acute renal failure in medical intensive care.

Data acquired prospectively from 134 patients with acute renal failure requiring dialysis in a medical intensive care unit (ICU) were analysed in order to derive indicators predicting ICU-survival. Mortality in the ICU was 56.7%. Linear discriminant analysis correctly predicted outcome in 79.9% at the start of dialysis, and 84.7% at 48 h after the first dialysis. The most important predictive variables were mechanical ventilation and low blood pressure. On the other hand, the total correct classification rates achieved by a standardised system for scoring ICU-patients (APACHE II) did not exceed 58.2%. It is concluded that outcome prediction by APACHE II and even by the discriminant functions is too inaccurate to become the basis for clinical decisions either concerning the initiation or the continuation of dialysis treatment in ARF.

Acute Kidney Injury↗
PubMed1990

Controversial indications. Rationale for thrombolysis: later than 4-6 h from symptom onset, and in patients with smaller myocardial infarctions. The ISAM Study Group.

To evaluate the effect of late reperfusion of an infarct-related coronary artery on left ventricular (LV) function in the month after myocardial infarction (MI), findings from 386 patients in the Intravenous Streptokinase in Acute Myocardial Infarction (ISAM) trial were studied. All patients had a late peaking in the creatine kinase-MB serum time-activity curve, suggesting absence of early reperfusion. Significantly better LV function associated with patency of the infarct artery at angiography 1 month after the acute event confirmed the beneficial effect of reperfusion even if achieved beyond the time window for myocardial salvage. Thrombolysis commenced later than 4-6 h after symptom onset will be of benefit as long at it reopens infarct arteries more often and earlier than occurs spontaneously or from anticoagulation. The value of the size of the sum of ST-segment elevation (sigma ST increases) on admission ECG was evaluated from the total ISAM study population. The relation between sigma ST increases and final infarct size as well as mortality risk was highly significant. However, weak correlations largely limit the value of sigma ST increases to predict the outcome in an individual patient. Thus, whatever the relative beneficial effect in patients with smaller or larger MI may be, it would be unwarranted to withhold thrombolytic therapy from patients with smaller sigma ST increases on admission ECG.

Aged↗
PubMed1990

Outcome prediction models on admission in a medical intensive care unit: do they predict individual outcome?

Prospectively acquired data from 941 patients staying greater than 24 h in a medical ICU were analyzed to determine the relevance of scoring on ICU admission by the following methods of outcome prediction: Acute Physiology and Chronic Health Evaluation (APACHE II), Simplified Acute Physiology Score (SAPS), and Mortality Prediction Model (MPM). Analysis was performed separately for all patients (group A) and for a subsample (group B), obtained by excluding coronary care patients. Calculation of risk and classification of patients were carried out as recommended in the literature for MPM, APACHE II, and SAPS. In group A, sensitivities (correct prediction of hospital mortality) were 44.7%, 51.1%, and 21.2% and specificities (correct prediction of survival) were 84.5%, 85.4%, and 96.8%, respectively; overall correct classification rates were 73.3%, 75.8%, and 75.6%. In group B, sensitivities were slightly higher, but total correct classification rates did not reach group A levels. Goodness-of-fit testing showed low levels of fit for all methods in both groups. Application of APACHE II to diagnostic subgroups, using disease-adapted risk calculations, revealed marked inconsistencies between the estimated risk and the observed mortality. We conclude that the estimation of risk on admission by the three methods investigated might be helpful for global comparisons of ICU populations, although the lack of disease specificity reduces their applicability for severity grading of a given illness. The inaccuracy of these methods makes them ineffective for predicting individual outcome; thus, they provide little advantage in clinical decision-making.

Female↗
PubMed1989

Impact of late coronary artery reperfusion on left ventricular function one month after acute myocardial infarction (results from the ISAM study).

To evaluate the impact of late reperfusion of an infarct-related coronary artery on left ventricular (LV) function in the month after myocardial infarction, findings from 368 patients in the Intravenous Streptokinase in Myocardial Infarction study are presented. All patients had a late peaking in the creatine kinase-MB serum time-activity curve, suggesting absence of early reperfusion. Contrast angiography was performed 1 month after the acute event. The infarct-related coronary artery was patent in 74 of 116 (64%) streptokinase-treated patients and 141 of 252 (56%) patients treated with anticoagulant therapy (placebo group). In all baseline variables, including the actually developed enzymatic and electrocardiographic infarct sizes, there were no differences between the patent- or occluded-artery groups. A patent infarct artery 1 month after infarction was associated with significantly better LV function regardless of the vessel involved and whether or not patients had been treated with streptokinase. Ejection fraction in patients with patent versus occluded artery was 56 +/- 13 versus 50 +/- 14 (p less than 0.0005). Most benefit was noted in patients in whom the proximal left anterior descending coronary artery was affected: ejection fraction was 52 +/- 14 versus 36 +/- 12% (p less than 0.0005). Our data confirm that restoration of adequate flow through an infarct-related coronary artery beyond the time window for actual salvage of ischemic myocardium has a definite beneficial effect on LV function.

Aged↗
PubMed1989

[Circadian variation in the incidence of myocardial infarction. New perceptions about the mechanisms of acute coronary disease].

The time of acute myocardial infarction (MI) was determined from the onset of symptoms and an analysis made of the time-activity course of the plasma CK-MB isoenzyme in 1741 patients of the prospective multicentre ISAM study (much greater than Intravenous Streptokinase in Acute Myocardial Infarction much less than). The occurrence of MI had a circadian variation with a marked peak between 6 a.m. and 12 noon compared with other periods during the day (P less than 0.001). Between 8 and 9 a.m., the period of highest incidence, the number of MIs was about four times higher than between midnight and 1 am (the period of lowest incidence). There was a good correlation between the clinical and enzymatic criteria for onset of MI (r = 0.95; P less than 0.001). A similar circadian pattern was obtained independent of site of MI, age and sex of patients, as well as severity and extent of the coronary heart disease. The temporal relationship between increased incidence of acute coronary heart disease (MI, sudden cardiac death, symptomatic or silent myocardial ischaemia) in the morning and a rise in platelet aggregation in the morning may point to a causal relationship.

Adolescent↗
PubMed1989

Increased morning incidence of myocardial infarction in the ISAM Study: absence with prior beta-adrenergic blockade. ISAM Study Group.

The time of acute myocardial infarction was determined in all 1,741 patients of the ISAM (Intravenous Streptokinase in Acute Myocardial Infarction) Study, based on onset of clinical symptoms and evaluation of plasma CK-MB enzyme time-activity curves. The incidence of myocardial infarction was markedly increased between 6:00 AM and 12:00 noon compared with other times of day (p less than 0.001). Myocardial infarction occurred 3.8 times more frequently between 8:00 and 9:00 AM (hour of maximum incidence) than between 12:00 midnight and 1:00 AM (hour of minimum incidence). Time of myocardial infarction based on clinical and enzymatic methods correlated well (r = 0.95). Patients with higher or lower left ventricular ejection fraction, higher or lower degree of wall motion abnormalities and residual stenosis of the coronary arteries, and one-, two-, or three-vessel disease exhibited a similar circadian pattern, suggesting that the morning is a risk period for patients with mild as well as severe coronary artery disease. Only the group of patients receiving beta-adrenergic blocking therapy before the event did not show an increased morning incidence of myocardial infarction. This observation may contribute to an understanding of the mechanisms by which beta-blockers reduce the incidence of myocardial infarction. Further investigation of physiologic changes occurring during the morning period of increased risk of myocardial infarction may lead to better understanding of the disorder. Design and timing of cardioprotective medication may play a crucial role in improving prevention of acute myocardial infarction.

Adrenergic beta-Antagonists↗
PubMed1989

Osmolality of nonionic contrast media.

Solutions of different low osmolar contrast media (CM) obviously show clinically relevant differences in the osmolality despite equal iodine concentrations and similar molecular structure. To obtain precise and comparable data, the osmolality of five batches (usually) each of contrast media, iopamidol, iohexol, iopromide, and ioxaglate-all preparations commercially available-were measured by means of the vapor pressure method. The osmolality of the solutions of sodium meglumine ioxaglate with the same iodine concentration is lower than that of the nonionic CM examined. Iopromide showed the lowest osmolality and iohexol the highest value of the nonionic preparations. The differences are statistically significant as a rule. They are attributed to a varying association and hydration of the CM molecules in the solution.

Contrast Media↗
PubMed1988

Functional versus structural changes of forearm vascular resistance in hypertension.

Structural changes in resistance vessels have been considered an important factor in triggering and maintaining chronic hypertension in humans and in experimental animals. To determine whether the increased forearm vascular resistance observed following vasodilator maneuvers in hypertensive patients is predominantly due to structural or to functional changes, we examined the influence of different vasodilator stimuli on forearm blood flow and blood pressure in 22 male patients with established essential hypertension and in 22 age-matched normotensive men (age range, 28-52 years). Blood pressure was measured directly, and blood flow was measured by venous occlusion plethysmography. The maneuvers applied were 1) arterial occlusion combined with handgrip exercise and local heating, 2) intra-arterial infusion of the calcium entry blocker nifedipine, 3) intra-arterial infusion of the nonspecific vasodilator sodium nitroprusside, 4) arterial occlusion initiated after intra-arterial infusion of nifedipine. Vascular resistance during vasodilation induced by arterial occlusion or infusion of nifedipine or sodium nitroprusside remained significantly higher in the hypertensive than in the normotensive subjects. However, the maximal vasodilation achieved by the combination of arterial occlusion and nifedipine resulted in a similar resistance in both groups (1.6 +/- 0.2 in the hypertensive vs 1.4 +/- 0.2 mm Hg/ml/min/100 ml tissue in the normotensive subjects. These data suggest that there is an important functional component of the elevated resistance in patients with essential hypertension.

Adult↗