Biomedical subjects

R McCabe

Publications and source records attributed to R McCabe.

At least 19 recordsLinked to original sources

PubMed2006

The therapeutic relationship in psychiatric settings.

OBJECTIVE: To discuss the current climate of research on the therapeutic relationship (TR) in mainstream psychiatric settings. METHOD: Consideration of theoretical frameworks, quantitative and qualitative research methods, along with potentials for interventions. RESULTS: Most of the concepts and methods used to investigate the TR in conventional psychiatric settings have been imported from psychotherapy and, despite significant differences between the two, there is little specific research. A distinction is suggested between therapeutic relationships and patient-clinician interactions. Relationships predict outcome and may be assessed with operationalized methods. Specific communicative skills may be helpful in the treatment of particular illnesses. The feasibility and effectiveness of potential interventions in the TR have rarely been studied. CONCLUSION: Specific conceptual and methodological work is required to develop a better understanding of TRs in psychiatric settings. Further research should include intervention studies and might support a stronger emphasis on TRs in training and supervision.

Communication↗

PubMed2004

Do people with schizophrenia display theory of mind deficits in clinical interactions?

BACKGROUND: Having a 'theory of mind' (ToM) means that one appreciates one's own and others' mental states, and that this appreciation guides interactions with others. It has been proposed that ToM is impaired in schizophrenia and experimental studies show that patients with schizophrenia have problems with ToM, particularly during acute episodes. The model predicts that communicative problems will result from ToM deficits. METHOD: We analysed 35 encounters (> 80 h of recordings) between mental health professionals and people with chronic schizophrenia (out-patient consultations and cognitive behaviour therapy sessions) using conversation analysis in order to identify how the participants used or failed to use ToM relevant skills in social interaction. RESULTS: Schizophrenics with ongoing positive and negative symptoms appropriately reported first and second order mental states of others and designed their contributions to conversations on the basis of what they thought their communicative partners knew and intended. Patients recognized that others do not share their delusions and attempted to reconcile others' beliefs with their own but problems arose when they try to warrant their delusional claims. They did not make the justification for their claim understandable for their interlocutor. Nevertheless, they did not fail to recognize that the justification for their claim is unconvincing. However, the ensuing disagreement did not lead them to modify their beliefs. CONCLUSIONS: Individuals with schizophrenia demonstrated intact ToM skills in conversational interactions. Psychotic beliefs persisted despite the realization they are not shared but not because patients cannot reflect on them and compare them with what others believe.

Adult↗

PubMed2003

Are therapeutic relationships in psychiatry explained by patients' symptoms? Factors influencing patient ratings.

OBJECTIVE: To investigate the therapeutic relationship and how it is influenced by sociodemographic and clinical factors. METHOD: This study analysed self-ratings of the therapeutic relationship in 90 first-admitted, 72 long-term hospitalised and 41 out-patients with schizophrenia along with 249 alcoholic and 42 depressive in-patients and their association with sociodemographic and clinical variables. In all the patients, the therapeutic relationship was assessed using a simple scale based on three items. RESULTS: The therapeutic relationship differed significantly across groups. It was rated most positively by alcoholic patients and least positively by long-term hospitalised schizophrenia patients. Increased observer-rated psychopathology was significantly associated with a poorer therapeutic relationship in all groups except the hospitalised schizophrenia patients. In this group, increased self-rated symptoms were associated with a poorer relationship. In multiple regression analyses, 3-28% of the relationship variance was explained by psychopathology. CONCLUSIONS; Patient ratings of the therapeutic relationship were partially explained by psychopathology, leaving the greater part of the variance to be explained by factors other than sociodemographic and clinical characteristics.

Adult↗

PubMed2001

Theoretical frameworks for understanding and investigating the therapeutic relationship in psychiatry.

BACKGROUND: Mental health care is delivered through a relationship between a clinician and a patient. Although this therapeutic relationship is of central importance for mental health care, it appears to be relatively neglected in psychiatric research. Empirical research has for the most part adopted concepts and methods developed in psychotherapy and general medical practice. Hence, unpacking the presuppositions that have informed research on the therapeutic relationship to date may be a useful first step in developing this field. METHOD: A review of the literature was carried out. RESULTS: Six central theories are identified as framing the definitions and methods on this topic: role theory, psychoanalysis, social constructionism, systems theory, social psychology and cognitive behaviourism. To date, role theory, psychoanalysis and systems theory appear to be the frameworks most often applied in research in this field. Each perspective offers a unique emphasis in the analysis of the therapeutic relationship, which is reflected in the empirical work from each perspective discussed herein. CONCLUSIONS: None of the theories identified have been fully specified and comprehensively investigated in psychiatric settings. However, more than one approach may be used for thinking about relationships, depending on the treatment situation. Further specification and testing of the theories in psychiatric practice--taking account of the specific context--is warranted to underpin more pragmatic research. A stronger link between fundamental psychological and sociological research and applied health care research would advance our understanding of which elements of positive therapeutic relationships are instrumental in improving patient outcome and ultimately contribute to improving mental health care.

Humans↗

PubMed2001

Ammonia uptake and its effects on ionoregulation in the freshwater crayfish Pacifastacus leniusculus (Dana).

Exposure of adult crayfish Pacifastacus leniusculus to Artificial Freshwater (AFW) media containing 1.5 m and 0.15 mmol x l(-1) total ammonia [Tamm; 0.1 x acute lethal concentration (24 h LC50) and 0.01 x 24 h LC50] and adjusted to pH 6.5, pH 8.2 and pH 10.5 resulted in significant increases in haemolymph ammonia over a 24-h period. Ammonia accumulated most rapidly at pH 10.5. These media were chosen to expose animals to a range of different un-ionised ammonia (UIA) [NH3] and ionised ammonia [NH4+] concentrations. From comparisons of measured transepithelial potential differences (PDte) with calculated Nernst potentials (PDNH4+) for the known haemolymph-to-medium gradients of [NH4+], it was deduced that, in pH 8.2 and pH 6.5 AFW, NH4+ was not in thermodynamic equilibrium across the integument (presumably gill epithelium). In pH 10.5 AFW with 1.5 mmol x l(-1) Tamm (predominantly NH3), the accumulation of ammonia in the haemolymph was in the NH4+ form due to haemolymph pH regulation by the crayfish in this alkaline external medium. Measured net fluxes of ammonia (Jamm(net)) were inwardly directed and maximal when [NH3] was the main component externally, but were also significant at pH 8.2 with high [NH4+] ([NH4+]:[NH3] approximately 20:1). Haemolymph Na+ depletion was significant and, over the 24-h exposure period, most rapid in high [NH3] medium but [Cl-] was unaffected. However, paradoxically, sodium uptake (measured JNa(in) on immediate transfer to high Tamm medium) was not significantly inhibited when [NH3] was the predominant ammonia species. In 1.5 mmol x l(-1) Tamm (mainly [NH4+), VNa(in) (the active component of JNa(in)) was significantly inhibited, particularly at low external [Na+]. This inhibition could not be demonstrated as one of competition at an Na+/NH4+ apical gill exchange site. The resultant net efflux of sodium from the animal showed that the ability of the animals to balance sodium losses at low external [Na+] was severely affected. Longer exposure to pH 10.5 AFW with high [NH3] (12 h) resulted in significantly increased JNa(out), while not significantly affecting JNa(in). Analysis of urinary Na+ losses showed that, while urinary flow rate and water reabsorption was most likely unaffected by ammonia exposure, final urine [Na+] was significantly elevated. The resulting urinary Na+ loss accounted for 63% of the increased JNa(out) in high [NH3] medium.

Ammonia↗

PubMed1999

Therapeutic relationships and quality of life: association of two subjective constructs in schizophrenia patients.

Subjective quality of life is an important criterion in outcome evaluation that has been well-researched in psychiatry. By comparison, the therapeutic relationship which may also be subjectively assessed has been relatively neglected as an outcome criterion although it has predictive power in relation to outcome. This exploratory study investigated subjective quality of life and therapeutic relationships in first-admission (N = 90) and long-term (N = 168) schizophrenia patients, each at two points of time. The follow-up period was 9 months for the first-admission sample and 1.5 years for the long-term sample. A significant relationship was found between global assessments of quality of life and therapeutic relationships in long-term, but not in first-admission patients. This finding was consistent at both assessments, suggesting that therapeutic relationships may become more central to quality of life in long-term care situations and that patients' views of this relationship are increasingly embedded in their overall appraisal of life.

Adult↗

PubMed1997

Posterior lumbar interbody fusion. A biomechanical comparison, including a new threaded cage.

STUDY DESIGN: In vitro biomechanical testing was performed on eight lumbar calf spines. OBJECTIVES: To compare the initial stiffness of a standard method of posterior lumbar interbody fusion using structural autograft with the same procedure using additional posterior instrumentation. These constructs also were compared to a new titanium implant. SUMMARY OF BACKGROUND DATA: Posterior lumbar interbody fusion is gaining wide acceptance for the treatment of segmental spinal instability, spondylolisthesis, and discogenic pain. Many methods have been described, including use of autograft or allograft bone, in either structural or nonstructural form, with or without additional fixation. A new threaded titanium interbody implant has been designed to increase initial stability while allowing bony ingrowth for fusion. METHODS: Eight lumbar calf spines were subjected to axial compression, sagittal moments (flexion-extension), and axial torque while displacement was measured. Stiffness was calculated from the load displacement curves for each construct under each load pattern. RESULTS: The posterior lumbar interbody fusion by bone graft alone was the least stiff construct of all modes tested. In two of eight specimens the bone graft dislodged posteriorly into the canal during torsional testing. The titanium interbody implant was similar in stiffness to the bone graft posterior lumbar interbody fusion with posterior instrumentation group in all three modes. They were both significantly stiffer than the normal spine, the destabilized spine, and the posterior lumbar interbody fusion by bone graft alone (P < 0.05). CONCLUSIONS: In this model, the posterior lumbar interbody fusion with bone graft alone had less initial stiffness than that of the intact spine. The addition of posterior instrumentation or interbody implants can increase initial stiffness significantly.

Animals↗

PubMed1997

Tissue matrix protein expression in human osteoblasts, osteosarcoma tumors, and osteosarcoma cell lines.

Treatment for osteosarcoma is problematic because there are no prognostic markers. Diagnosis is primarily limited to cytologic grading. Oncogenesis alters cell structure therefore osteoblast tissue matrix proteins (extracellular matrix, cytoskeletal, intermediate filament, and nuclear matrix proteins), components of the cell substructure, are candidates for osteosarcoma markers. Structural proteins of the extracellular matrix, e.g. the collagens, are useful for diagnosis but not for tumors that produce little osteoid. To identify principal cellular tissue matrix proteins that distinguish normal from transformed human osteoblasts, their expression in normal osteoblasts, two osteosarcoma cell lines, and three primary osteosarcoma tumors were compared. The tumors were graded as (i) intermediate, (ii) high, and (iii) high grade recurrent. The 1-D SDS/PAGE profiles of the major components of the nuclear matrix and intermediate filament fractions from normal osteoblasts did not vary with biopsy site, age, or sex of patients. These profiles included known cytoskeletal proteins and OB250, a approximately 250 kD protein(s) observed in the intermediate filament fraction. A loss of protein bands, including OB250, was observed in the osteosarcoma cell lines and tumors. The intermediate and high grade tumors exhibited nearly identical protein profiles including potential tumor-specific proteins and collagen, consistent with the presence of intracellular collagen fibers in osteosarcoma. A microsequence was obtained for OT25, a novel low molecular weight protein observed in osteosarcoma cell lines. Fibrinogen gamma-chain, a protein that mediates cell adhesion was recovered from the high grade recurrent tumor.

Adult↗

PubMed1996

A new therapeutic option for the treatment of pneumonia.

Patients with bacterial pneumonia often are treated empirically with parenteral broad-spectrum antimicrobials intended to cover potential gram-negative and gram-positive pathogens. However, beta-lactamase-mediated resistance has developed to many of these antimicrobials, particularly third-generation cephalosporins, and has led to the development of fourth-generation agents that are relatively beta-lactamase stable. The purpose of these studies was to compare the efficacy and safety of the fourth-generation agent, cefepime, with that of the third-generation agent, ceftazidime, in the treatment of hospitalized patients with moderate-to-severe bacterial pneumonia. A total of 336 (97 evaluable) patients were enrolled in an open-label study, and 99 (23 evaluable) patients were enrolled in a blinded study of patients with lower respiratory tract infections (LRTI) including pneumonia. Patients were randomized to receive either cefepime 1 g every 12 hours or ceftazidime 1 g every 8 hours given as an intravenous infusion over 30 minutes. Efficacy analysis included the evaluable patients while the safety analysis included all patients. The results in the open-label study were as follows: In patients with pneumonia, clinical response was satisfactory in 58 (85%) of 68 patients in the cefepime group and 21 (72%) of 29 patients in the ceftazidime group. Bacteriologic eradication occurred for 75 (93%) of 81 pathogens and 30 (94%) of 32 pathogens isolated from the 68 cefepime-treated patients and 29 ceftazidime-treated patients, respectively. The results in the blinded study were as follows: In patients with pneumonia, clinical response was satisfactory in 12 (80%) of 15 cefepime patients and in 7 (88%) of 8 ceftazidime patients, and the bacteriologic eradication rates were 85% (17/20 pathogens) and 73% (8/11 pathogens) isolated from the 15 cefepime-treated patients and the eight ceftazidime-treated patients, respectively. Among the most frequent adverse events in both groups were nausea, diarrhea, vomiting, and abdominal pain. Similar adverse events were noted in the 99 patients in the blinded study. These studies indicate that the efficacy and safety of cefepime administered at 1 g twice daily is comparable to that of ceftazidime administered at 1 g three times daily for treatment of hospitalized patients with pneumonia caused by susceptible pathogens.

Acute Disease↗

PubMed1996

Free-to-total prostate specific antigen ratio as a single test for detection of significant stage T1c prostate cancer.

PURPOSE: We investigated whether impalpable, invisible (stage T1c) but significant prostate cancer can be detected better by determining the free-to-total prostate specific antigen (PSA) ratio of equivocal PSA serum levels. MATERIALS AND METHODS: The specificity of free-to-total PSA ratio using research monoclonal enzyme immunoassays was compared to that of PSA greater than 4.0 ng./ml. in 117 consecutive patients with PSA 3 to 15 ng./ml. (Hybritech Tandem-R assay) due to untreated benign prostatic hypertrophy or prostate cancer. Of the patients 77% underwent adenectomy or radical prostatectomy with thorough pathological evaluation of surgical specimens. RESULTS: Benign prostatic hypertrophy had a greater median free-to-total PSA ratio than stages T1c and T2 or greater prostate cancer (0.16 versus 0.09 and 0.11 ng./ml., p = 0.0001 and p = 0.0268, respectively). In stage T1c prostate cancer, areas under receiver operating characteristic curves were 0.58 and 0.84 for PSA and free-to-toal PSA ratio, and free-to-total PSA ratio correlated with prostate volume (r = 0.49, p = 0.005) and Gleason score (r = -0.37, p = 0.036). Pathologically, 84% of stage T1c cancers were significant and comparable to stage T2 or greater cancers. CONCLUSIONS: Free-to-total PSA ratio enhances the efficacy of PSA measurement by improving specificity for detecting impalpable, invisible but significant stage T1c prostate cancer.

Adult↗

PubMed1995

Treatment goal-planning: outcome findings of a British prospective multi-centre study of adolescent inpatient units.

A set of 16 treatment goals, related to 4 areas of adolescent functioning, were defined and employed in the initial and discharge assessments of 276 patients, admitted to 4 inpatient units, examined during a multi-centre prospective study of adolescent psychiatric hospitalizations. At discharge, subjects showed a substantial improvement across all treatment goals; least improvement was observed amongst those goals most frequently targeted. The clinical investigators consider the treatment goal definitions used in this study a meaningful way of measuring psychiatric disturbances in adolescence as well as a useful measure of change in an inpatient population. Further development of the treatment goal definitions would produce a robust clinical and audit tool.

Adolescent↗

PubMed1994

Clinical pharmacology and tissue disposition studies of 131I-labeled anticolorectal carcinoma human monoclonal antibody LiCO 16.88.

Antibody LiCO 16.88 is a human IgM recognizing a 30- to 45-kDa intracytoplasmic antigen present in human adenocarcinoma cells. An 8-mg sample of antibody labeled with 5 mCi 131I was co-administered i.v. with 120 mg (three patients), 240 mg (three patients) or 480 mg (four patients) unlabeled antibody as a 4-h infusion. The plasma half-life was 24 +/- 1.2 h and the immediate apparent volume of distribution was 5.2 +/- 0.2 l at the 28-mg dose level. The plasma half-lives and the cumulative urinary excretion of radiolabel did not seem to vary significantly with increasing doses of unlabeled antibody. However, both the volume of distribution and the clearance rate from plasma increased significantly with increasing antibody dose. Uptake of antibody into tumor tissues obtained during laparotomy 8-9 days after administration varied between 0.00002% ID/g and 0.00127% ID/g. In five of seven patients, the tumor content of antibody was higher than that in adjacent normal tissue. Tumor-to-normal tissue ratios ranged from 0.8 to 10 (mean = 3.8 +/- 1.0). In general, the higher radioactivity(cpm)/g tumor was confirmed by both immunoperoxidase and autoradiography. Antibody 16.88 localizes in tumors after administration and may be considered for use in radioimmunotherapy trials.

Antibodies, Monoclonal↗

PubMed1994

A biomechanical analysis of prophylactic fixation for pathological fractures of the distal third of the humerus.

Twenty-four matched pairs of fresh-frozen humeri from human cadavera were divided randomly into four groups, in order to determine the most biomechanically desirable construct for the prophylactic fixation of impending fractures of the distal third of the humerus. Group I comprised intact humeri and matched humeri in which a 50 per cent lateral, semicylindrical cortical defect of the distal third had been created, resulting in a reproducible model of an impending fracture due to a lytic defect involving 50 per cent cortical disruption at the distal end of the humeral medullary canal. In Group II, such a lateral defect was created in both the right and the left, matched humeri. Group III was composed of humeri in which the defect had been fixed prophylactically with a single plate and the contralateral humeri, which had been treated with double-plating. Group IV comprised specimens in which the defect had been fixed with double-plating as well as those fixed with Rush rods. The fixation of each specimen in Groups III and IV was supplemented with bone cement. Each specimen was tested in torsion to failure, and the resulting peak torque, torsional stiffness, and total energy absorbed were analyzed for each group. The Group-I specimens that had a defect had a significantly lower (p < 0.05) peak torque, torsional stiffness, and total energy absorbed than the intact specimens; all of the specimens with a defect failed at the defect, and all of the intact specimens failed proximally. In Group II, there was a high side-to-side association with respect to peak torque, torsional stiffness, and total energy absorbed.(ABSTRACT TRUNCATED AT 250 WORDS)

Biomechanical Phenomena↗

PubMed1993

Anterior cervical discectomy, fusion, and plating. A comparative animal study.

Thirty-five goats were used as animal models for three-level anterior cervical discectomy and fusion. The goats were divided equally into five experimental groups: Group I, three-level anterior cervical discectomy without fusion; Group IIa, three-level discectomy with autogenous bone (Smith-Robinson technique); Group IIb, autogenous bone grafting plus anterior plate application; Group III, three-level discectomy and fusions with fresh frozen allograft bone; Group IIIa, graft only; and Group IIIb, anterior plating. The goats were killed, and spines were removed and analyzed for evidence of fusion. Radiographic union was judged to have occurred in 0% of Group I disc spaces, 48% of Group IIa, 52% of Group IIb, and 38% of Groups IIIa and IIIb. Histologic fusion was judged to have occurred in 0% of Group I specimens, 38% of Group IIa, 45% of Group IIb, 0% of Group IIIa, and 19% of Group IIIb. The histologic fusion rate was significantly higher in Groups IIa and IIb than in Groups I and IIIa. There was no statistically significant increase in the histologic fusion rate between goats with anterior cervical plating and goats without plating. Biomechanically, the spines in Groups IIb and IIIb, ie, those with anterior plates applied, were stiffer in axial load, torsion, and flexion/extension. Peri-end-plate vascularity was significantly diminished in those groups that had anterior plates applied. Qualitative analysis of fluorochrome labels showed that autografts revascularized more rapidly than did allografts in both the nonplated and plated groups. Histomorphometric analysis failed to reveal any significant device-related osteopenia in those vertebrae spanned by the anterior plate. We found that although autograft bone led to a significantly higher rate of union than did allograft bone, the addition of anterior plate fixation did not significantly increase union rate. Biomechanical rigidity was significantly increased in all modes of testing by the use of an anterior plate. The decreased vascular response seen in spines that underwent plating may be responsible for the lack of increased union. The increased rigidity found with anterior plating supports its use in traumatic conditions. The failure, however, to increase significantly the union rate in this model fails to lend support to the use of anterior cervical plating for degenerative discectomy and fusion procedures.

Animals↗

PubMed1993

Pedicle screw pullout strength. Correlation with insertional torque.

This study was designed to correlate several parameters regarding pedicle screw bone/metal interface strength. The insertional torque measured during tapping and placement of pedicle screws was correlated with the bone mineral density of the vertebral body, the dimensions of the pedicle, the method of preparation of the pedicle, and the amount of load and number of cycles to failure of the bone/metal interface. Thirty human cadaveric lumbar vertebrae were instrumented with 6.5-mm pedicle screws. The maximum torque achieved during insertion was digitally recorded. A cyclic pedicle screw pullout test was performed. A linear correlation existed between both the insertional torque when tapping or when inserting a screw and the number of cycles to ultimate pedicle screw pullout. An inverse linear relationship was found between the pedicle width and cycles to failure. There was no linear correlation found when comparing the number of cycles to failure to bone mineral density. These findings suggest that insertional torque is a good predictor of bone-metal interface failure. Bone mineral density of the vertebral body was less effective as a predictor of failure. Smaller pedicle width correlated with increased insertional torque and cycles to failure. This may explain why patients with osteoporosis on radiography may still obtain stable fixation with pedicle screws. Other factors, such as pedicle dimensions and shape, affect screw purchase as much as vertebral body bone density. Insertional torque less than 4.0 inch-pounds led to early pedicle screw pullout. This study forms the basis for the authors' clinical use of an instrumented torque screwdriver to measure insertional torque in the operating room.

Aged↗

PubMed1993

Failure to taste zinc sulphate solution does not predict zinc deficiency in pregnancy.

As part of a double-blind randomised controlled trial to test the efficacy of 20 mg of zinc supplementation during pregnancy, 494 mothers were enrolled at booking. After giving informed consent they were asked to taste a dilute solution of zinc sulphate. Of the 489 mothers who were given the solution, 44 (9%) were unable to taste it. Mothers who failed this test did not differ significantly from the rest of the population in background factors such as social class, ethnic group, maternal age or parity. Significantly more non-tasting mothers had had a previous growth-retarded infant. Their diets did not differ in any way from those of the tasters. Zinc supplementation did not affect their taste as assessed at the end of pregnancy. Of the possible outcome measures considered, the zinc taste test did predict whether the mother was to develop diastolic hypertension (23% of non-tasters, 8% of tasters), but the mean birthweight, preterm delivery rate and other outcomes were identical.

Chi-Square Distribution↗

PubMed1993

Biomechanical analysis of mallet finger fracture fixation techniques.

A biomechanical study was conducted to determine the best fixation technique for mallet finger fracture among four commonly used methods. Considerations were technical complications, biomechanical properties, and maintenance of reduction. Techniques tested included Kirshner wire, figure-of-eight wire, tension band wire, and tension band suture. Technical complications were frequent with both the Kirschner wire and tension band wire techniques. Biomechanical testing yielded significantly greater energy absorbed to failure and a trend toward greater peak loads to failure for both the figure-of-eight wire and tension band suture techniques. Irreversible loss of reduction during testing occurred in all of the Kirschner wire-fixed fractures, in 60% of the tension band wire-fixed fractures, and in 50% of the figure-of-eight wire-fixed fractures. No irreversible failure occurred in the tension band suture group.

Aged↗

PubMed1993

Comparison of the efficacy and safety of ceftibuten and cefaclor in the treatment of pneumonia and bronchiectasis.

In a multicentre, international study of 187 adult patients with bacterial pneumonia or bronchiectasis, the safety and efficacy of a regimen of 200 mg ceftibuten administered twice-daily was compared with cefaclor given in a dosage of 500 mg three times a day. Of the 94 evaluable patients, 66 received ceftibuten and 28 received cefaclor. The overall bacteriological response was similar in the two treatment groups with elimination of the original pathogen in 91% and 89% of the patients receiving ceftibuten and cefaclor, respectively. The overall clinical response mirrored the bacteriological results with a successful clinical outcome in 92% of ceftibuten-treated patients compared with 93% in patients receiving cefaclor. Adverse experiences were, in general, few and mild, being reported in 8% and 17% of patients receiving ceftibuten and cefaclor, respectively.

Adolescent↗