Biomedical subjects

Yasuhiro Yonekawa

Publications and source records attributed to Yasuhiro Yonekawa.

At least 37 records · Page 2Linked to original sources

PubMed2004

Population-based study on incidence, survival rates, and genetic alterations of low-grade diffuse astrocytomas and oligodendrogliomas.

We carried out a population-based study on low-grade diffuse gliomas in the Canton of Zurich, Switzerland (population 1.16 million). From 1980 to 1994, 987 astrocytic and oligodendroglial tumors were diagnosed, of which 122 (12.4%) were low-grade (WHO grade II). The incidence rates adjusted to the World Standard Population, per million population per year, were 2.28 for low-grade diffuse astrocytomas, 0.89 for oligoastrocytomas, and 2.45 for oligodendrogliomas. The survival rate (mean follow-up 7.5+/-4.8 years) was highest for patients with oligodendroglioma (78% at 5 years, 51% at 10 years), followed by those with oligoastrocytoma (70% at 5 years, 49% at 10 years) and fibrillary astrocytoma (65% at 5 years, 31% at 10 years). Survival of patients with gemistocytic astrocytoma was poor, with survival rates of 16% at 5 years and 0% at 10 years. Younger patients (<50 years) survived significantly longer than older patients (>50 years; P=0.013). DNA sequencing, performed in 84% of cases, revealed that TP53 mutations were most frequent in gemistocytic astrocytomas (88%), followed by fibrillary astrocytomas (53%) and oligoastrocytomas (44%), but were infrequent (13%) in oligodendrogliomas. The presence of TP53 mutations was associated with shorter survival of patients with low-grade diffuse gliomas (log-rank test; P=0.047), but when each histological type was analyzed separately, an association was observed only for oligoastrocytoma ( P=0.05). Loss on 1p and 19q were assessed by quantitative microsatellite analysis in 67% of cases. These alterations were frequent in oligodendrogliomas (1p, 57%; 19q, 69%), less common in oligoastrocytomas (1p, 27%; 19q, 45%), rare in fibrillary astrocytomas (1p, 7%; 19q, 7%), and absent in gemistocytic astrocytomas. None of these alterations were predictive of survival. These results establish the frequency of key genetic alterations in low-grade diffuse gliomas at a population-based level. Multivariate Cox's regression analysis indicates that only age and histological type, but not genetic alterations, are significant predictive factors.

Age Factors↗

PubMed2004

Spontaneous otogenic intracerebral pneumocephalus: case report and review of the literature.

Pneumocephalus is commonly associated with head and facial trauma, ear infection or surgical interventions. We describe the rare case of a spontaneous pneumocephalus arising from lateral mastoid air cells. A 48-year-old man presented with a 10-day history of sudden, repetitive, 'hammering-like' acoustic sensations in his left ear that were followed by word-finding difficulties and loss of vision in the right visual field. Imaging revealed a large, left temporal pneumatocele associated with a small acute intracerebral hemorrhage. Left temporal and subtemporal craniotomy and decompression were performed. Further exploration confirmed a dural and osseous defect in the anterolateral surface of the mastoid that was consecutively closed watertight. Although extremely rare, a spontaneous pneumocephalus with mastoidal origin should be considered as a possible diagnosis in patients with suggestive acoustic phenomena and other non-specific neurological symptoms.

Aphasia↗

PubMed2004

Moyamoya angiopathy with dolichoectatic internal carotid arteries, patent ductus arteriosus and pupillary dysfunction: a new genetic syndrome?

We report on 2 children with moyamoya angiopathy and bilateral dolichoectatic internal carotid arteries in combination with iris hypoplasia with bilateral fixed dilated pupils and a history of patent ductus arteriosus. Both were symptomatic with moyamoya angiopathy and underwent bilateral extracranial-intracranial (EC-IC) bypass operations for cerebral revascularization. This is the first report on moyamoya angiopathy and bilateral dolichoectatic internal carotid arteries with simultaneous occurrence of ocular and cardiovascular malformations. There have been descriptions of cerebral vascular abnormalities in combination with either congenital heart disease or ocular abnormalities but not with both presenting together. The combination of these separate congenital developmental defects may not be purely coincidental: we propose that the 2 probands are affected with a not yet recognized clinical syndrome of probably genetic etiology.

Carotid Artery, Internal↗

PubMed2003

PTEN methylation and expression in glioblastomas.

The tumor suppressor gene PTEN on chromosome 10q23.3 regulates the Akt signaling pathway and modulates cell growth and apoptosis. The PTEN gene is mutated in 20-40% of glioblastomas. In this study, we assessed whether loss of PTEN expression is also caused epigenetically. Methylation-specific PCR revealed that CpG islands of the PTEN promoter were methylated in 27 of 77 (35%) glioblastomas and in 4 of 11 (36%) glioblastoma cell lines. Only two glioblastomas showed loss of PTEN immunoreactivity in the entire biopsy; both had a missense PTEN mutation and LOH at the PTEN locus, but lacked PTEN methylation. In biopsy specimens with focal loss of PTEN expression, DNA samples extracted from microdissected foci showed PTEN methylation only in areas with loss of PTEN expression. These results suggest that PTEN methylation occurs frequently in glioblastomas and may be associated with focal loss of PTEN expression. However, the correlation between PTEN methylation, PTEN mutations, LOH at the PTEN locus, and loss of PTEN protein expression was inconsistent. Possible reasons for discrepancies between gene status and protein expression include differences in the biological effect of specific PTEN mutations and the possibility that the processed PTEN pseudogene on 9p21 is expressed in glioblastomas and co-reacts with the PTEN antibody.

Adult↗

PubMed2003

Endovascular cooling with heat exchange catheters: a new method to induce and maintain hypothermia.

OBJECTIVE: To test the convenience of a new cooling technique with intravenous heat exchange catheters. DESIGN: Retrospective chart review. SETTING: University hospital neurointensive care unit. PATIENTS: Twenty patients with severe subarachnoid hemorrhage Hunt and Hess Grade 3-5 treated with mild hypothermia. INTERVENTIONS: Cooling to reach target body core temperature (33 degrees C-34 degrees C) was induced as quickly as possible in all patients. In the first ten patients (group one) moderate hypothermia was induced and maintained using cooling blankets. In group two, an 8.5F heat exchange catheter was placed central venous and temperature-adjusted normal saline circulated in a closed-loop system entailing two balloons. MEASUREMENTS AND RESULTS: A total of 2,007 values of body core temperature (BCT) were registered every hour. Foley temperature catheters were used for monitoring BCT in the bladder. The time to reach the target BCT and the stability of temperature during hypothermia were compared between the two groups. No specific complications associated with the new cooling device were observed. Time to reach the target temperature in group two was significantly shorter than in group one (190+/-110 and 370+/-220 min) ( P=0.023). In group one significantly more temperature values were out of the target range (127 of 792 values; 16.0%) than in group two (62 of 1,215 values; 5.1%) ( P<0.0001). CONCLUSIONS: The new endovascular cooling technique seems to be superior for rapid induction of hypothermia and maintaining a more stable temperature than the cooling techniques using blankets and ice bags.

Body Temperature↗

PubMed2003

Amino acid composition of brain cysts: levels of excitatory amino acids in cyst fluid fail to predict seizures.

A recent study describing two epileptic patients with brain cysts has suggested that elevated concentrations of excitatory amino acids in cysts may play a role in induction and maintenance of epileptogenesis [Epilepsy Res. 28 (1997) 245]. Here, we report that only in 3 out of 22 patients with brain cysts undergoing brain surgery cyst fluids displayed highly increased amounts of the excitatory amino acids aspartate and/or glutamate. Two of these patients experienced epileptic seizures prior to neurosurgical intervention. Thus, highly increased excitatory amino acid levels are present only in a subset of patients with brain cysts. Our observation that one patient with highly increased glutamate and aspartate concentrations in the cyst did not display seizures or typical epileptiform potentials in the EEG questions that these excitatory amino acids in the cyst fluid are directly involved in epileptogenicity. This patient displayed an increased level of adenosine in the cyst fluid, which is known to have anticonvulsant properties and might provide protection from seizures. In summary, there is no evidence for a close correlation between excitatory amino acids in brain cysts and the occurrence of seizures.

Adenosine↗

PubMed2003

Noninvasive measurement of regional cerebral blood flow and regional cerebral blood volume by near-infrared spectroscopy and indocyanine green dye dilution.

To find a suitable method for measuring regional cerebral blood flow (rCBF) rapidly at the bedside is still a matter of investigation. The purpose here was to develop a noninvasive method for bedside rCBF measurement and to validate it with a standard method such as perfusion-weighted magnetic resonance imaging (MRI). In 11 healthy volunteers 44 measurements with near-infrared spectroscopy (NIRS) and perfusion-weighted MRI without and with a mean continuous positive airway pressure (CPAP) of 10 mbar were carried out. Four (NIRS) optodes were placed bilaterally on the forehead and 25 mg indocyanine green (ICG) was injected. New algorithms were developed to calculate rCBFNIRS and rCBVNIRS. In 6 volunteers data analysis was successful. No complications associated with the method were observed. During CPAP breathing rCBFNIRS decreased from 18.5 + 6.9 16.1 + 6.2 ml/100 g/min (P = 0.034). Mean values for rCBFMRI decreased from 256 +/- 90 to 216 +/- 62 ml/100 g/min (P = 0.012). Bland and Altman plots showed that the differences did not vary in any systematic way over the range of rCBF or rCBV values assessed and 100% of differences were within the interval mean +/- 2 SD of differences. Limits of agreement (mean +/- 2 SD) were +/- 76.4 ml/100 g/min for rCBF and +/- 15.6 ml/100 g for rCBV. The NIRS ICG dye dilution technique is a promising method for serial noninvasive bedside CBF measurements. The preliminary data indicate that measurements are in agreement with values obtained by perfusion-weighted MRI.

Adult↗

PubMed2003

Metabolic changes after H(2) 15O-positron emission tomography with acetazolamide in a patient with moyamoya disease: case report and review of previous cases.

Perioperative ischemic complications not directly related to surgery require special attention in patients with moyamoya disease; positron emission tomography (H(2) 15O-PET) and single-photon emission computed tomography have been considered indispensable for evaluating pre- and postsurgical cerebral hemodynamics. The clinical records of 14 patients with moyamoya disease who underwent 26 extracranial-intracranial bypass operations were reviewed with special reference to perisurgical complications. One patient developed multiple postoperative ischemic infarctions and died of ischemic brain edema. The history of this patient with prolonged acidosis is analyzed, and the role of metabolic changes induced by H(2) 15O-PET with acetazolamide challenge is reviewed. Seven (77.8%) of nine patients operated on within 48 hours after H(2) 15O-PET with acetazolamide (group 1) developed metabolic acidosis, whereas only three (17.6%) of 17 patients operated on >48 hours (group 2) after the examination had intraoperative pH of <7.35. In group 1, the mean intraoperative pH was 7.328, which was significantly lower than the mean pH of 7.393 (P <.0001) in group 2. After H(2) 15O-PET with acetazolamide challenge, patients must be carefully observed concerning acidosis and volume state. We recommend at least 48 hours between examination and surgery for patients with moyamoya disease so that their conditions can stabilize. Furthermore, special care should be taken to avoid additional perioperative risk factors such as hypotension, hypocapnia, hypercapnia, and hypovolemia.

Acetazolamide↗

PubMed2003

Long-term hypothermia in patients with severe brain edema after poor-grade subarachnoid hemorrhage: feasibility and intensive care complications.

The purpose was to evaluate the feasibility and intensive care complications of long-term hypothermia (>72 hours) in the treatment of severe brain edema after poor-grade subarachnoid hemorrhage (SAH) Hunt and Hess grade 4 to 5. Among 156 patients with SAH, 21 patients were treated with mild hypothermia (33.0 to 34.0 degrees C) combined with barbiturate coma because of severe brain edema and elevated intracranial pressure (>15 mm Hg) after early aneurysm clipping. Hypothermia was sustained for at least 24 hours after maintaining an intracranial pressure of <15 mm Hg. Nine patients were treated for <72 hours (group 1: mean 42.2 hours, range 8-66 hours) and 12 for >72 hours (group 2: mean 153.9 hours, range 78-400 hours). Three patients (14%) died during the hypothermia treatment. Good functional outcome after 3 months (Glasgow Outcome Score 4-5) was achieved in 10 patients (48%). The outcome did not differ between the two groups. All patients developed severe infections. In group 2 the mean value of minimal leukocyte counts during hypothermia was significantly lower (6.9 vs. 11.8 x 109/L; P = 0.001), and thrombocytopenia (<150 x 109/L) occurred significantly more often (48 vs. 33%; P = 0.032). In 48% of patients with poor-grade SAH, good functional outcome was achieved with combined mild hypothermia and barbiturate coma after early aneurysm surgery. This may be a feasible treatment even for longer than 72 hours. All patients developed severe infections as potentially hazardous side effects. To determine whether mild hypothermia alone is effective in the treatment of severe SAH patients, controlled studies to compare the effects of barbiturate coma alone, mild hypothermia alone, and combined barbiturate coma with hypothermia are needed.

Barbiturates↗

PubMed2003

Emergency craniotomy for intraparenchymal massive hematoma after embolization of supratentorial arteriovenous malformations.

OBJECTIVE: We sought to evaluate the efficacy of emergency craniotomy for patients with massive hematoma secondary to endovascular embolization of supratentorial arteriovenous malformations (AVMs) and to investigate relevant factors affecting outcome. METHODS: Within the past 15 years, 605 patients with intracranial AVMs have undergone 1066 endovascular embolizations at our institution. Of these, 24 patients experienced intracranial hemorrhage during or after the procedure. Fourteen patients were demonstrated to have massive intraparenchymal hematomas and deteriorated to a comatose state (Glasgow Come Scale score < or =6). Twelve patients underwent craniotomy within 170 minutes of being diagnosed with intraparenchymal hemorrhage. The surgical procedures performed were hematoma evacuation with total (6 patients) or partial (2 patients) resection of the AVM or hematoma evacuation only (4 patients). The clinical records of these 12 patients were analyzed retrospectively. RESULTS: Nine patients recovered to a favorable condition (good recovery, four patients; moderately disabled, five patients), one patient remained in a persistent vegetative state, and two patients died. The interval between hemorrhage and emergency craniotomy was significantly shorter in patients with favorable outcomes than in those with poor clinical outcomes. Advanced age and a larger volume of intraoperative blood loss were the factors relevant to poor outcome. Temporal lobe location of the AVM and incomplete embolization tended to correlate to poor clinical outcome, but this correlation was not statistically significant. The sizes of the AVM and the hematoma did not correlate to patient outcome. There was no difference in outcomes with regard to the surgical procedure performed. CONCLUSION: In patients with massive postembolization hematomas, emergency craniotomy should be performed as soon as possible to achieve a favorable outcome. Cooperation among interventional neuroradiologists, intensive care physicians, and neurosurgeons is essential to manage AVM patients with critical postembolization hemorrhage. There is no need to persist in performing simultaneous total resection of the AVM at the emergency craniotomy.

Adult↗

PubMed2003

Long-term seizure outcomes following amygdalohippocampectomy.

OBJECT: Analyses of the results of surgery for epilepsy are hindered by inconsistent classifications of seizure outcome, small numbers of patients, and short postoperative follow-up periods. The authors conducted a retrospective study with a reassessment of the long-term seizure outcomes in patients who underwent selective amygdalohippocampectomy (SelAH) for pharmacotherapy-resistant mesial temporal lobe epilepsy (MTLE) at the Zurich University Hospital from 1975 to 1999. METHODS: Year-by-year data and the last available data on seizure outcomes were retrospectively assessed for 369 consecutively surgically treated patients who had participated in a follow-up period longer than 1 year as of 1999 and whose outcomes were classified according to the Engel scale and the proposed new International League Against Epilepsy (ILAE) scale. Patients were grouped into nonlesional and lesional MTLE groups depending on whether they harbored a gross anatomical lesion that caused the MTLE. Differentiation was made between curative and palliative operations. Complications related to surgery are reported for 453 patients who underwent SelAH and participated in more than 3 months of follow-up review. The last available outcome data according to the Engel scale were found to be generally similar to those of the new ILAE classification, with 66.9% of patients free from disabling seizures (Engel Class I) compared with 57.1% who were completely seizure and aura free (ILAE Class 1). The last available data on seizure outcome were not significantly different between patients in the lesional and nonlesional MTLE groups. In the lesional group, seizure outcomes were significantly better when patients underwent surgery early in the course of the disease. Overall, 70% of the patients received reductions in their antiepileptic drug treatment at the time of the last available follow-up review. Complications related to the surgical procedures were rare. CONCLUSIONS: The authors conclude that SelAH is a safe and effective surgical procedure for MTLE.

Adult↗

PubMed2003

A population-based study of the incidence and survival rates in patients with pilocytic astrocytoma.

OBJECT: The incidence of pilocytic astrocytomas and the rate of patient survival were analyzed in a population-based study in the canton of Zürich, Switzerland. METHODS: Between 1980 and 1994, 987 astrocytic and oligodendroglial tumors were diagnosed, of which 55 (5.5%) were pilocytic astrocytomas. The incidence rate, adjusted to the World Standard Population, was 4.8 per 1 million per year. The mean age at clinical diagnosis was 19.6 +/- 12.7 years, and the male/female ratio was 1.12. The most frequent tumor sites were the cerebellum (40%), followed by supratentorial locations (35%), the optic pathway and hypothalamus (11%), and the brainstem (9%). The mean follow-up period was 12 years. Observed survival rates were 100% at 5 years and 95.8% at 10 years after diagnosis (relative survival rate at 10 years: 96.8%). Seven patients (13%) received postoperative radiotherapy, but this did not significantly affect survival. In all patients the tumors were histologically classified as WHO Grade I, except in two patients who had anaplastic pilocytic astrocytoma (Grade III), one of whom died after 7 years, whereas the other was still alive after 10 years. CONCLUSIONS: This population-based study shows that, because of the benign biological behavior of pilocytic astrocytomas and advances in microneurosurgery, the survival rates for patients with these tumors are excellent, regardless of postoperative radiotherapy.

Adult↗

PubMed2003

Aneurysms at a temporopolar artery origin from the internal carotid artery: report of two cases.

OBJECTIVE AND IMPORTANCE: Origination of the temporopolar artery (TPA) from the supraclinoid internal carotid artery (ICA) represents a rare anatomic variation, and the presence of aneurysms at this uncommon site has never before been reported. CLINICAL PRESENTATION: Two patients presented with a sudden onset of headaches and meningism. Computed tomography demonstrated diffuse subarachnoid hemorrhage in both cases. Cerebral angiography revealed ruptured aneurysms originating at a TPA origin from the ICA. INTERVENTION: The patients were surgically treated, and the aneurysms were successfully clipped. For technical reasons, the TPA was sacrificed in both cases. CONCLUSION: These are the first reported cases of aneurysms originating at the TPA origin from the ICA. Awareness of the existence of this variation is necessary, particularly for the management of superior wall aneurysms of the ICA.

Adult↗

PubMed2003

Moyamoya disease.

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Cerebrovascular Circulation↗

PubMed2002

Evaluation of brain toxicity following near infrared light exposure after indocyanine green dye injection.

Indocyanine green (ICG) has excellent safety records and is widely used in medical diagnosis. Recently, a new method has been developed to estimate cerebral blood flow (CBF) using ICG in combination with near-infrared spectroscopy (NIRS). The new technique may be of wide clinical interest, as it is noninvasive and easy to perform at the bedside in stroke patients. Additionally, ICG with the use of specific wavelength lasers is documented to be effective in photodynamic therapy (PDT). Under normal conditions ICG does not cross the intact blood brain barrier (BBB). However, in patients with brain injuries where the BBB may be disturbed, ICG could accumulate in brain parenchyma and in combination with NIR-light exposure, phototoxicity could occur. The aim of the present study was to examine the possible toxicity of ICG in combination with NIRS in a specific setting for CBF measurements. In five rats with mannitol induced BBB breakdown no traces of ICG were found during spectrophotometric analysis of the brain cell suspensions. In ten rats with disrupted BBB there were no significant increases of brain temperature or histological signs of brain damage following 1 h NIR-light exposure after ICG injection. The existing literature concerning the application of ICG in combination with NIR light is reviewed.

Animals↗

PubMed2002

Interventional MR-guided neuroendoscopy: A new therapeutic option for children.

Neuroendoscopic treatment of hydrocephalic children is an established surgical modality. Open magnetic resonance imaging (MRI) technology introduces new imaging features that, in combination with endoscopy, seem particularly valuable for performing these operations. "Near" real-time production of MR images in 3 dimensions during the procedure allows real-time neuronavigation, thus, facilitating guidance of an endoscope. Additionally, intraoperative changes such as brain shift, effects of perforation, and drainage of cysts are shown during an ongoing procedure. The patency of cysts or fluid compartments inside the ventricular system can be controlled by intraoperative injection of diluted gadolinium into the cystic compartments. These new therapeutic options were applied in 2 hydrocephalic children with complex ventricular cysts: a 3-month-old girl with a large, septated arachnoidal cyst and internal hydrocephalus and a boy of 7 years, 2 months with congenital hydrocephalus and premature closure of the coronary sutures.

Arachnoid Cysts↗

PubMed2002

Histological yield, complications, and technological considerations in 114 consecutive frameless stereotactic biopsy procedures aided by open intraoperative magnetic resonance imaging.

OBJECT: The authors undertook a prospective study of frameless, magnetic resonance (MR)-guided stereotactic brain biopsy procedures performed with the aid of an open MR system. Morbidity and mortality rates, frequency of postoperative hemorrhage, and histological yield were evaluated, as well as the size and location of the lesions under investigation. METHODS: During a period of 51 months (July 1996-November 2000), 114 consecutive frameless stereotactic biopsy procedures were performed with the aid of an open intraoperative MR system to investigate supratentorial lesions in 113 patients. The median volume of the lesions was 33.5 cm3, and 31.9% were deep seated. All biopsy samples comprised pathological tissue and in 111 (97.4%) of 114 a specific neuropathological diagnosis was made. A follow-up computerized tomography (CT) scan was obtained on the 1st postoperative day in all patients to evaluate postoperative complications. In two cases (1.8%), a hemorrhage was found on postoperative CT scans, with no neurological worsening of the patients. Morbidity with neurological worsening was seen in three patients; it was transient in two of them (1.8%), and in one (0.9%) subsequent emergency craniotomy was necessary because of increased edema. There were no infections, but there was one death (0.9%) CONCLUSIONS: Open intraoperative MR imaging transforms a blind conventional stereotactic procedure into a visually controlled procedure that is adaptable to dynamic anatomical changes. Routine postprocedural MR imaging makes follow-up CT scanning obsolete. This largest reported series of intraoperative MR-guided biopsy procedures shows results that are at least comparable with those in reports of larger series of conventional stereotactic biopsy sampling. The mean procedure time was 60 minutes including planning, and this method produced low morbidity and complication rates and a high histological yield.

Adolescent↗

PubMed2001

Phenotype versus genotype correlation in oligodendrogliomas and low-grade diffuse astrocytomas.

Oligodendrogliomas typically show loss of heterozygosity (LOH) on chromosomes 1p and 19q, which correlates with their response to chemotherapy, whereas low-grade astrocytomas are characterized by frequent TP53 mutations and lack of sensitivity to alkylating therapeutic agents. Unequivocal histological distinction of low-grade diffuse astrocytomas from oligodendrogliomas and oligoastrocytomas is often difficult. To elucidate the relationships between morphological phenotype and genetic profile, we screened 19 oligodendrogliomas (WHO grade II) and 23 low-grade diffuse astrocytomas (WHO grade II) for TP53 mutations and LOH on 1p and 19q. In oligodendrogliomas, LOH on chromosomes 1p and/or 19q was found in 15 cases (79%) and TP53 mutation was detected in 4 cases (21%). The presence of a typical perinuclear halo in >50% of tumour cells and a chicken-wire vascular pattern were significantly associated with LOH on 1p or 19q (93% of cases). This suggests that oligodendrogliomas with classical histologic features are likely to have a better prognosis. In low-grade diffuse astrocytomas, LOH on chromosomes 1p and/or 19q was found in three cases (13%) and TP53 mutation was detected in ten cases (43%). Histologically, five low-grade astrocytomas (22%) contained small areas with oligodendroglial differentiation, but this did not correlate with the presence of TP53 mutations or LOH on 1p and 19q. In both oligodendrogliomas and astrocytomas, LOH on chromosomes 1p or 19q and TP53 mutation were mutually exclusive. Methylation of the promoter of the gene for O (6)-methylguanine-DNA methyltransferase (MGMT), a DNA repair protein, which confers resistance to chemotherapy with alkylating agents, was detected in 47% of oligodendrogliomas and 48% of low-grade diffuse astrocytomas. There was no correlation with LOH on chromosomes 1p/19q, suggesting that MGMT may not be a prognostic marker for oligodendrogliomas.

Adult↗