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At least 343 records · Page 19Linked to original sources

PubMed2005

Seizures as the only clinical manifestation of reactive hypoglycemia: a case report.

A 45-yr old diabetic patient, who had received a diagnosis of grand mal epilepsy, for two episodes of nocturnal tonic-clonic convulsions, underwent continuous glucose monitoring (CGM). During CGM, the patient had an episode of tonic-clonic convulsion, and at the same time a prolonged nocturnal hypoglycemia (<2.2 mmol/l) was observed. CGM revealed that tonic-clonic convulsions, which had been interpreted as a manifestation of epilepsy, were in fact a symptom of severe hypoglycemia. In order to assess the pathogenesis of hypoglycemia, the patient underwent a 75-g oral glucose tolerance test, that was interrupted shortly afterwards for hypoglycemic symptoms (i.e., reactive hypoglycemia). To our knowledge, this is the first case ever reported of reactive hypoglycemia associated with Type 2 diabetes.

Blood Glucose↗

PubMed2026

Effects of time-restricted eating on markers of glucose metabolism and regulation in individuals with prediabetes or type 2 diabetes: a systematic review and meta-analysis of randomised controlled trials.

AIMS/HYPOTHESIS: This systematic review and meta-analysis aimed to investigate the effects of time-restricted eating (TRE) on glucose metabolism and regulation in individuals with prediabetes (fasting blood glucose of 5.6-6.9 mmol/l or HbA1c of 39-47 mmol/mol [5.7-6.4%]) or type 2 diabetes (fasting blood glucose ≥7 mmol/l or HbA1c ≥48 mmol/mol [6.5%]). METHODS: A literature search was performed in MEDLINE, Embase and CENTRAL from inception to 5 August 2025. Moreover, forward and backward citation searches were performed. Eligible studies were RCTs in adults with prediabetes or type 2 diabetes, lasting ≥2 weeks, reporting markers of glucose metabolism and regulation, comparing TRE (≤12 h eating window) with a non-time-restricted control diet. Studies involving pregnancy, other fasting regimens, or non-peer-reviewed publications were excluded. Data were pooled as weighted mean differences with 95% CIs using random-effects generic inverse variance models in Cochrane Review Manager Web, and results are presented as forest plots. The certainty of evidence was defined using Grading of Recommendations, Assessment, Development and Evaluations methodology, and risk of bias was estimated by using the Revised Cochrane risk-of-bias tool for randomised trials (RoB 2). RESULTS: Out of 2043 records identified through the database search, as well as 1249 from forward and backward citation searches, ten RCTs including 599 participants were included. The mean length of the studies was 4 months, and the eating windows ranged from 4 to 10 h per day. The pooled meta-analysis showed no overall effect of TRE on HbA1c (-3.33 mmol/mol; 95% CI -6.87, 0.20 (-0.30% points; -0.63, 0.02); p=0.06, moderate certainty). Nevertheless, following stratification by subgroups, TRE resulted in a reduction in HbA1c of 0.93 mmol/mol (-1.70, -0.17 [-0.09% points; -0.16, -0.02]; p=0.02) in individuals with prediabetes but not in individuals with type 2 diabetes (-4.68 mmol/mol; -10.08, 0.72 (-0.43% points; -0.92, 0.07); p=0.09). TRE reduced fasting blood glucose in the pooled analysis (-0.30 mmol/l; -0.53, -0.07; p<0.01, moderate certainty) as well as in the subgroup analyses in individuals with prediabetes (-0.14 mmol/l; -0.27, -0.01; p=0.03) and with type 2 diabetes (-0.48 mmol/l; -0.78, -0.17; p<0.01). Moreover, TRE lowered body weight by 1.6 kg (-2.2, -1.0; p<0.001) in the pooled analysis. The evidence was limited by imprecision arising from wide confidence intervals in some of the included studies, which may be due to small sample sizes. Lastly, the effects of TRE on markers of insulin sensitivity, beta cell function and continuous glucose monitoring measurements were inconclusive. CONCLUSIONS/INTERPRETATION: Moderate-certainty evidence indicates that TRE reduces fasting blood glucose but not HbA1c. The subgroup analyses revealed that TRE improved HbA1c and fasting glucose in individuals with prediabetes and improved fasting glucose in individuals with type 2 diabetes. Future large-scale studies should investigate long-term effects of TRE in prevention and treatment of type 2 diabetes. TRIAL REGISTRATION: PROSPERO CRD42024523591 FUNDING: This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Three authors (JS, A-DT, THA) are employed at Steno Diabetes Center Copenhagen, a public hospital and research institution under the Capital Region of Denmark, partly funded by a grant from the Novo Nordisk Foundation.

Humans↗

PubMed2006

Potentially implantable miniature batteries.

All presently used batteries contain reactive, corrosive or toxic components and require strong cases, usually made of steel. As a battery is miniaturized, the required case dominates its size. Hence, the smallest manufactured batteries are about 50 mm3 in size, much larger then the integrated circuits or sensors of functional analytical packages, as exemplified by implantable glucose sensors for diabetes management. The status of the miniaturization of the power sources of such implantable packages is reviewed. Three microcells, consisting only of potentially harmless subcutaneously implantable anodes and cathodes, are considered. Because their electrolyte would be the subcutaneous interstitial fluid, the cells do not have a case. One potentially implantable cell has a miniature Nafion-coated Zn anode and a biocompatible hydrogel-shielded Ag/AgCl cathode. The core innovation on which the cell is based is the growth of a hopeite-phase Zn2+ conducting solid electrolyte film on the discharging anode. The film blocks the transport of O2 to the Zn, preventing its corrosion, while allowing the necessary transport of Zn2+. The second cell, with the same anode, would have a bioinert hydrogel-shielded wired bilirubin oxidase-coated carbon cathode, on which O2 dissolved in the subcutaneous fluid would be electroreduced to water. In the third cell, the glucose of the subcutaneous interstitial would be electrooxidized to gluconolactone at an implanted wired glucose anode, similar to that tested now for continuous glucose monitoring in diabetic people, and O2 in the subcutaneous fluid would be electroreduced to water on its wired bilirubin oxidase cathode.

Electricity↗

PubMed2006

Is glycemic variability important to assessing antidiabetes therapies?

Traditionally, statistical estimation of glycemic variability includes computing standard deviation of glucose readings or related statistics (eg, M value, mean amplitude of glucose excursions, and so forth). We advocate an alternative approach using risk measures of variability, which have substantial clinical and numerical advantages. In addition, continuous glucose monitoring (CGM) data have clinically important inherent temporal structure that should be taken into consideration. Thus, temporal variability methods are discussed for the analysis and interpretation of CGM output.

Blood Glucose↗

PubMed1981

Artificial pancreas as an aid during insulinoma resection.

Blood glucose control by an artificial pancreas facilitated the intraoperative management of two patients with insulin-secreting pancreatic islet cell tumors (one had a large adenoma, the other diffuse islet-cell hyperplasia). The artificial pancreas is a glucose-controlled insulin and dextrose infusion system uniquely suited for the control of blood glucose concentrations during surgery. The artificial pancreas produced a stable glycemic baseline before surgery, prevented hypoglycemia during palpation of the pancreas and manipulation of the tumor, and indirectly amplified small decreases in the blood sugar level with large increases in the rate of dextrose infusion. The advantages and limitations of continuous glucose monitoring during surgery and the use of this instrument in locating occult insulin-secreting tumors are reviewed.

Adenoma↗

PubMed2004

Diurnal glycemic profile in obese and normal weight nondiabetic pregnant women.

OBJECTIVE: A paucity of data exists concerning the normal glycemic profile in nondiabetic pregnancies. Using a novel approach that provides continuous measurement of blood glucose, we sought to evaluate the ambulatory daily glycemic profile in the second half of pregnancy in nondiabetic women. STUDY DESIGN: Fifty-seven obese and normal weight nondiabetic subjects were evaluated for 72 consecutive hours with continuous glucose monitoring by measurement interstitial glucose levels in subcutaneous tissue every 5 minutes. Subjects were instructed not to modify their lifestyle or to follow any dietary restriction. For each woman, mean and fasting blood glucose values were determined; for each meal during the study period, the first 180 minutes were analyzed. RESULTS: For the study group, the fasting blood glucose level was 75 +/- 12 mg/dL; the mean blood glucose level was 83.7 +/- 18 mg/dL; the postprandial peak glucose value level was 110 +/- 16 mg/dL, and the time interval that was needed to reach peak postprandial glucose level was 70 +/- 13 minutes. A similar postprandial glycemic profile was obtained for breakfast, lunch, and dinner. Obese women were characterized by a significantly higher postprandial glucose peak value, increased 1- and 2-hour postprandial glucose levels, increased time interval for glucose peak, and significantly lower mean blood glucose during the night. No difference was found in fasting and mean blood glucose between obese and nonobese subjects. CONCLUSION: Glycemic profile characterization in both obese and normal weight nondiabetic subjects provide a measure for the desired level of glycemic control in pregnancy that is complicated with diabetes mellitus.

Adult↗

PubMed2006

Making glucose oxidase fit for biofuel cell applications by directed protein evolution.

Progress in miniature chip-design raises demands for implantable power sources in health care applications such as continuous glucose monitoring of diabetic patients. Pioneered by Adam Heller, miniaturized enzymatic biofuel cells (mBCs) convert blood sugars into electrical energy by employing for example glucose oxidase (GOx) on the anode and bilirubin oxidase on the cathode. To match application demands it is crucial to increase lifetime and power output of mBCs. The power output has been limited by the performance of GOx on the anode. We developed a glucose oxidase detection assay (GODA) as medium-throughput screening system for improving GOx properties by directed protein evolution. GODA is a reaction product detection assay based on coupled enzymatic reactions leading to NADPH formation which is recorded at 340 nm. The main advantage of the assay is that it detects the production of d-gluconolactone instead of the side-product hydrogen peroxide and enables to improve bioelectrochemical properties of GOx. For validating the screening system, a mutagenic library of GOx from Aspergillus niger (EC 1.1.3.4) was generated and screened for improved activity using Saccharomyces cerevisiae as host. Directed evolution resulted in a GOx mutant I115V with 1.4-1.5-fold improved activity for beta-d-glucose (Vmax from 7.94 to 10.81 micromol min(-1) mg(-1); Km approximately 19-21 mM) and oxygen consumption kinetics correlate well [Vmax (O2) from 5.94 to 8.34 micromol min(-1) mg(-1); Km (O2) from 700 to 474 microM]. The developed mutagenic protocol and GODA represent a proof-of-principle that GOx can be evolved by directed evolution in S. cerevisiae for putative use in biofuel cells.

Bioelectric Energy Sources↗

PubMed2004

Lack of accuracy of continuous glucose sensors in healthy, nondiabetic children: results of the Diabetes Research in Children Network (DirecNet) accuracy study.

OBJECTIVE: The workup of hypoglycemia requires frequent glucose sampling. We designed these studies to determine if the Continuous Glucose Monitoring System (CGMS) and the GlucoWatch G2 Biographer (GW2B) are sufficiently accurate to use in nondiabetic children. Study design Fifteen healthy children (aged 9-17 years, 11 boys) wore a GW2B and a CGMS during a 24-hour period, and reference serum glucose was measured hourly during the day and half-hourly overnight. RESULTS: Compared with the reference glucose, the median absolute difference in concentrations measured by the GW2B (487 pairs) was 13 mg/dL, and the difference measured by the CGMS was 17 mg/dL (668 pairs), with 30% and 42% of values using the GW2B and CGMS, respectively, deviating >20 mg/dL from the reference value. The GW2B reported values <60 mg/dL in 73% of subjects, the CGMS in 60% of subjects. In none of these episodes was serum glucose truly low. Spurious high glucose concentrations also were observed with the sensors. The mean reference glucose was lowest at 5 am (89 mg/dL) and highest at 11:30 pm (106 mg/dL) during the 24-hour period. CONCLUSIONS: Neither the CGMS nor the GW2B is accurate enough to establish population standards of the glycemic profile of healthy children and cannot be recommended in the workup of hypoglycemia in nondiabetic youth.

Adolescent↗

PubMed2000

Rise in background current over time in a subcutaneous glucose sensor in the rabbit: relevance to calibration and accuracy.

In order to calibrate a continuous glucose monitor, accurate determination of the background current (I0) is necessary, in part because I0 could change over time. We compared two methods of I0 measurement: (1), extrapolation of sensor output data (as a function of glucose level) to the intercept at zero glucose and (2) direct measurement of the output of a blank anode with no enzyme coat. We implanted telemetric sensors subcutaneously in rabbits and measured their outputs during tri-level glucose clamps once per week for 5 weeks. The two methods yielded similar results. I0 rose substantially over time and this increase reached significance during week 3 by the direct method but not until week 5 by the extrapolation method. Using the direct method, I0 rose from 3.41 (0.60-8.48 nanoamperes (nA), median and range) during week 1 to 13.42 (9.1-14.3) during week 5. Using the extrapolation method, I0 rose from 0.57 (0-16.7) during week 1 to 15.3 (12.2-21.6) during week 5. We conclude that I0 can rise over time. If this rise went undetected and was assumed to be stable, a one-point calibration procedure would overestimate glycemia in the hypoglycemic range, i.e. fail to appreciate the severity of hypoglycemia. It is recommended that during validation of a chronic glucose sensor, I0 be measured sequentially over time.

Animals↗

PubMed2002

Calibration of a subcutaneous amperometric glucose sensor. Part 1. Effect of measurement uncertainties on the determination of sensor sensitivity and background current.

The calibration of a continuous glucose monitoring system, i.e. the transformation of the signal I(t) generated by the glucose sensor at time (t) into an estimation of glucose concentration G(t), represents a key issue. The two-point calibration procedure consists of the determination of a sensor sensitivity S and of a background current I(o) by plotting two values of the sensor signal versus the concomitant blood glucose concentrations. The estimation of G(t) is subsequently given by G(t) = (I(t)-I(o))/S. A glucose sensor was implanted in the subcutaneous tissue of nine type 1 diabetic patients during 3 (n = 2) and 7 days (n = 7). For each individual trial, S and I(o) were determined by taking into account the values of two sets of sensor output and blood glucose concentration distant by at least 1 h, the procedure being repeated for each consecutive set of values. S and I(o) were found to be negatively correlated, the value of I(o) being sometimes negative. Theoretical analysis demonstrates that this phenomenon can be explained by the effect of measurement uncertainties on the determination of capillary glucose concentration and of sensor output.

Biosensing Techniques↗

PubMed2004

Accuracy of continuous nocturnal glucose screening after 48 and 72 hours in type 2 diabetes patients on combined oral and insulin therapy.

OBJECTIVE: To evaluate the accuracy of nocturnal continuous glucose monitoring by CGMS. RESEARCH DESIGN AND METHODS: A CGMS was inserted in 14 type 2 diabetic patients on combined oral and insulin therapy at altogether 15 occasions. During the second (48 hours) and third (72 hours) night of registration each subject was observed and plasma glucose was analysed seven times during the night by venous sampling and compared to CGMS. These venous values were not used for calibration of the sensor. Pairs of data were analysed using correlation coefficient, Bland-Altman graphs and Clarke Error Grid analysis. RESULTS: 32% of CGMS data did not meet the quality criteria for optimal accuracy and were excluded. A correlation coefficient of 0.80 (p < 0.0001) was seen after 48 hours and a lower coefficient of 0.33 (p = 0.0082) after 72 hours. Bland-Altman analyses demonstrated that the dispersion of the values around the mean of differences was wider after 72 hours as compared to after 48 hours. In the Clark Error Grid analysis 100% of data were within zones A and B after 48 hours, with 60% in zone A. After 72 hours only 44% were in zone A and 7% of data were in the clinically unacceptable zone D. CONCLUSION: The MiniMed Medtronic CGMS has acceptable nocturnal accuracy after 48 hours of registration, but the accuracy thereafter deteriorates with time, implicating that the CGMS thereafter may prove less useful for nocturnal monitoring.

Administration, Oral↗

PubMed2002

Sequential kidney/islet transplantation using prednisone-free immunosuppression.

Islet transplantation is becoming established as a treatment option for type I diabetes in select patients. Individuals with type I diabetes who have previously received a successful kidney allograft may be good candidates for islet transplantation. They have already assumed the risks of chronic immunosuppression, so the added procedural risk of a subsequent islet transplant would be minimal. Furthermore, because of the preimmunosuppressed state it is possible that islet-after-kidney transplantation may result in a more efficient early islet engraftment. Consequently, insulin independence might be achieved with significantly fewer islets than the approximately 8-10,000 islet equivalents/kg/b.w. currently required. A mass that usually demands two or more cadaveric donors. A case of successful islet-after-kidney transplantation is described using the steroid-free Edmonton immunosuppression protocol. Characteristics of the final islet product are: a) islet equivalents: 265,888 (4100 islet equivalents/kg/b.w.); b) islet purity: 75-80%; c) viability: >95% (trypan blue exclusion); and d) mean islet potency (static low-high glucose challenge): 4.16 +/- 1.91-fold increase. Post-transplant the patient's hypoglycemic episodes abated. Exogenous insulin requirements were eliminated at week 12 post-transplant as basal and Ensure (Abbott Laboratories, Abbott Park, IL, USA) oral glucose stimulated C-peptide levels peaked and stabilized. Twenty-four-hour continuous glucose monitoring confirmed moment-to-moment glycemic control, and periodic nonfasting finger stick glucose determinations over the next month confirmed glycemia was controlled. Hemoglobin A1c levels declined from a pretransplant level of 6.9% to 5.3%. Renal allograft function remained changed.

Blood Glucose↗

PubMed2000

Fructosamine levels demonstrate improved glycemic control for some children attending a diabetes summer camp.

Residential summer camps for youths with diabetes may have a positive effect on glycemic control. Hemoglobin A1c (HbA1c) is considered the best measure of control, but it reflects too long a period to evaluate a camp session. The fructosamine test reflects control over a period of 2-3 wk and may be ideal for this purpose. A portable device was used to examine the relationship between 2 wk of glycemic control and the change in fructosamine in order to determine whether control improved at camp. Thirty children, 8-12 yr old, were studied during a 2-wk session of a diabetes summer camp. Pre-camp HbA1c levels were obtained from the childrens' physicians. Each camper measured his/her blood glucose four times daily. Insulin doses were readjusted frequently by camp physicians. Each child's fructosamine was measured at the beginning and end of camp. The baseline fructosamine correlated with HbA1c. The final fructosamine correlated with the 2-wk mean glucose. The subgroup who started camp in below average glycemic control improved their fructosamine levels by the end of camp. Those who started camp in better control did not change. Without continuous glucose monitoring, it is impossible to accurately determine how well fructosamine reflects glucose levels. In this study, fructosamine correlated with the mean glucoses and with an HbA1c obtained prior to camp. Fructosamine appears to be a valid measure of glycemic control and being at camp was at least transiently beneficial to the children who needed it most.

Journal Article↗

PubMed2002

The relationship between blood glucose excursions and painful diabetic peripheral neuropathy: a pilot study.

AIMS: Peripheral neuropathy affects 30% of Type 1 diabetic patients. Unfortunately, 10-20% of affected patients have disabling symptoms. The aim of this study was to examine the relationship between blood glucose excursions and pain in patients with symptomatic diabetic neuropathy. METHODS: Twenty Type 1 diabetic patients with peripheral neuropathy (10 painful and 10 painless) wore a continuous glucose monitoring system for 3 days. Symptomatic patients kept a daily pain score diary. The mean amplitude of glycaemic excursions (MAGE) and the M-values (measure of glucose deviations from an arbitrarily selected point) were calculated. RESULTS: Groups were matched for (mean +/- sd) age: 52.0 +/- 11.1 years; duration of diabetes: 24.8 +/- 10.7 years; HbA1c: 9.7 +/- 2.3%; duration of neuropathy: 5.6 +/- 2.6 years; and CGMS performance. The painful group had a greater mean glucose (12.1 +/- 2.9 mmol/l vs. 9.3 +/- 1.9 mmol/l, P = 0.02), a greater M-value (68.4 vs. 31.1, P = 0.02) and more glycaemic excursions (13 vs. 10, P < 0.01), compared with the painless group. However, there was no difference in the MAGE between both groups, and no correlation between the number of glycaemic excursions and the number of painful episodes in the painful group. CONCLUSIONS: Patients with painful neuropathy have greater glucose flux and possibly poorer diabetes control, compared with patients with painless neuropathy.

Adult↗

PubMed2003

Subcutaneous glucose sensor values closely parallel blood glucose during insulin-induced hypoglycaemia.

AIMS: To assess the accuracy of the Minimed continuous glucose monitoring system (CGMS) in estimating blood glucose concentration during a controlled reduction in blood glucose. RESEARCH DESIGN AND METHODS: We studied nine adolescent diabetics (age 14 +/- 1.5 years) wearing the CGMS during hyperinsulinaemic hypoglycaemic clamp studies. The glucose values obtained by the CGMS were compared with the venous blood samples taken during the studies and measured at the bedside using a glucose oxidase technique. RESULTS: Blood glucose was lowered from euglycaemia to a mean of 2.8 mmol/l over 120 min and maintained at that level for a further 40 min. A total of 429 paired glucose measurements were available for analysis. Analysis using weighted Deming regression and t-tests revealed small differences between the methods, with blood glucose levels slightly higher than interstitial fluid levels. The mean difference across all values was 0.13 mmol/l. The observed difference was greatest at blood glucose values < 3.3 mmol/l. CONCLUSIONS: This study suggests that during a fall in systemic glucose the subcutaneous glucose sensor provides an accurate reflection of blood glucose. However, a small difference is apparent at blood glucose values < 3.3 mmol/l.

Adolescent↗

PubMed1994

Calibration problems of subcutaneous glucosensors when applied "in-situ" in man.

Continuous glucose monitoring is the conditio sine qua non to achieve total automation in glucose-controlled insulin-delivery. Several types of glucosensors have been designed according to the enzyme-amperometric method to measure the glucose in different human compartments. However, problems such as long-term stability and calibration prevent this technique being put into practice. A feasible method is needed to calibrate the glucosensor and at the same time should be accepted by the patients. To achieve calibration we determined the absolute tissue glucose, as well as the microdialysis recovery in-vivo, in healthy subjects under normal conditions and during a hyperglycaemic clamp by applying a device based on the recirculation of phosphate buffer saline in a microdialysis probe implanted in the s.c. adipose tissue. The first experiments carried out were promising and encouraging, but further investigations are still needed to favour an ideal "before implantation, all in-vitro" method to calibrate a s.c. glucosensor.

Biosensing Techniques↗

PubMed1985

Insulin infusion therapy. Potential benefits and risks.

A mass of evidence favors the concept of euglycemic management of insulin-dependent diabetes, despite significant potential complications. Patients with advanced nephropathy and/or autonomic neuropathy are very poor risks, and infusion therapy does not reverse well-established complications. To well-motivated, educated patients, infusion therapy offers the conveniences of more flexible timing of meals and of having a premeal bolus infusion rather than a premeal injection. With improvement in the technology of continuous glucose monitoring and closed-loop systems, as well as basic improvements in immunologic techniques for islet transplantation, the future may offer a choice of excellent euglycemic therapies for insulin-dependent diabetes. Meanwhile, infusion therapy, which was once only a research tool, is now widely available and is appropriate for near-euglycemic management of diabetes in selected patients.

Abscess↗

PubMed1990

Dietary manipulation as a primary treatment strategy for pregnancies complicated by diabetes.

The mainstay of management for gestational diabetic women (GDM) has been dietary. If it is inadequate to sustain normoglycemia, insulin therapy must be initiated. We studied whether we could prevent macrosomia by insulin therapy based on four daily self blood glucose levels (SBG). Fifty GDM, ages 28-39 years were, recruited to the study. They were divided based on fasting glucose (FBS) level on the glucose tolerance test (GTT): those with FBS less than 90 mg/dl were managed by diet alone; those with FBS greater than 90 mg/dl were immediately started on insulin. The four SBG checks [FBS and 1 hour after each meal (lhpc)] correlated with the continuous glucose monitor with r = 0.91. The women were asked to perform a dipstick for ketones on their urine upon awakening and whenever a meal or snack had been missed. Insulin was initiated when the SBG monitoring indicated that: (1) the FBS was 80 mg/dl whole blood from fingerstick (WBG) or the plasma glucose (PG) greater than 90 mg/dl and/or (2) the lhpc was greater than 140 mg/dl WBG and/or (3) the patient had persistent ketonuria on the prescribed diet which cleared only when the caloric intake was increased to a point which precipitated postprandial hyperglycemia. The prescribed diet was calculated based on body weight to be 30 kcal/kg if the women were between 80 and 120% ideal body weight; or was calculated to be 24 kcal/kg if their weight was greater than 120% ideal body weight. The calories were divided such that 40% was carbohydrate, 20% protein, and 40% fat.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗