SEARCH · PubMed Health

Results for “postoperative recurrence”

Explore indexed PubMed citations for clinical trials, systematic reviews and public health research. Read source abstracts and follow each citation to its original PubMed record.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 19 recordsLinked to original sources

PubMed2006

Long-term outcome from a study on the prevention of postoperative recurrence in patients with renal cell carcinoma: could PBL be a predictor of postoperative recurrence in patients postoperatively treated with IFN-gamma?

This study examined the outcome of postoperative recurrence therapy on renal cell carcinoma (RCC) prevention involving treatment with single doses of interferon-gamma (IFN-gamma). From 1990-2000, 37 patients with no distant metastasis at the time they underwent a nephrectomy were enrolled in this investigation. Subcutaneous IFN-gamma was administered once a week. Total and differential white blood cells were counted before the pre-administration of IFN-gamma and then monthly thereafter for all patients. Blood lymphocyte subsets were analyzed phenotypically by direct immunofluorescence. Disease-free survival rates (DFSR) at 5 and 10 years were 81.7% and 75.9%, respectively. To clarify the effects of preoperative peripheral blood lymphocyte (PBL) and NK activity on DFSR, we categorized the patients into two groups according to the median number of PBL before the administration of IFN-gamma. Except for CD11b, PBL level had no effect on DFSR. Multiple logistic regression analysis showed that CD11b levels greater than 16.5% were associated with 25.35 odds ratio increase in the risk of postoperative recurrence. A multivariate analysis found that CD11b may be an independent factor for postoperative recurrence. In terms of preventing postoperative recurrence, our results showed that an elevated CD11b level may indicate patients who can benefit from further combination therapy.

Adult↗

PubMedDate not supplied

Dynamic MR imaging of recurrent postoperative cervical cancer.

The value of dynamic-contrast enhanced MR imaging using FLASH technique was studied in 13 patients with postoperative recurrent cervical cancer verified histopathology and in 9 patients without recurrence. Dynamic FLASH imaging and conventional spin-echo T1- and T2-weighted sequences were compared in a prospective fashion with regard to accuracy of the diagnosis of recurrent tumor using biopsy results as the gold standard. The contrast between the recurrent tumor and the surrounding pelvic tissues was also analyzed. The accuracy of depicting recurrent tumor or dynamic images (82%) was superior to that of pre- and postcontrast T1-weighted images and T2-weighted images (64%, 68%, and 64%, respectively). The contrast between the recurrent tumor and pelvic fat was greater on precontrast T1-weighted and dynamic images than on T2-weighted and postcontrast T1-weighted images. The dynamic images clearly showed involvement of the surrounding pelvic organs, because enhancement was observed exclusively in the tumor in the early dynamic phase. Accuracy regarding involvement of the urinary bladder or rectal wall on pre- and postcontrast T1-weighted images and T2-weighted images was lower than that on the dynamic images. Dynamic MR imaging has potential for use in the detection and evaluation of the extent of recurrent postoperative cervical cancer.

Adult↗

PubMed2001

Pediatric Crohn's disease: risk factors for postoperative recurrence.

OBJECTIVE: Postoperative recurrence of Crohn's disease in adults has been extensively studied; however, the course of Crohn's disease after surgery in children has not been well defined. The aim of this study was to examine the postoperative course of pediatric Crohn's disease and the factors that may predict early postoperative recurrence. METHODS: We identified 100 resective surgeries in 79 children with Crohn's disease seen at the Children's Hospital of Philadelphia between 1978 and 1996. A retrospective, multivariable analysis of factors potentially influencing postoperative clinical recurrence was performed. Preoperative and postoperative height measurements were compared, and z scores were computed for height-for-age. Two-tailed t test was used for the analysis. RESULTS: Clinical recurrence rates were 17% at 1 yr, 38% at 3 yr, and 60% at 5 yr. Patients with colonic Crohn's disease had a significantly shorter postoperative recurrence-free interval (median 1.2 yr) than patients with ileocecal (median 4.4 yr) or diffuse disease (median 3.0 yr) (p = 0.01). On multivariable analysis, a high Pediatric Crohn's Disease Activity Index at the time of surgery (p = 0.01) and preoperative use of 6-mercaptopurine (6-MP) (p < 0.005) were also independently associated with higher postoperative recurrence rates. There was a significant improvement in z scores for height (p = 0.04) after surgery. CONCLUSIONS: In children undergoing resective surgery for Crohn's disease, high rates of postoperative Crohn's disease recurrence are associated with severe disease at the time of surgery, colonic Crohn's disease, and the preoperative use of 6-MP. Patients who require preoperative use of 6-MP are likely to suffer from a more aggressive disease and would benefit from postoperative 6-MP prophylaxis. Height growth was improved after intestinal resection for Crohn's disease.

Adolescent↗

PubMedDate not supplied

Regional body FDG-PET in postoperative recurrent hyperparathyroidism.

PURPOSE: The use of preoperative imaging studies in patients with persistent or recurrent hyperparathyroidism after initial operation is generally accepted to improve the success rate and minimize the morbidity from reoperative surgery. The purpose of this study was to define the performance of FDG-PET for the localization of hyperfunctioning parathyroid tissue prior to reoperation. METHOD: Twenty patients with biochemical evidence of recurrent or persistent hyperparathyroidism following previous neck surgery were investigated. Regional body PET imaging of the neck and upper chest (axial field of view 27.5 cm) was acquired 45 min after 5-10 mCi FDG was given intravenously. RESULTS: Subsequent surgery revealed solitary parathyroid adenomas in 14 patients, seven hyperplastic glands in 2 patients, and parathyroid carcinoma in 1 patients. FDG-PET correctly identified 79% (11/14) of the parathyroid adenomas, 29% (2/7) of the hyperplastic glands, and the parathyroid carcinoma. FDG-PET was negative in 79% (30/38) of the surgically identified normal parathyroid glands. Eight false-positive findings led to a positive predictive value of 64%. CONCLUSION: These preliminary data suggest that regional body FDG-PET is a promising procedure in the evaluation of patients with persistent or recurrent postoperative hyperparathyroidism.

Adenoma↗

PubMed1996

Recurrent postoperative parathyroid carcinoma: FDG-PET and sestamibi-SPECT findings.

Parathyroid carcinoma is a rare cause for primary hyperparathyroidism. A 65-yr-old man presented with postoperative, recurrent hyperparathyroidism after resection of parathyroid carcinoma. Misleading findings were demonstrated by both double-phase 99mTc-sestamibi scintigraphy and MRI. The location and extent of the parathyroid carcinoma were correctly detected by PET using 18F-fluorodeoxyglucose. FDG-PET provided accurate information before reoperation and proved to be valuable for preoperative surgical planning.

Aged↗

PubMed1995

Scanning electron-microscopic lesions in Crohn's disease: relevance for the interpretation of postoperative recurrence.

BACKGROUND/AIMS: Endoscopic postoperative recurrence often occurs a few months after surgical therapy for Crohn's disease, even if the resection margins were macroscopically free of disease. Why the disease primarily recurs at the anastomotic site is not known. This study investigated resection margins in Crohn's disease in an attempt to clarify whether early lesions are relevant to the interpretation of postoperative recurrence. METHODS: Specimens of surgically resected bowel from 29 patients with Crohn's disease and tissue from 11 controls were studied with a scanning electron microscope. RESULTS: In Crohn's disease, a triad of early lesions occurring in both histopathologically unaffected and affected mucosa was revealed; the triad consisted of mucosal architectural alterations, epithelial bridge formation, and goblet-cell hyperplasia or hypertrophy or both. Seventy-three percent of patients showed early alterations within histopathologically unaffected margins in the small bowel, and 71% had such alterations in the large bowel. CONCLUSIONS: The findings provide further evidence for the concept of diffuse involvement of the whole gastrointestinal tract by the disease process. The endoscopic recurrence rate in the first year after the operative procedure is almost identical to the number of early lesions present during surgery. The term "postoperatively recurrent disease" should be used only if relevant clinical parameters change.

Crohn Disease↗

PubMed1990

[Cooperative study on surgical adjuvant immunochemotherapy for prevention of postoperative recurrence of gastric cancer (II). Cooperative study group on surgical adjuvant immunochemotherapy for prevention of postoperative recurrence of gastric cancer supported by the Ministry of Health and Welfare (Kondo's group])

A cooperative study on surgical adjuvant immunochemotherapy for prevention of postoperative recurrence of gastric cancer was carried out by Kondo's group from July 1974 to December 1977. A total of 848 patients with gastric cancer underwent curative resection were eligible. Of 848 patients, 819 cases with complete description of patient's background were evaluable: Group A (surgery + MMC + 5-FU:chemotherapy) 253 cases, group B (surgery + MMC + 5-FU + OK-432 or PSK:immunochemotherapy) 282 and group C (surgery alone) 284. The 5-year corrected survival rates of total cases using Cox's proportional hazard model were 76.2% with group A, 73.6% with group B and 73.3% with group C. And the 10-year survival rates were 67.6% with group A, 64.3% with group B and 63.9% with group C. The difference in survival rate among groups A, B and C was not statistically significant. In the evaluation of prognostic factors by Cox's proportional hazard model, level of curative resection, extent of resection, histological stage and Kajitani's classification had an influence upon survival rates, in which degrees of metastasis in lymph node and serous infiltration were also involved. The significance of postoperative adjuvant immunochemotherapy has not been clarified.

Adjuvants, Immunologic↗

PubMed2003

Cytokeratin 19 expression in hepatocellular carcinoma predicts early postoperative recurrence.

Clinicopathologic features and postoperative outcomes were investigated for patients who underwent curative surgery for biliary marker (CK7 and CK19)-positive hepatocellular carcinoma (HCC). Of 157 HCCs, 93 were CK7(-)CK19(-), 49 were CK7(+)-CK19(-), 1 was CK7(-)CK19(+), and 14 were CK7(+)- CK19(+). Semiquantitative analysis of expression levels demonstrated a significant correlation between CK7 and CK19 expression. Of various clinicopathologic parameters, tumor differentiation exhibited a significant correlation with CK7 and CK19 expression. All 15 patients with CK19-positive HCC also had anti-HBc. Log-rank test revealed that CK7 expression, CK19 expression, high aspartate aminotransferase (AST) activity, low albumin concentration, portal invasion, intrahepatic metastasis, and severe fibrosis (cirrhosis) reduced the tumor-free survival rate. Multivariate analysis demonstrated that CK19 expression, intrahepatic metastasis, and severe fibrosis were independent predictors of postoperative recurrence, while CK7 expression was not. Twelve of 15 patients with CK19-positive HCC had tumor recurrence within 2 years after surgery, a significantly higher incidence of early recurrence than for CK19-negative HCC. The incidence of extrahepatic disease, especially lymph node metastasis, was significantly higher for patients with CK19-positive HCC. These findings indicate that CK19 expression is a predictor of early postoperative recurrence due to increased invasiveness.

Adult↗

PubMed2001

Factors in the natural history of chronic subdural hematomas that influence their postoperative recurrence.

OBJECT: Factors affecting the postoperative recurrence of chronic subdural hematomas (CSDHs) have not been sufficiently investigated. The authors have attempted to determine features of CSDHs that are associated with a high or low recurrence rate on the basis of the natural history of these lesions and their intracranial extension. METHODS: One hundred six patients (82 men and 24 women) harboring 126 CSDHs who were treated at Tokyo Kosei Nenkin Hospital between January 1989 and April 1998 were studied. Types of CSDHs were classified according to hematoma density and internal architecture, and the intracranial extension of the hematomas were investigated. The postoperative recurrence rate was calculated for each factor. Based on the internal architecture and density of each hematoma, the CSDHs were classified into four types, including homogeneous, laminar, separated, and trabecular types. The recurrence rate associated with the separated type was high, whereas that associated with the trabecular type was low. Chronic subdural hematomas are believed to develop initially as the homogeneous type, after which they sometimes progress to the laminar type. A mature CSDH is represented by the separated stage and the hematoma eventually passes through the trabecular stage during absorption. Based on the intracranial extension of each hematoma, CSDHs were classified into three types, including convexity, cranial base, and interhemispheric types. The recurrence rate of cranial base CSDHs was high and that of convexity CSDHs was low. CONCLUSIONS: Classification of CSDHs according to the internal architecture and intracranial extension may be useful for predicting the risk of postoperative recurrence.

Adult↗

PubMed1995

Combined radiochemotherapy for postoperative recurrence of oesophageal cancer.

Postoperative recurrences are common after resection for oesophageal cancer. From January 1986 to September 1993 31 patients (30 males, one female, mean (SD) age: 57.5 (8.8) years) were treated for locoregional recurrence (n = 24), metastases (n = 6) or both (n = 1) occurring 15.0 (12.6) months after initial surgery. Radiotherapy and chemotherapy were combined in all cases. Symptomatic improvement was seen in 23 cases (74%) and lasted (excluding treatment period) for 6.3 (4) months. Objective tumoral response was seen in 20 patients (65%) including eight (26%) complete responses. Survival rates were at respectively six months, one, two, and three years: 70.7%, 47.1%, 17.1%, 4.3%. In conclusion, these results show that combined therapy could have a beneficial symptomatic effect and can be associated with prolonged survival in patients with postoperative recurrences of oesophageal cancer.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed2000

Risk factors, prevention, and management of postoperative recurrence after resection of hepatocellular carcinoma.

OBJECTIVE: To evaluate the current knowledge on the risk factors for recurrence, efficacy of adjuvant therapy in preventing recurrence, and the optimal management of recurrence after resection of hepatocellular carcinoma (HCC). SUMMARY BACKGROUND DATA: The long-term prognosis after resection of HCC remains unsatisfactory as a result of a high incidence of recurrence. Prevention and effective management of recurrence are the most important strategies to improve the long-term survival results. METHODS: A review of relevant English articles was undertaken based on a Medline search from January 1980 to July 1999. RESULTS: Pathologic factors indicative of tumor invasiveness such as venous invasion, presence of satellite nodules, large tumor size, and advanced pTNM stage, are the best-established risk factors for recurrence. Active hepatitis activity in the nontumorous liver and perioperative transfusion also appear to enhance recurrence. Recent molecular research has identified tumor biologic factors such as the proliferative and angiogenic activities of the tumor as new risk factors for recurrence. There is a lack of convincing evidence for the efficacy of neoadjuvant or adjuvant therapy in preventing recurrence. Retrospective studies suggested that postoperative hepatic arterial chemotherapy might improve disease-free survival, but results were conflicting. For the management of postoperative recurrence, studies have consistently indicated that surgical resection should be the treatment of choice for localized recurrence, be it in the liver remnant or extrahepatic organs. Transarterial chemoembolization and percutaneous ethanol injection are widely used to prolong survival in patients with unresectable intrahepatic recurrence, and combined therapy with these two modalities may offer additional benefit. CONCLUSIONS: Knowledge of the risk factors for postoperative recurrence provides a basis for logical approaches to prevention. Minimal surgical manipulation of tumors to prevent tumor cell dissemination, avoidance of perioperative blood transfusion, and suppression of chronic hepatitis activity in the liver remnant are strategies that may be useful in preventing recurrence. The efficacy of postoperative adjuvant regional chemotherapy deserves further evaluation. New concepts on the influence of tumor biologic factors such as angiogenic activity on recurrence of HCC suggest a potential role of novel approaches such as antiangiogenesis for adjuvant therapy in the future. Currently, the most realistic approach in prolonging survival after resection of HCC is early detection and aggressive management of recurrence. Randomized trials are needed to define the roles of various treatment modalities for recurrence and the benefit of multimodality therapy.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed2000

Risk factors for surgery and postoperative recurrence in Crohn's disease.

OBJECTIVE: To assess the impact of possible risk factors on intestinal resection and postoperative recurrence in Crohn's disease (CD) and to evaluate the disease course. SUMMARY BACKGROUND DATA: The results of previous studies on possible risk factors for surgery and recurrence in Crohn's disease have been inconsistent. Varying findings may be explained by referral biases and small numbers of patients in some studies. METHODS: Data on initial intestinal resection and postoperative recurrence were evaluated retrospectively in a population-based cohort of 1,936 patients. The influence of concomitant risk factors was assessed using uni- and multivariate analyses. RESULTS: The cumulative rate of intestinal resection was 44%, 61%, and 71% at 1, 5, and 10 years after diagnosis. Postoperative recurrences occurred in 33% and 44% at 5 and 10 years after resection. The relative risk of surgery was increased in patients with CD involving any part of the small bowel, in those having perianal fistulas, and in those who were 45 to 59 years of age at diagnosis. Female gender and perianal fistulas, as well as small bowel and continuous ileocolonic disease, increase the relative risk of recurrence. CONCLUSIONS: Three of four patients with CD will undergo an intestinal resection; half of them will ultimately relapse. The extent of disease at diagnosis and the presence of perianal fistulas have an impact on the risk of surgery and the risk of postoperative recurrence. Women run a higher risk of postoperative recurrence than men. The frequency of surgery has decreased over time, but the postoperative relapse rate remains unchanged.

Adolescent↗

PubMed2005

Preventive effect of nutritional therapy against postoperative recurrence of Crohn disease, with reference to findings determined by intra-operative enteroscopy.

OBJECTIVE: The aim of this study was to elucidate the predictive value of intra-operative enteroscopy (IOE) and the effect of enteral nutrition (EN) with regard to the postoperative recurrence of Crohn disease (CD). MATERIAL AND METHODS: Forty patients requiring surgery for severe intestinal complications of CD were examined by IOE, and the severity of the remnant small intestine was determined. Patients were subclassified into either an EN group (>1,200 kcal/day) or a non-EN group (<1,200 kcal/day) according to the amount of daily EN intake after surgery. Contributions of IOE findings and EN to postoperative recurrence were analysed retrospectively. RESULTS: IOE identified intestinal lesions in 39 patients and active intestinal lesions in 24 patients. The cumulative rate of postoperative recurrence was significantly higher in patients with cobblestone appearance confirmed by IOE (p=0.006). However, other active intestinal lesions were not related to postoperative recurrence. EN reduced the cumulative rate of postoperative recurrence (p=0.017), especially in patients with penetrating type (p=0.005), in patients who did not have colitis (p=0.051) and in patients who did not have active intestinal lesions confirmed by IOE (p=0.02). CONCLUSIONS: EN is a prophylactic that prevents the postoperative recurrence of small intestinal CD. Patients with the penetrating type of CD, and those who do not have active lesions in the small intestine according to IOE, are candidates for EN after surgery.

Adolescent↗

PubMed1993

[Postoperative recurrence form of Crohn's disease: comparison between perforating and non perforating types].

Postoperative recurrence rate and recurrence form were analyzed in two clinical forms of Crohn's disease at primary resection, one of which was perforating and the other was non perforating. Forty four patients with Crohn's disease were included in this study, 18 of them were perforating type and 26 were non perforating type. Crude recurrence rates were 39% (7/18 cases) in perforating type group and 54% (14/26 cases) in non perforating type group, which were not significantly different. Cumulative recurrence rates 5 years after initial operation were 58% in perforating type group and 47% in non perforating group without statistically significance. The recurrence form was perforating type more frequently in perforating type group (86%) than non perforating group at primary resection (29%) with statistically significance (p = 0.013). Postoperative recurrence form had a tendency to be similar to the form at primary resection. It was suggested from this study that Crohn's disease had two different disease entities; perforating and non perforating types and that postoperative recurrence should be examined carefully from the view of primary resection.

Adolescent↗

PubMed1996

Prognostic factors for postoperative recurrence of Crohn's disease. Gruppo Italiano per lo Studio del Colon e del Retto (GISC)

UNLABELLED: Prognostic factors for postoperative recurrence of Crohn's disease (CD) have been widely investigated but not yet clearly identified. PURPOSE: Aim of this study was, therefore, to analyze the association between demographic, clinical, laboratory, and surgical characteristics of patients and the cumulative probability of endoscopic postoperative recurrence. METHODS: The study was performed in 110 patients who were enrolled in the Italian multicenter, randomized, controlled trial on the effectiveness of 5-aminosalicylic acid (5-ASA) in the prevention of postoperative recurrence in CD. Patients had undergone their first intestinal resection for CD of the terminal ileum with or without involvement of cecum ascending colon. Recurrence was defined on the basis of endoscopy. The following variables were evaluated as potential prognostic factors: gender, age, years since diagnosis, clinical course (perforative and non-perforative), Crohn's Disease Activity Index score, white blood count, erythrocyte sedimentation rate, C-reactive protein, and orosomucoids assessed before the operation. Timing of operation (elective or urgent), type of anastomosis (end-to-end, end-to-side, side-to-side), and prophylactic treatment were also evaluated. Colon ileoscopy was performed at 6, 12, 24, and 36 months after operation. The association between variables and the cumulative proportion of recurrence was analyzed both by univariate analysis (life table method, log-rank test) and multivariate regression analysis (Cox's model, stepwise procedure). RESULTS: Results of this study indicate that, of the features considered before surgery, only leukocytosis (white blood count, >9,000 ml) was significantly associated with an increased risk of recurrence (P < 0.05) at univariate analysis. This finding was not confirmed by multivariate analysis. A trend toward a higher risk of recurrence for patients who have had a resection with end-to-end anastomosis compared with those who have had a resection and other types of anastomosis was also observed. This trend reached significantly in the group of patients submitted to treatment with 5-ASA. The multivariate analysis showed that 5-ASA-treated patients with end-to-end had a risk of recurrence more than threefold higher than those with other types of anastomosis (relative risk, 3.40; 95 percent confidence interval, 1.00-11.96; P < 0.03). CONCLUSIONS: From a practical point of view, it has been estimated that the combination of intestinal resection plus side-to-side or end-to-side anastomosis with oral 5-ASA treatment reduces by 64 percent the postoperative recurrence rate in CD at three years follow-up.

Adult↗

PubMed1999

Prevention of postoperative recurrence in Crohn's disease.

Postoperative recurrence of Crohn's disease is often inevitable. Certain risk factors such as smoking, young age, and a perforating disease behavior have been identified. Patients with an enhanced risk profile should be treated with mesalamine or with azathioprine, the latter of which has higher success rates. An endoscopic evaluation of the neoterminal ileum performed 6 to 12 months after surgery provides important prognostic information regarding the further clinical course of the disease and can be used as a guide to optimize medical therapy.

Anti-Inflammatory Agents, Non-Steroidal↗

PubMed1995

[Percutaneous ethanol injection therapy for the treatment of postoperative recurrent primary liver cancer].

This article reported 109 cases of postoperative recurrent primary liver cancer, treated with percutaneous ethanol injection therapy (PEIT) under the guidance of conventional ultrasonic transducer, the total number of injection being 637 times. No metastasis through the needle track or other serious complications were encountered. The 1.3 and 5 year survival rates were 92.6%, 47.8%, and 19%, respectively. We noted that the key factor affecting the efficacy of treatment was the accurate localization of puncture, rather than the times of injection or the quantity of ethanol injected. Criteria for the judgement of treatment and precautions to be noted concerning the procedure were suggested. It is concluded that PEIT is the treatment of choice in the management of non-operable, single, and comparativly smalle focus of postoperative recurrent primary liver cancer.

Adult↗

PubMed2005

[Minimally invasive technique treatment of postoperative recurrent bone cysts in juvenile patients].

OBJECTIVE: To study the effect of minimally invasive treatment of postoperative recurrent bone cysts in juvenile patients. METHODS: From December 1984 to December 2003, 36 cases of postoperative recurrent bone cysts after focal curettage and bone graft included 19 males and 17 females, aging 9-21 years with an average of 15 years. The size of bone cyst ranged from 2.5 cm x 6.0 cm to 3.5 cm x 13.0 cm with an average of 3.0 cm x 8.0 cm. The locations were proximal humerus in 18 cases, humeral shaft in 10 and femoral trochanteric region in 8. The focal curette and bone graft were given once in 23 cases, twice in 10 cases and 3 times in 3 cases. The interval between recurrence and minimally invasive treatment was 5-13 months (6.5 months on average). The posteroanterior and lateral X-ray films were taken to determine the location, range and feature of the focus. Under local anesthesia, 2 canulated needles were used; one was used to aspirate the contents of the cyst, the other was used to inject hydrocortisone acetate. The dose was determined according to the range of the focus. The treatment was repeated every 3. 5-4 months until the focus healed. RESULTS: All patients were followed up from 3 to 18 years with an average of 5 years. The minimally invasive treatment was repeated 3-11 times with an average of 6 times. Twenty-six cases healed completely, 6 cases healed significantly, and 4 cases healed partially. No local or general complications occurred during the treatment. CONCLUSION: This minimally invasive method for the treatment of postoperative recurrent bone cyst in juvenile patients has following advantages : less pain, easy manipulation, no hospitalization, low cost and definite effect.

Adolescent↗