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Biomedical subjects

D Essfeld

Publications and source records attributed to D Essfeld.

At least 19 recordsLinked to original sources
PubMed2006

Hand-grip strength of young men, women and highly trained female athletes.

Hand-grip strength has been identified as one limiting factor for manual lifting and carrying loads. To obtain epidemiologically relevant hand-grip strength data for pre-employment screening, we determined maximal isometric hand-grip strength in 1,654 healthy men and 533 healthy women aged 20-25 years. Moreover, to assess the potential margins for improvement in hand-grip strength of women by training, we studied 60 highly trained elite female athletes from sports known to require high hand-grip forces (judo, handball). Maximal isometric hand-grip force was recorded over 15 s using a handheld hand-grip ergometer. Biometric parameters included lean body mass (LBM) and hand dimensions. Mean maximal hand-grip strength showed the expected clear difference between men (541 N) and women (329 N). Less expected was the gender related distribution of hand-grip strength: 90% of females produced less force than 95% of males. Though female athletes were significantly stronger (444 N) than their untrained female counterparts, this value corresponded to only the 25th percentile of the male subjects. Hand-grip strength was linearly correlated with LBM. Furthermore, both relative hand-grip strength parameters (F (max)/body weight and F (max)/LBM) did not show any correlation to hand dimensions. The present findings show that the differences in hand-grip strength of men and women are larger than previously reported. An appreciable difference still remains when using lean body mass as reference. The results of female national elite athletes even indicate that the strength level attainable by extremely high training will rarely surpass the 50th percentile of untrained or not specifically trained men.

Adult↗
PubMed2006

Recovery of hand grip strength and hand steadiness after exhausting manual stretcher carriage.

Rescue activities frequently require not only substantial and sustained hand-grip forces but also a subtle coordination of hand and finger muscles, e.g. when manipulating injection syringes after manual stretcher carriage. We investigated the recovery kinetics of manual coordination and muscle strength after exhausting stretcher carriage (4.5 km/h, load at each handle bar: 25 kg). Hand steadiness (frequency and duration of wall contacts when holding a metal pin into a small bore) and parameters of hand-grip strength were determined in 15 male volunteers before and immediately after the stretcher carriage. Measurements were repeated after 0.5, 1, 4 and 24 h of recovery. Mean carrying time was 215+/-87 s (SD), mean transport distance amounted to 264+/-104 m. During the carriage test, forces at the stretcher handles oscillated in the order of +/-50 N within each gait cycle. Immediately after exhaustion, hand steadiness was significantly deteriorated (threefold increase in frequency and duration of wall contacts), maximum and mean hand-grip force over 15 s were reduced by almost 20%. While the recovery of hand steadiness was complete by minute 30 after stretcher carriage, a significant reduction in maximum and mean hand-grip force by 12% could still be observed after 24 h. The present findings demonstrate that hand steadiness recovers much faster than maximum hand-grip strength after exhaustive manual stretcher carriage (less than 30 min vs. more than 24 h). Probably, muscle damage induced in particular by the eccentric components during stretcher transport seems to affect only the generation of large forces. By contrast, the generation and coordination of the much lower forces required for hand-steadiness appears to be impaired only during the short transient of metabolic recovery.

Adult↗
PubMed2006

Physical performance, body weight and BMI of young adults in Germany 2000 - 2004: results of the physical-fitness-test study.

In westernized countries the sedentary lifestyle in conjunction with a hypercaloric diet has caused an increase in the number of obese adults. Moreover, recent studies suggest that the prevalence of overweight in children increased during the last decade. However, the literature has to be interpreted with some caution since the majority of epidemiological studies examining health, fitness, and obesity rely on self-reported data rather than measurements. A further limitation is that most studies examine either physical activity or nutrition, only few deal with both aspects simultaneously. In the present study we analyzed both aspects in more than 58,000 persons aged between 17 and 26 years. All of them were applicants for the German Bundeswehr, which accepts only volunteers with school leaving certificates and a body mass index (BMI) below 30 kg . m (-2). The admitted subjects performed a Physical-Fitness-Test (PFT) consisting of 5 simple sport tests (shuttle run, sit-ups, push-ups, standing jump, Cooper test). For 23 000 subjects additional measurements of body height and body weight as well as information about their education level were available. These data were combined with the PFT results. We found large deficits in the physical fitness of young adults: More than 37 % of the participants failed to pass the PFT, with failure rates of the male volunteers increasing significantly since 2001. While the female volunteers showed virtually constant body weight and BMI, the corresponding values of men increased monotonously between the age of 17 and 26 years. Physical fitness was positively, BMI negatively correlated with education level. The present findings suggest that body weight increases and fitness decreases in non-obese young adults in Germany. Despite the correlations between BMI and physical fitness the terms "overweight" and "physically unfit" should not be regarded as synonyms.

Adolescent↗
PubMed2003

Reduction of blood pressure response during strength training through intermittent muscle relaxations.

UNLABELLED: The increase in blood pressure during training is a disadvantage of strength training in the elderly. To reduce this effect it is generally recommended to apply lower levels of relative muscle strength with longer contraction durations or higher number of repetitions (continuous mode (CM), e. g. 50% of maximal strength, 10 to 15 repetitions without pauses). Alternatively, higher contraction forces could be combined with frequent periods of muscle relaxation and fewer repetitions (intermittent mode (IM), e. g. 80% of maximal strength, 8 repetitions consisting of 1.5 s concentric contraction, 1.5 s eccentric contraction and 3 s pause). We compared the blood pressure effects of both approaches during leg press exercise in two age groups (10 subjects aged 22 to 42 y, 9 subjects aged 60 to 72 y). Blood pressure was measured continuously by a non-invasive method (FINAPRES, Ohmeda 2300, Englewood USA). RESULTS: 1. The age of the subjects had no significant influence on the slopes of blood pressure increase during the different exercise modes. 2. The frequent insertion of short (3 s) periods of muscle relaxation (IM) decreased the blood pressure response more effectively than a reduction in contraction strength alone (CM). Short muscle relaxations have an immediate, mechanical effect on blood pressure and they allow a metabolic recovery which attenuates the trend of blood pressure increase.

Adult↗
PubMed1999

Origin of back pain during bedrest: A new hypothesis.

Back pain during bed rest has frequently been reported. Until recently, studies concentrated mainly on length changes of the spine. Functional aspects such as reduced movements of the back, although anecdotally reported, could neither be quantified nor were they taken into account as a potential cause of back pain. In the present study the geometry of the spinal columns of eight healthy men was continuously recorded over 24 h before, during, and after a seven-day 6 degree head-down tilt period (Series 1). The approach is based on the measurement of skin distances between four pairs of miniaturized ultrasound transmitters and receivers fixed on the back in parallel to the thoracic and lumbar spine. After a four-week break, the entire study was repeated with the same subjects (Series 2). The major findings are: 1. The length increase of the spine segments investigated was virtually identical in both series. 2. During the bedrest period significantly greater pain occurred in Series 1 as compared to Series 2. Pain was generally confined to the lumbar region about 10 cm lateral of the spinous processes. 3. Pain was most prominent when trunk motions were minimal, while movements over the maximal range of the spine transiently reduced the pain remarkably. 4. During bed rest, the amplitude of voluntary movements of the lumbar segment was reduced in particular during Series 1. It is concluded that back pain during bed rest is induced by reduced amplitudes of spine movements rather than by increases in the spine length. It is suggested that isometric muscle contractions of low intensity are a primary course of back pain. Regular, slow, large-amplitude movements of the spine are recommended as a countermeasure.

Adult↗
PubMed1999

Effects of hyperoxia on oxygen uptake kinetics in cystic fibrosis patients as determined by pseudo-random binary sequence exercise.

Patients with cystic fibrosis (CF) have been shown to exhibit impaired oxygen uptake (VO2) kinetics independent of their physical fitness. This study investigated whether oxygen supplementation improves VO2 kinetics in CF as determined by cycle ergometry at submaximal exercise intensities using a pseudo-random binary sequence exercise test i.e. a simultaneous application of different frequencies of sinusoidal work. The subjects were 9 CF patients and 13 healthy controls (HC) and they exercised while breathing humidified and heated air with a fractional concentration of oxygen in inspired air (F(I)O2) of either 0.21 or 0.40. With a F(I)O2 of 0.21 the respiratory exchange ratio (R) was higher in CF than in HC both at rest (0.91 vs 0.81) and during exercise (0.97 vs 0.89). Oxygen saturation (SO2) was slightly lower in CF. but remained above 90% during exercise (92.7% vs 95.2%). Spectrum analysis revealed that in CF, the amplitude ratio (AR) between V02 and exercise intensity was lower over a wide frequency range (P < 0.05). In addition, CF showed a larger negative phase shift (PS) at lower frequencies (P < 0.005). With a F(I)O2 of 0.40, SO2 increased to about 97% in both groups; while R remained higher in CF (0.92) compared to HC (0.81). In the control group, the O2 supplement raised AR but the VO, kinetics of the CF patients were not significantly affected. In HC the enhanced AR during oxygen supplementation would suggest a cardiopulmonary limitation of VO2 at the onset of submaximal exercise. In CF patients low AR and PS would indicate an attenuated VO2 response attributable to an impaired oxygen utilization in the muscles because the oxygen supplement normalised SO2 but failed to improve R and VO2 kinetics.

Adolescent↗
PubMed1999

Cardiac output, leg blood flow and oxygen uptake during foot plantar flexions.

When studying the adjustment of muscle perfusion during exercise, the influence of central factors (e.g. blood volume, central blood pressure and venous return) can be reduced by choosing small muscle groups. In the present study parallel determinations of cardiac output (CO), leg blood flow (LBF) and pulmonary oxygen (VO2) uptake were performed in 9 healthy male subjects at the onset and cessation of dynamic foot plantar flexions. The volunteers exercised with both feet for 5 minutes at 3 different resistances corresponding to 6%, 18% and 30% of the mean maximal voluntary contraction. Doppler measurements at the aortic root and in the femoral artery were utilized to estimate CO and LBF. Oxygen uptake was analyzed breath-by-breath as the difference between inspired and expired oxygen volumes. Within the first 10 s of exercise LBF increased from 400 ml x min(-1) to about 1,000 ml x min(-1) at all exercises intensities. During the subsequent 5 minutes of exercise, LBF decreased to about 800 ml x min(-1) at the lowest intensity. By contrast, it increased to about 1,900 ml x min(-1) at the highest intensity. The changes in CO during exercise were quantitatively identical with the changes in LBF. The present results suggest that the fine adjustment of muscle blood flow and muscle metabolism starts only after a fast and uniform circulatory on response. The second component may lead to leg perfusion values above, at or below the initial peak perfusion levels. The off-transients of LBF displayed no comparable fast responses. They were slower than the recovery kinetics of any cardiovascular parameter measured in the present study.

Adult↗
PubMed1999

Comparison between the physiological response to roller skiing and in-line skating in biathletes.

PURPOSE: Roller skiing is frequently used in Nordic disciplines during the off-season periods. Recently, in-line skating has become a potential alternative. In the present study, the responses of heart rate, oxygen uptake, respiratory exchange ratio, and lactic acid concentration to roller skiing and in-line skating were compared in competitive biathletes. METHODS: Eight male subjects performed three tests with both devices on a hilly outdoor track. They were requested to adjust their speed in such a way that the following criteria were met: intensity 1, lactate concentration about 2 mmol x L(-1); intensity 2, lactate concentration about 4 mmol x L(-1); AND intensity 3, maximal speed. RESULTS: Though the subjects were not experienced in-line skaters, all managed to adjust the required intensities. This was achieved through increased velocities during in-line skating. Independent of the exercise intensity the differences in speed ranged between 1.0 and 1.4 m x s(-1). The relationships between lactic acid concentration, oxygen uptake, respiratory exchange ratio, and heart rate were not influenced by the test device. The respiratory exchange ratio amounted to 0.88, 0.95, and 1.02 for intensities 1 to 3, respectively. CONCLUSIONS: These results show that in-line skating can be regarded as an alternative to roller skiing for off-seasonal training in Nordic disciplines. A potential advantage of in-line skating is that aerobic training intensities can be obtained at competitive velocities.

Adult↗
PubMed1998

Leg blood flow during slow head-down tilt with and without leg venous congestion.

The effects of slow changes in body position on leg blood flow (LBF) were studied in nine healthy male subjects. Using a tilt table, sitting volunteers were tilted about 60 degrees backwards to a supine position within 40 s. To modify the venous filling in the legs, the tilt manoeuvre was repeated with congestion of the leg veins induced by two thigh cuffs inflated to a subdiastolic pressure of 60 mmHg. Doppler measurements in the femoral artery were used to estimate LBF. Additional Doppler measurements at the aortic root in five of the subjects were taken for the determination of cardiac output. The LBF was influenced by body position. In the control experiment it increased from 500 ml x min(-1) in the upright to 780 ml x min(-1) after 15 min in the supine position. A mean maximal value of 950 ml x min(-1) was observed 20 s after the tilt. Heart rate remained almost constant during the tilt phase, whereas stroke volume increased from 90 ml to 120 ml and it remained at that level after the cessation of the tilt. Congestion of the leg veins had no significant effect on heart rate, stroke volume and mean blood pressure. However, it increased vascular resistance of the leg during and after the tilt. After 15 min in the tilted position LBF amounted to 600 ml x min(-1). The results suggest that the filling of the leg veins is inversely related to leg blood flow. The most likely mechanism underlying this observation is a local effect of venous filling on vasomotor tone.

Adult↗
PubMed1998

Recovery of free ADP, Pi, and free energy of ATP hydrolysis in human skeletal muscle.

We measured significant undershoots of the concentrations of free ADP ([ADP]) and Pi ([Pi]) and the free energy of ATP hydrolysis (DeltaGATP) below initial resting levels during recovery from severe ischemic exercise with 31P-nuclear magnetic resonance spectroscopy in 11 healthy sports students. Undershoots of the rate of oxidative phosphorylation would be predicted if the rate of oxidative phosphorylation would depend solely on free [ADP], [Pi], or DeltaGATP. However, undershoots of the rate of oxidative phosphorylation have not been reported in the literature. Furthermore, undershoots of the rate of oxidative phosphorylation are unlikely because there is evidence that a balance between ATP production and consumption cannot be achieved if an undershoot of the rate of oxidative phosphorylation actually occurs. Therefore, oxidative phosphorylation seems to depend not only on free [ADP], [Pi], or DeltaGATP. An explanation is that acidosis-related or other factors control oxidative phosphorylation additionally, at least under some conditions.

Adenosine Diphosphate↗
PubMed1997

Exercise capacity during and after spaceflight.

UNLABELLED: Our aim was to elucidate why astronaut's exercise capacity after spaceflight is reduced. Therefore, the kinetics of oxygen uptake (VO2) as a measure for muscular aerobic capacity, as well as maximal oxygen uptake (VO2peak), and anaerobic threshold (PAT) as overall measures for exercise capacity were determined. Measurements of VO2peak and AT were restricted to pre- and postflight sessions. METHODS: Four crew-members of the D-2 mission (10 d) were cycling with steady state phases at 20 W and 80 W, followed by 450s of pseudo random binary sequence (PRBS) changes between 20 W and 80 W, and an incremental exercise test (10 W every 30 s) up to subjective exhaustion. Breath-by-breath VO2, VCO2, ventilation, HR, and blood pressure were continuously recorded. Blood lactate samples were drawn only during the incremental phase. The VO2 kinetics were determined by evaluation of the relationship between the workload and the instantaneous oxygen uptake of each subject. The cross-correlation function between both variables showed two characteristic items, the maximum as a measure for the muscular aerobic capacity, and its lag representing time consuming processes. RESULTS AND DISCUSSION: Each subject showed an individual characteristic of VO2 kinetics. In flight, no significant changes were detected compared to preflight data. Decreases in lags of cross-correlation function maxima and decreases in mean blood pressure during exercise indicate lowered blood volumes 2 d after the flight. Lowered blood volumes can explain the losses in exercise capacity. The maximum of the cross-correlation function did not change significantly which indicates unchanged muscular oxidative capacity.

Adult↗
PubMed1996

Physical responses to different modes of interval exercise in patients with chronic heart failure--application to exercise training.

METHOD: In exercise training with chronic heart failure patients, working muscles should be stressed with high intensity stimuli without causing cardiac overstraining. This is possible using interval method exercise. In this study, three interval exercise modes with different ratios of work/ recovery phases (30/60 s, 15/60 s and 10/60 s) and different work rates were compared during cycle ergometer exercise in heart failure patients. Work rate for the three interval modes was 50% (30/60 s), 70% (15/60 s) and 80% (10/60 s) of the maximum achieved during a steep ramp test (increments of 25 w/10 s) corresponding to 71, 98 and 111 watts on average. Metabolic and cardiac responses to the three interval exercises were then examined including catecholamine levels and perceived exertion. Parameters measured during interval exercise were compared with an intensity level of 75% peak VO2, determined during an ordinary ramp exercise test (increments of 12.5 W.min-1). RESULTS: (mean +/- SEM) (1) In all three interval modes, VO2, ventilation and lactate did not increase significantly during the course of exercise. Mean values during the last work phase were between 754 +/- 30 and 803 +/- 46 ml.min-1 for VO2, between 26 +/- 3 and 28 +/- 1 l.min-1 for ventilation and between 1.24 +/- 0.14 and 1.29 +/- 0.10 mmol.l-1 for lactate. (2) In mode 10/60 s, heart rate and systolic blood pressure increased significantly (82 +/- 4 --> 85 +/- 4 beats.min-1; 124 +/- 5 --> 134 +/- 5 mmHg; P < 0.05 each), while in mode 15/60 s catecholamines increased significantly (norepinephrine 0.804 +/- 0.089 --> 1.135 +/- 0.094 nmol.l-1; P < 0.008; epinephrine 0.136 +/- 0.012 --> 0.193 +/- 0.019 nmol.l-1; P < 0.005). (3) In all three modes, rating of leg fatigue and dyspnoea increased significantly during exercise but remained within the range of values considered 'very light to fairly light' on the Borg scale. (4) Compared to an intensity level of 75% peak VO2, work rate during interval work phases was between 143 and 221%, while cardiac stress (rate-pressure product) was significantly lower (83-88%). CONCLUSION: All three interval modes resulted in physical response in an acceptable range of values, and thus can be recommended.

Chronic Disease↗
PubMed1996

Influence of gravity on cardiovascular reflexes from skeletal muscle receptors.

Skeletal muscles are important reflexogenic areas of the cardiovascular system. The afferent pathways of the reflex loops involve slow-conducting group III and group IV fibers that are excited by mechanical and chemical events in the muscle. The present paper reviews a series of experiments dealing with the question of whether those afferents are also influenced by gravitational forces. The results of these studies suggest the following answers: 1) gravitational forces can modulate cardiovascular reflexes from exercising skeletal muscles. 2) This effect is primarily due to changes in the interstitial fluid volume rather than to a direct mechanical influence, venous pressure, or venous volume. 3) The amplitudes of heart rate and blood pressure responses during exercise are inversely related to the local interstitial volume. Measurements during post-exercise circulatory arrest indicate that this sensitivity is mainly mediated by muscle chemoreceptors. These receptors, which also contribute to the spinal control of movement, generally appear to be sensitized by regional fluid losses and desensitized by overhydration of their environment.

Afferent Pathways↗
PubMed1995

Comparison of blood pressure and heart rate responses to isometric exercise and passive muscle stretch in humans.

The responses of mean arterial blood pressure (BPa) and heart rate (fc) to isometric contraction and passive stretch were compared in seven healthy male subjects at identical external forces. They were investigated in the sitting position with the hip and knee joint flexed to 90 degrees. Each subject performed two tests, separated by a day, in which the stimuli were applied in random order. After 5 min of rest they performed either 10-min static plantar flexion of one calf (200 N) or 10 min of passive calf muscle stretch at the same load. After 5-min rest, the second stimulus was applied for a further 10 min followed by 5-min rest. The second test was identical except for the sequence of the stimuli. The BPa was measured by a noninvasive and continuous method. Contraction of the vastus lateralis, gastrocnemius lateralis, and soleus muscles were determined by the myo-electric activity (electromyogram, EMG) by means of surface electrodes. The EMG activity of the vastus lateralis muscle remained at resting values throughout the experiments. Increases in EMG activity could only be detected for the triceps surae muscles during isometric contraction. During the initial 2 min of stimulation the BPa and fc responses to active contraction and passive stretch were comparable. Thereafter, both parameters showed significantly higher values during contraction. It was concluded that mechanical stress may have contributed to the early response of BPa during both passive stretch and voluntary contraction but that chemical stimuli were needed to maintain the peripheral cardiovascular drive.

Blood Pressure↗
PubMed1995

Time courses of cardiac output and oxygen uptake following stepwise increases in exercise intensity.

The adjustment of pulmonary oxygen uptake (VO2) following a step increase in work rate has been characterized as consisting of an early "cardiodynamic" component with unchanged mixed-venous O2-content ("phase 1") and a subsequent "metabolic" component ("phase 2") starting when venous blood from the muscle arrives at the lungs. The aim of the present study was to investigate whether the onset of phase 2 actually indicates the arrival of blood influenced by the altered muscle metabolism. Parallel measurements of cardiac output (Doppler technique) and VO2 (breath-by-breath measurements at the mouth) were performed in eight subjects during step increases in exercise intensity (from a 20 W baseline to either 80 W, 120 W, 160 W or 200 W). To vary the absolute cardiac output values for given muscle VO2 the subjects exercised both in upright and supine position. Individual time-courses of the arterio-venous O2 difference (a-v delta O2) were computed from cardiac output and VO2 data. Independent of body position two clear-cut phases of similar duration were seen both in VO2 and in the computed a-v delta O2. The duration of the first component with unchanged a-v delta O2 was about 20 s at the lowest step amplitudes (20-80 W and 20-120 W). It decreased to about 15 s for the 20-160 W and 20-200 W steps. At the lower exercise intensities the duration of phase 1 appears too long to be entirely due to the transit time of venous blood from the exercising muscles to the lungs.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1994

Postural effect on cardiac output, oxygen uptake and lactate during cycle exercise of varying intensity.

Owing to changes in cardiac output, blood volume distribution and the efficacy of the muscle pump, oxygen supply may differ during upright and supine cycle exercise. In the present study we measured, in parallel, circulatory (heart rate, stroke volume, blood pressure) and metabolic parameters (oxygen uptake, lactic acid concentration [la]) during incremental-exercise tests and at constant power levels ranging from mild to severe exercise. In supine position, cardiac output exceeded the upright values by 1.0-1.5 l.min-1 during rest, light ([la] < 2 mmol.l-1) and moderate ([la] = 2-4 mmol.l-1) exercise. At higher exercise intensities the cardiac output in an upright subject approached and eventually slightly exceeded the supine values. For both rest-exercise transitions and large-amplitude steps (delta W > or = 140 W) the cardiac output kinetics was significantly faster in upright cycling. The metabolic parameters (VO2 and [la]) showed no simple relationship to the circulatory data. In light to moderate exercise they were unaffected by body position. Only in severe exercise, when cardiac output differences became minimal, could significant influences be observed: with supine body posture, [la] started to rise earlier and maximal power (delta W = 23 W) and exercise duration (64 s) were significantly reduced. However, the maximal [la] value after exercise was identical in both positions. The present findings generally show advantages of upright cycling only for severe exercise. With lower workloads the less effective muscle pump in the supine position appears to be compensated for by the improved central circulatory conditions and local vasodilatation.

Adult↗
PubMed1994

Prediction of individual oxygen uptake on-step transients from frequency responses.

Power-oxygen uptake (VO2) frequency responses can be used to predict VO2 responses to arbitrary exercise intensity patterns. It is still an open question for which range of exercise intensities such computed VO2 response patterns yield valid predictions. In the present study, we determined the power-VO2 frequency response of nine sports students by means of pseudo-randomised switching between 20 W and 80 W during upright and supine cycle exercise. Starting from a baseline of 20 W each subject also performed sustained step increases to 40 W, 80 W, 120 W, and 160 W in both positions. The individual VO2 step responses were then compared with the expected VO2 time-courses predicted on the basis of the individual VO2 frequency responses. The comparison showed a close agreement for the 20 W-40 W and 20 W-80 W steps in both positions. With larger step amplitudes the VO2 kinetics became increasingly slower than the predicted VO2 time course in both positions. During additional ramp tests (10 W.30 s-1) whole blood lactic acid concentration [la-]b tended to be higher in the supine position at exercise intensities higher than 160 W. The mean power at 4 mmol.l-1 [la-]b amounted to 234 (SD 32) W and 253 (SD 44) W (P < 5%) in the supine and the upright position, respectively. The maximal oxygen uptake relative to body mass was not found to be significantly different [upright, mean 57 (SD 10) ml.(min.kg)-1; supine, mean 54 (SD 10) ml.(min.kg)-1].(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗