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Biomedical subjects

T Mustafa

Publications and source records attributed to T Mustafa.

At least 19 recordsLinked to original sources

Cytokine profile during latent and slowly progressive primary tuberculosis: a possible role for interleukin-15 in mediating clinical disease.

Recently, mouse models for latent (LTB) and slowly progressive primary tuberculosis (SPTB) have been established. However, cytokine profiles during the two models are not well established. Using quantitative reverse transcription-polymerase chain reaction (qRT-PCR) we studied the expression levels of interleukin (IL)-2, IL-4, IL-10, IL-12, IL-15, interferon (IFN)-gamma and tumour necrosis factor (TNF)-alpha during the course of LTB and SPTB in the lungs and spleens of B6D2F1Bom mice infected with the H37Rv strain of Mycobacterium tuberculosis (Mtb). The results show that, except for IL-4, cytokine expression levels were significantly higher during SPTB than LTB in both the lungs and spleens. During LTB, all the cytokines (except IL-2 in the lungs) had higher expression levels during the initial period of infection both in the lungs and spleens. During SPTB, the expression levels of IL-15 increased significantly from phases 1 to 3 in the lungs. The expression levels of IL-10, IL-12 and IFN-gamma increased significantly from 2 to 3 in the lungs. IL-10 and IL-15 increased significantly from phases 2 to 3, whereas that of TNF-alpha decreased significantly and progressively from phases 1 to 3 in the spleens. Over-expression of proinflammatory cytokines during active disease has been well documented, but factor(s) underlying such over-expression is not known. In the present study, there was a progressive and significant increase in the expression levels of IL-15, together with Th1 cytokines (IL-12 and IFN-gamma) during SPTB but a significant decrease during LTB. IL-15 is known to up-regulate the production of proinflammatory cytokines, IL-1beta, IL-8, IL-12, IL-17, IFN-gamma and TNF-alpha and has an inhibitory effect on activation-induced cell death. IL-15 is known to be involved in many proinflammatory disease states such as rheumatoid arthritis, sarcoidosis, inflammatory bowel diseases, autoimmune diabetes, etc. Our results, together with the above observations, suggest that IL-15 may play an important role in mediating active disease during Mtb infection.

Animals↗

Vaccine approaches to prevent tuberculosis.

Mycobacterium tuberculosis, the causative agent of tuberculosis (TB), is one of the main killers among infectious pathogens in the world and represents an important factor that sustain poverty in developing countries. Failure of the BCG vaccine to protect in endemic regions, and increasing problems with multi-drug-resistant TB calls for development of better vaccines to prevent reactivation of tuberculosis. It has been estimated that an effective post-exposure vaccine will prevent 30-40% of the TB cases. New vaccines should also prevent development of TB in HIV-infected individuals. Recent characterization of M. tuberculosis H37Rv by proteomic methods has revealed a large number of novel secreted proteins that should be investigated in mouse models for latent and slowly progressive TB. There is an important balance between control of infection and tissue destruction in TB, and M. tuberculosis has developed strategies to prevent immune-mediated sterilization. Central to this strategy is inhibition of apoptosis of macrophages. Development of novel vaccines should therefore take into consideration the effects on central markers to obtain a better picture of regulation of immunity, including FasL and Bcl-2 which are essential in regulation of apoptosis.

AIDS-Related Opportunistic Infections↗

Newly-developed measuring device for the quantitative assessment of thermal and pain thresholds of peripheral nerves.

Measuring devices for the quantitative assessment of thermal and pain thresholds are either simple and only suited for inexact tests or accurate and objective but expensive. The aim was there for to develop a cost effective device to enable a short and practical test of neurosensibility under clinical conditions. The result of this development is a new thermosensibility-measuring device (TSM) consisting of the measuring unit itself and a thermal probe. The data are registered and analysed through direct data transfer to a connected PC. Investigations carried out with this device revealed the construction to be efficient and easy to handle under clinical conditions. The TSM provides the examiner with the opportunity to monitor the neurosensory function of peripheral nerves in a reproducible way.

Diagnosis, Computer-Assisted↗

Short-term responses of coronary circulation to cortisol and estrogen in trout (Oncorhynchus mykiss).

This study was designed to investigate the short-term effects of cortisol and 17-beta-estradiol on the intact coronary tree of rainbow trout (Oncorhynchus mykiss). A non-working, isolated, and perfused heart preparation was used. The coronary pressure was monitored together with the coronary flow in order to calculate the coronary resistance. The drug effects were expressed as percent change in coronary resistance. At concentrations higher than 10(-5) mol l(-1), cortisol elicited a significant vasoconstriction (p<0.001) within 10 min of perfusion. The simultaneous administration of cortisol and adenosine (both at 10(-4) mol l(-1)) induced a significant reduction (p<0.001) of the coronary tree response elicited by each drug alone. The perfusion of the intact coronary trout system with 20 ng ml(-1) of 17-beta-estradiol elicited a significant vasodilative response (p<0.001) within 5-15 min of perfusion. This vasodilation did not involve nitric oxide, because no significant effect of Nomega-nitro-L-arginine (L-NA, a nitric oxide synthase inhibitor) in presence of the estrogen was observed. 17-beta-estradiol was also able to reduce the vasoconstriction induced by 10(-3) mol l(-1) acetylcholine. From these results it is possible to suggest that the steroid hormones, cortisol and 17-beta-estradiol, expound their action on the trout coronary tree through a non-genomic mechanism.

Animals↗

In situ expression of CD40, CD40L (CD154), IL-12, TNF-alpha, IFN-gamma and TGF-beta1 in murine lungs during slowly progressive primary tuberculosis.

The distribution and expression of CD40, its ligand CD40L (154) and related cytokines interleukin-12 (IL-12), tumour necrosis factor-alpha (TNF-alpha), interferon-gamma (IFN-gamma) and transforming growth factor-beta1 (TGF-beta1) were studied in the lungs of B6D2F1 hybrid mice during slowly progressive primary tuberculosis (TB) by immunohistochemistry. CD40 and CD40L are implicated in cell-mediated immunity (CMI) causing activation or apoptosis of infected cells. The phenomenon of apoptosis is associated with Mycobacterium tuberculosis survival. In this study, using frozen lung sections (n = 33), our results showed increased CD40, IL-12 and TGF-beta1 expression in macrophages with progression of disease. High percentages of mycobacterial antigens (M.Ags), CD40L and IFN-gamma expression were maintained throughout infection, and TNF-alpha-expressing cells were decreased. In lymphocytes, the percentage of IFN-gamma-positive cells was increased, but CD40L and IL-12 were maintained with the progression of disease. M.Ags, CD40 and CD40L were expressed in the same areas of the lesions. We conclude that changes in the expression of CD40-CD40L and cytokines associated with M. tuberculosis infection favour the hypothesis that M. tuberculosis causes resistance of host cells to apoptosis causing perpetuation of infection.

Animals↗

Effect of coronary perfusion on the basal performance, volume loading and oxygen consumption in the isolated resistance-headed heart of the trout Oncorhynchus mykiss.

Basal performance, volume loading response and oxygen consumption were determined in a resistance-headed preparation of the isolated trout heart. Two groups of hearts were used: the +CF group, in which the coronary vascular tree was perfused with a flow directly related to the pressure generated by the heart, and the -CF group, in which the coronary flow was set to zero. As a criterion for setting basal performance, the atrial input pressure was set in order to induce the ventricle to produce a cardiac output of 15 ml min(-1) kg(-1). Once basal conditions were obtained, the preparation was perfused for 30 min, and atrial and aortic pressure, cardiac output, heart rate, coronary pressure and coronary flow were determined at 5 min intervals. At the onset of perfusion, there was no difference in the basal performance between the two groups: the same preload was necessary to get the same cardiac output in both perfusion groups. None of the other performance parameters determined were different. However, after only 5 min of perfusion, the -CF hearts displayed significant adjustments, with increased atrial preload and ventricular preload (mean atrial pressure), and a significant decrease in cardiac output. At the end of the 30 min basal perfusion period, hearts were challenged with a stepwise increase in preload in order to obtain maximal stroke work (volume loading). The effect of coronary perfusion on the heart's response to volume loading was highly significant: the stroke work-preload relationship was significantly shifted towards higher preload values in the -CF group. Also, the maximal work produced by the heart under the experimental conditions used was lower in the -CF group. Rate of oxygen consumption of the heart increased significantly with volume loading, from a basal value of approximately 20 microl O2 min(-1) g(-1) to approx. 40 microl O2 min(-1) g(-1), but was not significantly affected by the absence of coronary perfusion. Mechanical efficiency under basal conditions was approximately 17%, but was not affected by either volume loading or coronary perfusion. Taken as a whole, these data represent direct evidence of the effect of coronary perfusion on the mechanical performance of the trout heart, but also show that these effects are limited by significant self-adjustments that occur in the heart.

Analysis of Variance↗

Increased Bcl-2 and reduced Bax expression in infected macrophages in slowly progressive primary murine Mycobacterium tuberculosis infection.

Mycobacterium tuberculosis (MTB) persists in host macrophages (Mphis) because it has developed mechanisms to escape Mphi killing. In vitro studies have shown that MTB can induce and inhibit apoptosis by causing the expression of Bax and Bcl-2, respectively, suggesting that the infected cells' fate depends on pro- and antiapoptotic signals. In the present study, we investigated the role of Bcl-2 in MTB infection in situ. The aim was to study the pattern and distribution of Bcl-2 and Bax in cellular infiltrates of MTB-infected B6D2F1 hybrid mice and correlate the expression with the presence of MTB antigens (MAgs). Using formalin-fixed lung tissues (n = 45), our results showed a significant difference in the percentage of Mphis stained for Bcl-2 or MAgs and Bax (P < 0.0001). Bcl-2 expression was increased in a population of Mphis and corresponded in intensity, colocalization and percentage with that of MAgs on the same cells, while Bax expression was reduced. In lymphocyte aggregates, Bcl-2 and Bax did not show any differences. We conclude that overexpression of Bcl-2 in Mphis containing MTB may be associated with intracellular survival of the bacilli, thus demonstrating one way by which MTB can escape the host's cellular response and killing.

Animals↗

Evidence that the angiotensin IV (AT(4)) receptor is the enzyme insulin-regulated aminopeptidase.

Central infusion of angiotensin IV or its more stable analogues facilitates memory retention and retrieval in normal animals and reverses amnesia induced by scopolamine or by bilateral perforant pathway lesions. These peptides bind with high affinity and specificity to a novel binding site designated the angiotensin AT(4) receptor. Until now, the AT(4) receptor has eluded molecular characterization. Here we identify the AT(4) receptor, by protein purification and peptide sequencing, to be insulin-regulated aminopeptidase (IRAP). HEK 293T cells transfected with IRAP exhibit typical AT(4) receptor binding characteristics; the AT(4) receptor ligands, angiotensin IV and LVV-hemorphin 7, compete for the binding of [(125)I]Nle(1)-angiotensin IV with IC(50) values of 32 and 140 nm, respectively. The distribution of IRAP and its mRNA in the brain, determined by immunohistochemistry and hybridization histochemistry, parallels that of the AT(4) receptor determined by radioligand binding. We also show that AT(4) receptor ligands dose-dependently inhibit the catalytic activity of IRAP. We have therefore demonstrated that the AT(4) receptor is IRAP and propose that AT(4) receptor ligands may exert their effects by inhibiting the catalytic activity of IRAP thereby extending the half-life of its neuropeptide substrates.

Aminopeptidases↗

Increased expression of fas ligand in human tuberculosis and leprosy lesions: a potential novel mechanism of immune evasion in mycobacterial infection.

To study the location and mechanism of apoptosis within the human tuberculosis (TB) and leprosy lesions, parallel sections were analyzed for mycobacterial antigens (M.Ag), Fas ligand (FasL), Fas, CD68 and Mac387 by immunohistochemistry, and apoptotic cells by the terminal deoxynucleotidyl-transferase-mediated dUTP-digoxigenin nick end labelling method. Cutaneous leishmaniasis and foreign body granulomas were analyzed for comparison. The heavily infected macrophages in multibacillary TB and leprosy granulomas very strongly expressed FasL, indicating that a mycobacterial infection can induce an increased expression of FasL in a population of infected macrophages, which may protect them from the attack of Fas-expressing lymphocytes. However, macrophages with high levels of leishmania amastigotes did not selectively express FasL, suggesting that this phenomenon is specific for the mycobacteria. Interestingly, in the well-formed TB granulomas, 84% of the multinucleated giant cells strongly expressed FasL. The expression of Fas was weak (34%) or absent. A higher number (33%) of epithelioid cells expressed FasL than Fas (23%). Lymphocytes were scanty among the epithelioid cells. The frequency of apoptotic cells was higher in the epithelioid cells (0.25%) than the mononuclear cells in the mantle zone (0.14%). Thus, the epithelioid cells and the multinucleated giant cells by virtue of the increased expression of FasL may make these granulomas an immune privileged site for mycobacteria.

Antigens, Bacterial↗

Characterization of the AT(4) receptor in a human neuroblastoma cell line (SK-N-MC).

Angiotensin IV (Ang IV), the 3-8 fragment of angiotensin II (Ang II), binds to a distinct receptor designated the AT(4) receptor. The peptide elicits a range of vascular and central actions including facilitation of memory retention and retrieval in several learning paradigms. The aim of this study was to characterize the AT(4) receptor in a human cell line of neural origin. Receptor binding studies indicate that the human neuroblastoma cell line SK-N-MC cells express a high-affinity Ang IV binding site with a pharmacological profile similar to the AT(4) receptor: (125)I]-Ang IV and (125)I]-Nle(1)-Ang IV bind specifically to the SK-N-MC cell membranes (K(d) = 0.6 and 0.1 nM) in a saturable manner (B(max) = 1.2 pmol/mg of protein). AT(4) receptor ligands, Nle(1)-Ang IV, Ang IV and LVV-haemorphin 7 (LVV-H7), compete for the binding of [(125)I]-Ang IV or [(125)I]-Nle(1)-Ang IV to the SK-N-MC cell membranes with rank order potencies of Nle(1)-Ang IV > Ang IV > LVV-H7 with IC(50) values of 1.4, 8.7 and 59 nM ([(125)I]-Ang IV) and 1.8, 20 and 168 nM ([(125)I]-Nle(1)-Ang IV), respectively. The binding of [(125)I]-Ang IV or [(125)I]-Nle(1)-Ang IV to SK-N-MC cell membranes was not affected by the presence of GTP gamma S. Both Ang IV and LVV-H7 stimulated DNA synthesis in this cell line up to 72 and 81% above control levels, respectively. The AT(4) receptor in the SK-N-MC cells is a 180-kDa glycoprotein; under non-reducing conditions a 250-kDa band was also observed. In summary, the human neuroblastoma cell line, SK-N-MC, expresses functional AT(4) receptors that are responsive to Ang IV and LVV-H7, as indicated by an increase in DNA synthesis. This is the first human cell line of neural origin shown to express the AT(4) receptor.

Angiotensin II↗

Distribution of angiotensin IV binding sites (AT4 receptor) in the human forebrain, midbrain and pons as visualised by in vitro receptor autoradiography.

Angiotensin IV and other AT4 receptor agonists, improve memory retention and retrieval in the passive avoidance and swim maze learning paradigms. Angiotensin IV binding sites (also known as the AT4 receptors) are widely distributed in guinea pig and monkey (Macaca fascicularis) brains where high densities of the binding sites have been detected in the hippocampus, neocortex and motor nuclei. However, the distribution of the binding sites in the human brain is not known. We have recently localised the angiotensin IV binding sites (AT4 receptors) in post-mortem human brain using iodinated Nle-angiotensin IV, a higher affinity and more stable analogue of angiotensin IV. This radioligand bound with relatively high affinity and specificity to angiotensin IV binding sites. In competition studies on consecutive sections through the prefrontal cortex and claustrum, angiotensin IV, Nle-angiotensin IV and LVV-hemorphin 7 competed for the binding of 125I[Nle]-angiotensin IV with nanomolar affinities. Angiotensin II and the AT1 and AT2 receptor antagonists were ineffective in competing for the binding at concentrations of up to 10 microM. We found high densities of 125I[Nle]-angiotensin IV binding sites throughout the cerebral cortex including the insular, entorhinal, prefrontal and cingulate cortices. Very high densities of the binding sites were observed in the claustrum, choroid plexus, hippocampus and pontine nucleus. Some thalamic nuclei displayed high densities of binding including the anteroprincipal, ventroanterior, anteromedial, medial dorsal and ventrolateral nuclei. The caudate nucleus, putamen, many amygdaloid nuclei and the red nucleus all displayed moderate densities of binding with a higher level detected in the substantia nigra pars compacta. In the hypothalamus, high densities binding sites were found in the ventromedial nucleus with lower levels in the dorsomedial and paraventricular nuclei. The distribution of 125I[Nle]-angiotensin IV binding sites in the human brain is similar to that found in other species and supports multiple roles for the binding sites in the central nervous system, including facilitation of memory retention and retrieval.

Aged↗

Diversity of lung and spleen immune responses in mice with slowly progressive primary tuberculosis.

The aim of the present study was to assess the compartmentalized immune response, in terms of cytokine secretion and cell activation, in lungs and spleens of mice with slowly progressive primary tuberculosis. Immunocyte populations from both organs were isolated and stimulated with concanavalin A, purified protein derivatives and MPT 59. Production of interferon-gamma (IFN-gamma) and interleukin-4 (IL-4) was measured using an enzyme-linked immunosorbent assay, and cell activation was measured using a tetrazolium colorimetric assay. The IFN-gamma and IL-4 levels in the supernatants of Mycobacterium tuberculosis antigen (Ag)-stimulated lung immunocytes from infected mice were higher than the levels from uninfected mice. However, only IL-4 levels were raised in the supernatants of Ag-stimulated spleen immunocytes from infected mice. Spontaneous and Ag-stimulated immunocyte activation was lower only in the lungs of infected mice compared with uninfected mice. The level of lung immunocyte activation was inversely associated with the extent of gross pulmonary pathology. In conclusion, cytokine secretion and cell activation were different between lungs and spleens in slowly progressive primary murine tuberculosis. Cytokine diversity may explain the confinement of tuberculous lesions in the lungs and the absence of lesions in the spleens of mice with slowly progressive tuberculosis.

Animals↗

In situ expression of cytokines and cellular phenotypes in the lungs of mice with slowly progressive primary tuberculosis.

The cellular phenotypes and the expression of cytokines were studied in the lungs of mice, using immunohistochemistry, during different phases of slowly progressive primary murine tuberculosis infection. During the first phase the small focal lesions in healthy mice contained predominantly interleukin-2 (IL-2)-expressing cells. A small number of tumour necrosis factor-alpha (TNF-alpha)-, monocyte chemoattractant protein-1 (MCP-1)- and IL-10-expressing cells were also present. IL-4-expressing cells were not detected. During the second phase the mice became unwell, but the bacterial counts and the size of focal lesions stabilized. IL-4-expressing cells appeared. The IL-10-, TNF-alpha- and MCP-1-expressing cells increased in number. On progression to phase three, the mice became seriously unwell and died rapidly. The inflammation spread to approximately 80% of the lung parenchyma. There was a marked increase in the number of IL-10-expressing cells. Expression of other cytokines was similar to that observed in the second phase. In the lesions, 3-6% of the macrophages (Mphi) containing mycobacterial antigens expressed high levels of IL-10 and TNF-alpha. The absolute numbers of CD3-, CD4- and CD11b-expressing cells in the lesions increased with the progression of infection. The numbers of CD8+ cells were reduced in the last phase of infection. The kinetics of T-lymphocyte subsets and the pattern of cytokine expression changed with the type and degree of tissue injury. The small number of Mphi with a heavy load of mycobacterial antigens may be the cause of this disturbance in cytokine balance, thus leading to progression of inflammation.

Animals↗

Effect of allicin from garlic powder on serum lipids and blood pressure in rats fed with a high cholesterol diet.

The use of fresh aqueous garlic extract is known to be effective in reducing thromboxane formation by platelets in both in vivo and in vitro animal models of thrombosis. In the present study, we studied the effect of Lichtwer garlic powder (containing 1.3% alliin equivalent to 0.6% allicin) on the serum cholesterol, triglyceride, glucose, protein, and systolic blood pressure in rats fed with a high cholesterol diet. Experimental rats were fed a 2% high cholesterol diet with and without garlic powder for 6 weeks. Control rats were fed a normal diet. The aqueous garlic powder extract was given orally to rats on a daily basis. It was observed that cholesterol-fed animals had a significant increase in serum cholesterol compared to the control group of rats fed on a normal diet. However, when the rats were fed with a high cholesterol diet mixed with garlic powder, there was a significant reduction in their serum cholesterol levels compared with the group which were on a diet containing high cholesterol without garlic powder. Serum triglyceride levels were also significantly lowered by garlic powder when compared to control and high cholesterol diet group rats. The blood pressure of the high cholesterol diet animals was significantly higher compared to the animals receiving the control diet. The blood pressure of the animals receiving garlic powder and high cholesterol diet was significantly lower as compared to the high cholesterol and control diet group. No significant changes were observed in the serum glucose and protein in all of the rats. These results show that garlic is beneficial in reducing blood cholesterol, triglycerides levels and systolic blood pressure in hypercholesterolemic rats. Our experimental results show that garlic may beneficially affect two risk factors for atherosclerosis--hyperlipidemia and hypertension.

Aged↗

Thromboxane-B(2) levels in serum of rabbits receiving a single intravenous dose of aqueous extract of garlic and onion.

We have shown previously that fresh garlic extract is effective in reducing thromboxane formation by platelets both in vivo and in vitro animal models of thrombosis. In the present study, the effect of different concentrations of a single dose of aqueous extracts of garlic and onion were evaluated on serum thromboxane-B(2)synthesis in rabbits. Different concentrations of garlic and onion were administered as single doses in the ear vein of rabbits. Rabbits were bled before and at different intervals after the infusion of garlic or onion extracts. Venous blood was collected and allowed to clot at 37 degrees C for 1 h. Thromboxane-B(2)level was measured in the serum by radioimmunoassay. It was observed that garlic inhibits the thrombin-induced platelet synthesis of TXB(2)in a dose-and time-dependent manner. Maximum inhibition of TXB(2)occurred between 0.5 h and 6 h at 25 and 100 mg kg(-1)garlic. At 24 h post-garlic infusion TXB(2)inhibition was reduced to 15% of the control and TXB(2)levels were comparable to that of the control values at 72 h pots-garlic infusion. Infusion of 100 mg kg(-1)onion extract did not elicit any inhibitory effect on TXB(2)synthesis in the serum of rabbit during the treatment period. The rapid recovery of platelet cyclooxygenase activity after infusion of a single dose of garlic suggests that garlic should be taken more frequently in order to achieve beneficial effects in the prevention of thrombosis.

Animals↗

Association between exercise and HIV disease progression in a cohort of homosexual men.

PURPOSE: To study the relationship between exercise and human immunodeficiency virus (HIV) disease progression. METHODS: 415 individuals (156 HIV positive, 259 HIV negative), from a cohort study of 851 homosexual men from New York City, 1985-1991. By 1991, 68 of the 156 persons developed Acquired Immune Deficiency Syndrome (AIDS) and 49 died with AIDS. Exercise was defined as self-report of exercising 3-4 times/week or daily at entry; less was considered nonexercise. CD4 lymphocyte decline was constructed for each subject by modeling log CD4 count against time in days. The association between exercise and progression to AIDS and death with AIDS, adjusting for baseline CD4 count, was determined using Cox model. Linear regression was used to model CD4 decline with exercise for HIV positive and HIV negative groups separately, adjusting for initial CD4 count. RESULTS: Having exercised was associated with slower progression to AIDS at 1 year (HR = 0.68, 90% confidence interval (CI): 0.4-1.17); hazard ratios (HR) at 2, 3, and 4 years were 0.96, 1.18, and 1.36, respectively. Having exercised was also associated with slower progression to death with AIDS at 1 year (HR = 0.37, 90% CI: 0.14-0.94) with hazard ratios at 2, 3, and 4 years of 0.68, 0.98, and 1.27, respectively, suggesting a protective effect close to the time exercise was assessed, but an increased risk after 2 years. Exercising 3-4 times/week had a more protective effect than daily exercise. Exercisers in the HIV positive group showed an increase in CD4 count during a year by a factor of 1.07. CONCLUSION: Moderate physical activity may slow HIV disease progression.

Acquired Immunodeficiency Syndrome↗

The value of strength training for older adults.

Health in older adults can best be measured in terms of functional status. Skeletal muscle strength has been reported to be a determinant of functional status in older individuals. Two major contributors to the decline in muscle function as a person ages are disuse and physical inactivity. Declining muscle function through a loss of muscular strength may decrease functional independence and mobility and increase the risk for falls and injuries, physical frailty, and disability. Older individuals lacking an appropriate amount of muscular strength may not be able to perform various activities of daily living, which are important indicators of independence.

Activities of Daily Living↗