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The right aortic arch with mirror-image branching of brachiocephalic arteries and aplasia of the left brachiocephalic trunk: surgically cured rare cause of cerebrovascular insufficiency.

A clinical case with rare anomaly: right aortic arch with mirror-image branching of brachiocephalic arteries and aplasia (isolation) of the left brachiocephalic trunk, causing cerebrovascular insufficiency and left arm claudication is described. Despite the clear neurologic manifestations of cerebrovascular insufficiency and absence of the pulse on the left arm, the pathology was not diagnosed until 35 years of age. The anomaly was diagnosed and surgically cured in the Department of Vascular Surgery of Vilnius University Emergency Hospital. Using transsternal median thoracotomy approach, 12 mm diameter PTFE vascular graft, arising from the ascending aorta and connected to the angle, made of branching left common carotid and left subclavian arteries, was implanted into the position of missing left brachiocephalic trunk. 3 years after surgery patient feels healthy and is working. To our knowledge this is the first reported case of surgical replacement of missing left brachiocephalic trunk in the right-sided aortic arch with mirror-image branching of brachiocephalic arteries.

Adult↗

[Iatrogenic injury of the brachiocephalic arterial trunk and its branches--case report].

Iatrogenic vascular traumas are increasing and their proportion exceeds 40% of all vascular injuries. We report on a rare case of iatrogenic injury of the brachiocephalic arterial trunk during surgical intervention due to postirradiation arteriopathy, which was successfully treated with a silver prosthesis graft. A 58-year-old male underwent surgery for metastases of papillary carcinoma of the thyroid gland, located in lymph nodes adjacent to the right common carotid artery and right subclavian artery. During the surgery, there was an intraoperative injury of the brachiocephalic arterial trunk that included spontaneous rupture and tear of the subclavian and common carotid artery, as the result of extreme fragility of the arterial wall, probably due to the previous irradiation therapy. Emergency sternotomy and clavicle resection were followed by blood flow reconstruction by use of an Y prosthesis that was applied for terminoterminal anastomosis between the brachiocephalic trunk to common carotid artery and subclavian artery. The authors concluded that irradiation therapy may lead to progressive arteriopathy in affected arteries.

Blood Vessel Prosthesis Implantation↗

[Anomalous case of the left common carotid artery arising from the brachiocephalic trunk].

We found an anomalous branch of the aortic arch during the students' dissection practice at Fukuoka Dental College in 1988. The results are as follows; This case was found in a 92-year-old female cadaver (cause of death: cardiac dissufficiency), whose brachiocephalic trunk arose from the aortic arch forming a striking trunk with the left common carotid artery. The diameter of this trunk was 17.2 mm at its origin and the longitudinal length was 11.0 mm. This case corresponded to Typus B of Adachi's classification, while to Type C of De Garis's.

Aged↗

[Surgery of occlusive lesions of the brachiocephalic trunk].

A detailed analysis of 33 cases of operations on the brachiocephalic trunk is reported. An experience with surgical treatment for occlusive lesions of the brachiocephalic trunk of various etiology to liquidate chronic ischemia of the brain has evidenced that in aorto-arteritis the prosthesizing of the brachiocephalic trunk with synthetic prosthesis yields the most favourable results.

Adolescent↗

[Esophageal atresia, brachio-cephalic arterial trunk and tracheomalacia (author's transl)].

The case of 6 children operated for type III esophageal atresia with re-establishment of continuity is reported owing to the association with anterior tracheal compression by the brachio-cephalic arterial trunk. In the 5 cases, control radiography after the intervention showed a tracheotomy opposite the superior esophageal pouch and sometimes a notch in the anterior trachea. In all of the cases, endoscopy confirmed the presence of compression of the anterior aspect of the trachea by the brachio-cephalic arterial trunk. In 2 cases, esophageal transit was normal, the signs of tracheal compression disappeared after section-reimplantation of the brachio-cephalic trunk. In the other cases esophageal complications existed: stenosis, choking during swallowing, reflux. The surgical treatment of these complications led to the disappearance of the respiratory disorders.

Brachiocephalic Trunk↗

Aesthetic and functional efficacy of subcuticular running epidermal closures of the trunk and extremity: a rater-blinded randomized control trial.

OBJECTIVE: To ascertain whether subcuticular epidermal closures of elliptical excisions of the trunk and extremities result in better functional and cosmetic outcomes than simple running epidermal closures of the same sites. DESIGN: Randomized controlled trial, with allocation of epidermal closure of elliptical excisions to 4 arms, including 1 control arm (simple running polypropylene sutures removed after 14 days) and 3 experimental arms (subcuticular running polypropylene sutures removed after 14 days, subcuticular running polypropylene sutures left in place, and subcuticular running polyglactin 910 sutures left in place). All experimental interventions were preceded by deep dermal closure with simple interrupted polyglactin 910 sutures. Interventions were delivered by 3 surgeons, who underwent 2 training sessions to minimize intersurgeon technique variability. SETTING: Institutional referral practice providing ambulatory care in an urban environment. PATIENTS: A consecutive sample of 36 adult patients (ages 18-65 years), each referred for concurrent elliptical excision of at least 2 clinically atypical nevi of the trunk and/or extremity, were included in the study. MAIN OUTCOME MEASURES: Primary outcome measures obtained at 3 and 9 months included scar width in millimeters and blinded observer ordinal scale assessment of overall scar appearance. Secondary outcome measures included ratings on the standardized Vancouver Scar Scale and the Hollander Scar Scale; an additional nonstandard item was added to assess pruritus. RESULTS: No difference among groups was found in scar width at 3 or 9 months. Differences among groups were detected in overall scar appearance (3 months, P<.001; 9 months, P<.001), vascularity (3 months, P = .001; 9 months, P<.001), excessive distortion (3 months, P = .04; 9 months, P = .02), contour irregularity (3 months, P<.001), and edge inversion (3 months, P = .01). The best overall appearance was with a subcuticular running polyglactin 910 suture left in place, and the next best was with a subcuticular running polypropylene suture left in place; differences across groups persisted but decreased in intensity at 9 months. A secondary analysis that matched high-tension anatomic sites (back and lower leg), and high and moderate tension sites (also chest and shoulder) yielded the same main effects and mostly the same results in pairwise comparisons. CONCLUSION: While scar width does not appear to vary significantly based on choice of epidermal closure, bilayered closures of the trunk and extremity have better overall appearance and less associated erythema at 3 and 9 months after surgery with the use of a subcuticular running polyglactin 910 suture left in place.

Abdomen↗

Polypoid sarcoma of the pulmonary trunk: analysis of the literature and report of a case with leptomeric organelles and ultrastructural features of rhabdomyosarcoma.

A case of polypoid sarcoma of the pulmonary trunk is described in an 80-year-old woman who had a 21-year history of episodic chest pain and hemoptysis. Ultrastructural examination revealed Z bands, characteristic of rhabdomyosarcoma, and leptomeric organelles. This is the 60th reported case of sarcoma of the pulmonary trunk. Symptoms in reported cases were variable, usually caused by tumor emboli to the lungs or by right ventricular outflow obstruction. Angiography was diagnostic. The tumor was characteristically polypoid, often multicentric, and by definition was fixed to the pulmonary trunk or valves. Non-differentiated sarcoma (often uniquely pleomorphic) was found in 37% of patients, leiomyosarcoma (once confirmed by electron microscopy) in 17%, myxosarcoma in 13%, elements of rhabdomyosarcoma in 8%, fibrosarcoma in 8%, elements of chondrosarcoma in 11%, and 5% were malignant mesenchymomas. The authors suggest that these tumors originate from the undifferentiated tissues of the bulbus cordis and propose the name myenchymoma for the tumor.

Adult↗

A randomized, prospective trial of adjuvant chemotherapy in adults with soft tissue sarcomas of the head and neck, breast, and trunk.

Since 1977, 31 patients were entered in a randomized, prospective study testing the efficacy of adjuvant chemotherapy after aggressive local treatment of high-grade sarcomas of the head, neck, breast, and trunk (excluding retroperitoneal sarcomas). All patients had complete resection of gross tumor and underwent postoperative radiotherapy (6000-6300 rads over 7-8 weeks). Seventeen patients received adjuvant chemotherapy consisting of doxorubicin (less than or equal to 550 mg/m2), cyclophosphamide (less than or equal to 5500 mg/m2), and methotrexate (less than or equal to 1000 mg/kg). Three-year actuarial disease-free survival in the chemotherapy arm was 77%, compared to 49% in the no-chemotherapy arm (P = 0.075). Three-year overall actuarial survivals in the two treatment arms, however, were 68% and 58%, respectively (P = 0.38). Considering only patients with tumors of the trunk (22 patients), 3-year actuarial disease-free survival in the chemotherapy arm was 92%, compared to 47% in the no-chemotherapy arm (P = 0.006). Actuarial 3-year overall survival in the chemotherapy arm was 82%, compared to 61% in the no-chemotherapy arm (P = 0.18). An additional 26 patients were treated in an identical fashion, but were not part of the randomized trial because of contraindications to chemotherapy, refusal to enter the randomized trial, or because they were treated before 1977 in a trial in which all patients received chemotherapy. Considering the entire group of 57 patients, follow-up ranged from 10 to 86 months (median, 35 months). Local control was achieved in 46 patients (81%); 3-year actuarial disease-free and overall survivals were 67% and 77%, respectively. A tendency toward improved disease-free survival was apparent among patients treated with chemotherapy (P = 0.018), but there was no statistically significant improvement in overall actuarial survival (P = 0.46). The subgroup of patients with sarcomas of the trunk (39 patients) demonstrated the greatest benefit from chemotherapy, with regard to disease-free survival (P less than or equal to 0.001). The most significant toxicity associated with chemotherapy was doxorubicin-induced cardiomyopathy, which resulted in clinically apparent congestive heart failure in five patients. Thus, the use of chemotherapy when combined with aggressive local measures appears to improve disease-free survival, but additional patients and longer follow-up are necessary to determine if improved overall survival will result.

Actuarial Analysis↗

Approximate surface development of the left side half-trunk by a free-formed model.

The approximate surface development, skin length, and surface area of the left side of the trunk of 51 female students were compared with regard to static and stretched postures. The data for each subject were obtained from geometrical models generated by moiré topography with a computer. When the chest was stretched, the anterior surface, the shoulder line, and the arm-base line were transformed from concave to convex, and a gap oriented toward the nipple widened out. The skin elongated vertically and transversely, except at the side of the waistline, where the skin contracted. The area at the top of the trunk decreased about 25%, while the other parts of the trunk increased 8-15%. The total anterior area was 1.20 m2 for the static posture and 1.29 m2 for the stretched posture. When the posterior surface was stretched, the shoulder line changed from convex to concave, the side line from quasi-straight to concave, and gaps oriented toward the chest line disappeared. The skin elongated most at the infrascapular region (20-35%), while the neck base line contracted (-11%). The center of the back and the lower arm base areas enlarged the most (25%) and the lumbar area enlarged the least (12%). The total posterior area was 1.26 m2 in the static posture and 1.37 m2 in the back-stretched posture. In conclusion, the back skin elongated and enlarged more when stretched than the frontal skin.

Adult↗

Ultrastructural studies of the superior cervical trunk of the mouse: distribution, cytochemistry and stability of fibrous elements in preganglionic fibers.

The ultrastructure of axons in the preganglionic cervical sympathetic trunk of the mouse is described with emphasis on the number, distribution and stability of fibrous elements in the axoplasm. Neurofilaments outnumbered microtubules in myelinated and non-myelinated axons of all sizes, and the ratio of neurofilaments to microtubules in non-myelinated axons at each point studied was fairly consistent and independent of axonal diameter. The density of neurofilaments and microtubules, however, was greater in axons of progressively smaller diameter. In non-myelinated axons and small myelinated axons neurofilaments were uniformly distributed throughout the axoplasm resulting in minimum and maximum interfilament distances of 300 angstrom and 500 angstrom respectively; the spacing of fibrous elements within any one axon was dependent upon its diameter and position with respect to the superior cervical ganglion in the preganglionic trunk. The maximum interfilament distance was also found in large myelinated axons where neurofilaments, occurring in fascicles, were separated by distances of approximately 500 angstroms. Cytochemical staining of axons with lanthanum hydroxide, ruthenium red or alkaline bismuth delineated the delicate filamentous matrix interconnecting microtubules, neurofilaments and other organelles in the axoplasm. Alkaline bismuth stain was most intense in myelinated axons where heaviest deposition of reaction product was associated with neurofilaments. Treatment in vitro of the cervical sympathetic trunk with 5 X 10(-5) M vinblastine sulfate dissociated microtubules and induced formation of crystalline arrays of "tubular" elements. A uniform center to center spacing of 250-300 angstrom was found for crystalloids in non-myelinted axons; however, in myelinated axons the center to center spacing was not uniform and varied in the range 300-600 angstrom. Neurofilaments and their surface projections were unaffected by vinblastine. Fixation in the presence of lanthanum enhanced delineation of crystalloid elements. Exposure of 0-4 degrees C for up to three hours had no consistent effect on microtubules or neurofilaments. In contrast, cold treatment disrupted the delicate axonal matrix and resulted in the formation of aggregates of coarse flocculent material in the axoplasm.

Animals↗

Localization of vasoactive intestinal peptide- and peptide histidine isoleucine amide-like immunoreactivities in the rat superior cervical ganglion and its nerve trunks.

Electrical stimulation of the preganglionic cervical sympathetic trunk causes an increase in dopa synthesis in the postganglionic neurons in the superior cervical ganglion (SCG). This transsynaptic biochemical effect can be blocked only partially by cholinergic antagonists, suggesting the involvement of a noncholinergic preganglionic sympathetic neurotransmitter(s). A survey of a large number of possible candidates for this neurotransmitter revealed that, in addition to cholinergic agonists, only a small group of peptides (all members of the secretin-glucagon family) stimulated dopa synthesis in the SCG. The effective peptides included vasoactive intestinal peptide (VIP), peptide histidine isoleucine amide (PHI), and secretin. Consequently we looked for the presence of immunoreactivities for these three peptides in the SCG. VIP- and PHI-like immunoreactive fibers were found in the SCG and in its major pre- and postganglionic nerve trunks. The distributions of the two immunoreactivities were very similar. Immunoreactive fibers were seen both singly and in bundles. In some instances, fibers were found apposed to neuronal cell bodies in the ganglion, and occasionally dense plexuses of fibers were found surrounding the neurons. In addition, punctate immunoreactive profiles were found apposed to the neurons in what appeared to be terminal fields. A small number of immunoreactive neuronal cell bodies were also seen in the ganglion. In a few instances, it was possible to establish, in serial sections, that the same cell body was immunostained with both VIP and PHI antisera. No secretin like-immunoreactive fibers or cells were observed. The presence of VIP-like and PHI-like-immunoreactive fibers in the cervical sympathetic trunk and in the SCG strengthens the possibility that these peptides, or a related molecule(s), serve as preganglionic neurotransmitters in this ganglion.

Animals↗

Distribution of GABA-immunoreactive nerve fibers and cells in the cervical and thoracic paravertebral sympathetic trunk of adult rat: evidence for an ascending feed-forward inhibition system.

Neurochemical and immunohistochemical evidence suggests that the superior cervical ganglion (SCG) contains all components of a gamma-aminobutyric acid (GABA)ergic transmission system, which includes GABAergic axons of unknown origin. The number of nerve fibers with and without GABA-like immunoreactivity was determined in interganglionic connectives at all cervical and thoracic levels of the paravertebral sympathetic trunk. In addition, the distribution of GABA-immunoreactive (IR) neurons was established within the ganglion chain and compared with the relative frequency of principal neurons richly innervated by GABA-IR axon terminals. The following results were obtained: 1) the total number of nerve fibers in cross sections did not significantly vary between the cervical levels, but it increased steadily from upper to lower thoracic segments; 2) in contrast, the number of GABA-IR fibers decreased from the cervical sympathetic trunk below the SCG (approximately 300 fibers) down to the seventh to tenth thoracic ganglion, below which no such fiber was seen; 3) GABA-IR nerve fibers originate from a subclass of GABA-IR cells; these are small, bipolar neurons with predominantly ascending, unmyelinated axon-like processes; 4) the number of principal neurons richly innervated by GABA-IR nerve fibers decreased from the SCG to the upper thoracic ganglia, and was very small below; and 5) apart from basket-like innervation, GABA-IR axons also formed diffuse networks around GABA-negative principal neurons predominantly in cervical and upper thoracic ganglia. These data suggest that the GABAergic innervation of paravertebral sympathetic ganglia is more complex than previously suspected. What appears as preganglionic afferents from several spinal segments (C8-Th7) innervate GABAergic neurons in the sympathetic trunk which have ascending axons and focus their inhibitory effects on the cervical sympathetic ganglia, predominantly the SCG. These data suggest that GABAergic small interganglionic neurons form a feed-forward inhibition system, which may be driven by multisegmental spinal input in the paravertebral sympathetic ganglion chain.

Afferent Pathways↗

fused-somites-like mutants exhibit defects in trunk vessel patterning.

We identified four mutants in two distinct loci exhibiting similar trunk vascular patterning defects in an F3 genetic screen for zebrafish vascular mutants. Initial vasculogenesis is not affected in these mutants, with proper specification and differentiation of endothelial cells. However, all four display severe defects in the growth and patterning of angiogenic vessels in the trunk, with ectopic branching and disoriented migration of intersegmental vessels. The four mutants are allelic to previously characterized mutants at the fused-somites (fss) and beamter (bea) loci, and they exhibit comparable defects in trunk somite boundary formation. The fss locus has been shown to correspond to tbx24; we show here that bea mutants are defective in the zebrafish dlC gene. Somitic expression of known vascular guidance factors efnb2a, sema3a1, and sema3a2 is aberrantly patterned in fss and bea mutants, suggesting that the vascular phenotype is due to loss of proper guidance cues provided by these factors.

Animals↗

Rhabdomyosarcoma of the extremities and trunk: analysis of 150 patients treated by surgical resection.

This report details the clinical experience of 150 patients with rhabdomyosarcomas treated by one group of surgeons. Of the 150 patients, 103 suffered from pleomorphic rhabdomyosarcomas, 40 patients had embryonal rhabdomyosarcomas, and 7 had alveolar cell type of rhabdomyosarcoma. The males suffered almost twice as much as the females from this form of cancer (96 males to 54 females). The fifth decade had the highest incidence of all rhabdomyosarcomas. The younger patients generally suffered from embryonal rhabdomyosarcomas and the older ones from pleomorphic rhabdomyosarcomas, although age was no barrier to the occurrence of embryonal rhabdomyosarcomas in some of the older patients and pleomorphic rhabdomyosarcomas in some of the younger patients. Caucasians were almost exclusively afflicted by this form of cancer (93% of this series). The lower extremity was the most frequent site of the lesion, occurring in 50.7% of the 150 cases. The upper extremity was the second most frequently involved site (28%), and the trunk was the least involved site (21.3%). Of the 150 patients studied, 40 were considered indeterminate. Thirteen patients are alive and free of cancer, but were treated less than 5 years ago; 12 patients reported for consultation only. There were 13 who were free of sarcomas at periods in excess of 2 years but were lost to follow-up. Two patients in this series died before the 5-year period, and autopsy revealed the death to be due to causes other than the rhabdomyosarcoma. Of the 110 determinate patients, 75 (68%) died as a result of the cancer. The 5-year survival rate equals 32%. The fact of the 30% 5-year survival after treatment for recurrences should help dismiss the pessimism which prevails once a recurrence is noted subsequent to major therapy. Age per se had no great effect on prognosis. The poorest results occurred in the 11-20 age range, with a 5-year survival of 15%. This value reflects on increased incidence of embryonal rhabdomyosarcomas which tend to be more malignant and metastasize earlier than do the pleomorphic type. The effect of location upon survival revealed that of 76 patients with involvement of the lower extremity, 34% survived 5 years or longer, and those with sarcomas of the trunk had the poorest survival (26%). The fact that the trunk, by virtue of its anatomy, limits the degree of surgery that can be perfomred, probably helps to explain this difference. The role of radiation therapy and chemotherapy awaits elucidation. Reports of combined surgery, radiation therapy, and chemotherapy are encouraging.

Adolescent↗

Osteosarcoma of the trunk treated by multimodal therapy: experience of the Cooperative Osteosarcoma study group (COSS).

The case histories of all patients with osteosarcoma of the trunk entered into the consecutive studies COSS 80 through COSS 86 of the Cooperative German/Austrian Osteosarcoma Study Group (COSS) were analyzed in order to evaluate their clinical characteristics and the impact of modern neoadjuvant therapy on prognosis. They were compared to those of all patients with extremity osteosarcoma treated according to the same protocols. While tumors of the trunk comprised only 32 (4.8%) of 665 primary classical osteosarcomas, secondary osteosarcomas were much more likely to be located in bones of the axial skeleton (6 of 18, 33%). Patients with primary osteosarcoma of the axial skeleton were older (mean: 20.8 vs. 15.2 years, P < 0.01) and were more likely to present with metastases at diagnosis (34% vs 12%, P < 0.001) than those with primary extremity osteosarcoma. In contrast to extremity tumors, local surgical treatment failure was very common in osteosarcomas of the trunk. Complete tumor removal was achieved in less than half of all evaluable cases. The prognosis of eight patients with localized primary axial osteosarcoma and effective surgical local control was not inferior to that of 483 equally evaluable patients with extremity tumors. In conclusion, while secondary systemic spread of axial osteosarcoma may be avoided in patients treated with multiagent chemotherapy, successful treatment is often barred by primary metastatic disease and inability to control the local tumor site.

Adolescent↗

Oscillatory interaction between human motor cortex and trunk muscles during isometric contraction.

We investigated oscillatory interaction between magnetoencephalographic signals of the human motor cortex and surface electromyogram from the paraspinal (PS) and abdominal (ABD) muscles. The results were compared with data obtained during contraction of the first dorsal interosseus (FDI) and tibialis anterior (TA) muscles. Significant coherence at 15-35 Hz was observed for both PS and ABD muscles in all subjects but the coherence was weak compared with that for FDI and TA. The cortical sources for both the PS and the ABD coherences were located in the motor cortex between the source areas for the FDI and TA coherences, thereby agreeing with the classical trunk area of the motor homunculus previously determined by invasive studies. The sources were strictly contralateral for PS but bilateral for ABD contractions. Our results indicate that during isometric contractions descending motor commands are modulated by cortical oscillations for both limb and trunk muscles, although the modulation is weaker and may be bilateral for trunk muscles.

Abdominal Muscles↗

Neck, trunk and limb muscle responses during postural perturbations in humans.

This study examined the EMG onsets of leg, trunk, and neck muscles in 10 standing human subjects in response to support surface anterior and posterior translations, and to plantar and dorsiflexion rotations. The objective of the study was to test the hypothesis that the responses radiating upward from distal leg muscles represent part of a large ascending synergy encompassing axial muscles along the entire length of the body. If these responses are not ascending, then the muscles of the neck, and possibly the trunk, can be independently activated by vestibular, proprioceptive or visual inputs. We analysed the timing of postural muscle responses within and between body segments in order to determine whether they maintained a consistent temporal relationship under translational and rotational platform movement paradigms. Our results did not strongly support an ascending pattern of activation in all directions of platform perturbation. Temporal differences between activation patterns to platform perturbations in the forward or backward directions were revealed. In response to posterior platform translations we observed an ascending pattern of muscle responses along the extensor surface of the body. In addition, responses elicited in the neck flexor and abdominal muscles occurred as early as those of the stretched ankle muscles. This pattern of upward radiation from stretched ankle muscles was not as clear for anterior platform displacements, where early neck flexor muscle responses were observed during the ascending sequence on the flexor surface of the body. Platform rotations caused fewer responses in the neck and upper trunk muscles than translations, and all muscles responses occurred simultaneously rather than sequentially. Probable differences in the stimulation of vestibular and neck proprioceptive inputs and the mechanical demands of the rotation and translation paradigms are discussed.

Adult↗

Two methods for determining trunk extensor endurance. A comparative study.

In the last few years epidemiological surveys have shown correlation between low endurance capacity of the trunk extensors and low back trouble. In this report two methods for the determination of trunk extensor endurance are compared. In method I the fixated subject is lying prone with the cranial border of the iliac crest at the edge of a couch. The endurance time for maintaining the upper part of the body horizontal was measured (max. 240 s). In method II the standing subject performed a horizontal isometric pull on a strain gauge force transducer equivalent to 60% MVC of the trunk extensors. The time until complete exhaustion in the muscles (inability to maintain the preset force level) was determined. The methods were applied to two groups of normal, healthy subjects: 1) 23 female (22-61 years) and 53 male (27-60 years) postmen. 2) 10 male students (20-37 years). The results show that method II is preferable to method I, not least in the field of ergonomics. Method II is easily practicable and does not demand expensive or complicated equipment. Furthermore this method gives reliable results suitable for statistical preparation, and is not influenced by anthropometrical factors.

Adult↗